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The waiting game

Local QOF targets 'failed to improve clinical care', study says

Locally extended QOF targets do not provide clinical benefits to GP patients, a study has suggested.

A team of researchers studied the effects of the ‘QOF+’ programme run in GP practices in the London borough of Hammersmith and Fulham since 2008, which saw practices offered additional payments for achieving local targets on diabetes, hyper-tension, coronary heart disease (CHD) and stroke.

Though these ‘stretch’ payments significantly boost to achievement of quality indicator targets, researchers from the Department of Primary Care and Public Health at Imperial College London found this was largely a result of increased exception reporting.

A major objective for the scheme was to ‘accelerate improvements in existing national QOF targets’ through funding these extra targets.

But the research paper, published in PLoS ONE, said: ‘The local pay for performance program led to significantly higher target achievements (hypertension: p-value <0.001, coronary heart disease: p-values <0.001, diabetes: p-values <0.061, stroke: p-values <0.003) However, the increase was driven by higher rates of exception reporting (hypertension: p-value <0.001, coronary heart disease: p-values <0.03, diabetes: p-values <0.05) in patients with all conditions except for stroke.’

It added that ‘the programme was not associated with discernible improvements in overall clinical quality’.

The paper concluded that policy makers should look closely at exception reporting, and define acceptable exception levels, when designing future ‘stretch’ QOF schemes.

It said: ‘Exception-reported patients are less likely to achieve clinical targets and the impact of their exclusion is to increase the cost to the scheme of each patient who does meet the targets.

‘Therefore, implementation of pay-for-performance programmes should be accompanied by measures to prevent higher exception reporting.’

PLoS ONE 2015; available online 26 March

Readers' comments (4)

  • you keep moving to unachievable targets (as currently set....96% for diabetes control!) the only way to achieve it is by exception reporting. Anything more than 80% is unrealistic for the vast majority of medical problems and it is totally unrealistic that any surgery with more than 10 patients per disease group can achieve.

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  • Vinci Ho

    Yes. One cannot keep pushing the bar moving the goal post to expect more positive outcomes .

    At each stage of development, humans ask the mighty machine if it knows how to reverse entropy(wastage in real life).

    The second law of thermodynamics states that in a natural thermodynamic process, there is an increase in the sum of the entropies of the participating systems

    In simple term , it means you cannot put energy(heat) into an 'engine' and expect all will be converted into another form(work) without substantially 'wasting' to the environment,hence, not only no free lunch but also no full 'efficiency

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  • Local QOF encourages GPs to follow local NICE ( Now I Can Experiment) guidelines.

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  • Azeem Majeed

    The local pay for performance program led to significantly higher target achievements for the management of hypertension, coronary heart disease, diabetes and stroke. However, the increase was driven by higher rates of exception reporting in patients. There were no statistically significant improvements in mean blood pressure, cholesterol or HbA1c levels. Thus, achievement of higher payment thresholds in the local pay for performance scheme was mainly due to increased exception reporting by practices. This may have been because the patients who were not exception-reported would not have benefited from more intensive treatment.

    Some policy-makers and health service managers may consider giving practices less scope to exclude patients from pay from performance targets in an attempt to improve quality of care. However, pay for performance programmes should not encourage over-treatment or inappropriate treatment; and exception reporting of suitable patients should always be allowed. Patients should also always be fully involved in decisions about their care and decide whether the incremental benefits of more intensive treatment will outweigh the potential problems (for example, from more intensive control of glucose in people with diabetes).

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