Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal studyBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6423 (Published 11 November 2014) Cite this as: BMJ 2014;349:g6423
All rapid responses
Re: Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study
As a coal face GP, I plan to share this paper with my registrar as possible evidence that how we care for our patients in Primary Care may indeed have impact on their admission chances. The significant reduction in admissions for some 8-11% for a set of major conditions we have all spent excessive measurement time on however did not fit with anecdotal personal experience, especially against a background of 34% increase in overall admission rates which did. Either I work in a different arena, the data does not add up, or we really need to understand this stuff.
1) If there was such an impact worth giving QOF credit for, would one not expect a slight dent in the trend on increasing admissions which appears on your data to hardly twitch from a linear ascent?
2) If no dent, then how significant in overall terms is this? ( Is it like the new drug that affects morbidity documentation but has no affect on mortality maybe?!)
3) Attempting to understand the data behind the conclusions (see original appendix) appeared to find trends of <1% and through logarithmic scaling magnified the effect - clearly all statistically sound, but blinded by maths, did not explain it to the jobbing punter who was hoping to understand!
4) If GPs spend more time on QOF related areas, they will spend less time on non-QOF related areas - so maybe an alternative conclusion is that it had NO overall effect.
5) If some believe your answer that incentives have impact on admissions, then enough incentives will allow us to close hospitals altogether and save even more...extrapolation funny old thing really!
Competing interests: I do not believe QOF is in the patient's best interest
Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions
Harrison et al have demonstrated an interesting association between introduction of the pay for performance scheme, the Quality and Outcomes Framework (QOF), and emergency hospital admission rates for targeted conditions1.
Their study compares admission rates for incentivised and non-incentivised ambulatory care sensitive conditions. We suggest cautious interpretation of this comparison as the two categories may be fundamentally different given the process of QOF indicator design2. First, clinical interventions generally require an evidence base (albeit, of variable levels) to support their inclusion as a QOF incentivised indicator. Second, the proposed indictor undergoes piloting in a small number of general practices for six months - including assessment of whether it caused a change in behaviour significant enough to be measured and outweigh the economic cost of incentivising. The clinicians in the pilot practices are also surveyed on how acceptable and achievable they think the indicators are.
Thus clinical interventions generally become QOF indicators if: they are relatively simple, of proved effectiveness and measurable; incentives have demonstrated potential for creating significant changes in clinical practice, and clinicians think they could reasonably achieve the target. In this study all of the incentivised targets will include interventions fitting these criteria, while non-incentivised conditions may not. A visual inspection of Figure 1 suggests that the non-incentivised ambulatory care sensitive conditions share more in common with the non-ambulatory care sensitive conditions than with the incentivised conditions, especially during the pre-QOF years.
One interpretation of the present study, suggested earlier by some of the co-authors is that focusing on high quality care upstream for the majority of patients may represent a cost-effective strategy for reducing unscheduled admissions3. An alternative interpretation of the present findings needs to include the possibility that they are, at least in part, the result of reverse causality with QOF incentives going to those conditions most likely to be associated with effective GP intervention and therefore reduced unscheduled admission rates.
1. Harrison MJ, Dusheiko M, Sutton M, et al. Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study. Bmj 2014;349:g6423.
2. Sutcliffe D, Lester H, Hutton J, et al. NICE and the Quality and Outcomes Framework (QOF) 2009-2011. Quality in primary care 2012;20(1):47-55.
3. Dusheiko M, Doran T, Gravelle H, et al. Does higher quality of diabetes management in family practice reduce unplanned hospital admissions? Health services research 2011;46(1 Pt 1):27-46.
Competing interests: No competing interests