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Chasing QOF targets could lead to riskier prescribing, study finds

Practices with a high QOF achievement in certain indicators were more likely to have patients admitted to hospital with an adverse drug reaction, potentially due to targets ‘tip[ping] relatively high-risk prescribing decisions in favour of prescribing’, a recent study has found.

The researchers from Imperial College said that that higher hospital admissions for adverse drug reactions (ADRs) were ‘associated with various primary care factors, including achievement of particular QOF indicators’.

Published in the BMJ Open, the study concluded that ‘further investigation would help to demonstrate if particular subgroups are at risk in pursuit of particular QOF targets’.

Researchers also found that a greater number of GPs, higher deprivation score and a higher proportion of GPs with UK qualifications contributed to increased hospital admissions for ADRs. 

The study looked at hospital and GP practice data for 2010-2012 across England to investigate which primary care factors may influence admissions for ADRs. 

It concluded: ‘A particular issue raised by our analysis is the possibility that QOF targets may act to tip relatively high-risk prescribing decisions in favour of prescribing. This suggestion has been made previously, and previous specific concerns about blood pressure targets have led NICE to apply age-caps to hypertension treatment targets, where evidence suggests treatment benefit is limited to certain age groups.

‘Further investigation of the associations identified using individual level data, which would allow meaningful comparisons of effect size by age and ethnicity, would help to demonstrate if there are particular subgroups at risk of more harm than benefit in the pursuit of particular QOF targets.’

While the results allude to QOF targets causing prescribing issues, the researchers also suggest that the results may be reflective of high quality care and increased identification of ADRs. 

Conclusions of the study have been questioned by some.

Dr Gavin Jamie, a GP from Swindon who runs the QOF Database website, said: ‘What the paper does not tell us is if these admissions are balanced by a reduced risk of cardiovascular disease for example.

’We cannot say from this paper whether there is overprescribing – these may simply be expected side effects that we can try and minimise but are probably inevitable.’

Professor Martin Roland, who oversaw the development of the original QOF, said: ‘GPs are well aware of the risks of polypharmacy and I think this study points to the need for doctors to exercise clinical judgement when deciding what’s best for their patients’.

But critics of QOF have said that QOF targets are not always in the best interests of the patient.

Dr Harry Yoxall, medical director of Somerset LMC, which helped develop a local based scheme to replace the QOF, said: ‘The study raises a lot more questions than it answers and we need to interpret the findings cautiously but a lot of GPs feel uneasy about strenuously achieving QOF targets as they are not always in the interest of the patient.

‘This is one of the reasons as to why Somerset has moved away from QOF to form our own arrangement and there have been suggestions in the past not to pursue particular QOF targets and to instead focus on the individual needs of each patient.’

‘QOF may tip decisions in favour of prescribing’

QOF data clinical targets 2  Neil O Connor

QOF data clinical targets 2 Neil O Connor

Our research team for this paper included two practicing GPs who had input into the development of the research questions and interpretation of findings. We feel that ADRs are an important issue to consider in the context of an ageing population and increasing polypharmacy, combined with pressure on GPs to meet QOF targets, which may tip prescribing decisions in favour of prescribing.

The risks of ADRs need to be set against the benefits of treatment (i.e. lower rates of ADRs could reflect under-treatment of disease), and although this is clearly considered prior to drug licensing agreements, the relevant information will not be fully developed at this point, for some patient sub-groups in particular. For example, those from older age-groups are often excluded from trials and may be relatively susceptible to ADRs.

There may be a role for GPSIs in elderly care to support optimal prescribing for this patient group. We note that time is required to manage prescribing in complex elderly patients and would therefore support GP contracts that reflect this need. Given the need to achieve the right balance between treatment and ADRs, it might be useful for ADRs to be monitored alongside QOF targets or their replacement.

We are currently considering associations between achievement of QOF targets and occurrence of particular types of ADR, at individual patient level.

Dr Ailsa McKay is an author of the study from the department of primary care and public health at Imperial College London


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