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QOF experts advise some thresholds ‘should be raised to 100%’

By Lilian Anekwe

The QOF has had a measurable impact on mortality, but it should be revamped to more effectively incentivise GPs to improve the nation's health, argue an influential group of primary care researchers.

In a major analysis due to be published in the British Journal of General Practice next month, UK researchers – including a member of the NICE independent QOF indicator advisory committee – argue measures of population health gain should be used to judge future clinical indicators and that in some cases QOF payment thresholds should be set at 100%.

Their analysis estimates that the 2004 contract has had a significant impact on mortality, and could have saved an additional 10,000 lives per year.

But after the target thresholds were adjusted in 2006, the reduction in population mortality was ‘effectively zero', prompting the researchers to call for population health gain to be used as an outcome measure with which to set future indicators and thresholds.

In the 2004 contract, researchers estimated that between seven and 16 additional lives were saved per 100,000 of the population per year, when general practice performance on clinical indicators improved from the pre-contract baseline to the level of the targets set for full incentive payments. This represents a saving of between 4,200 and 9,600 additional lives in England.

But after 2006, additional mortality reduction fell to zero for the typical general practice, because baseline performance had already exceeded the targets set for full incentive payment. This decrease in potential lives saved between 2004 and 2006 is due to substantial improvement in baseline performance between 2003 and 2005.

However, researchers estimated that if performance in the 2006 contract rose to 100% of all eligible – not exception reported – patients were treated, then this would potentially save 30 lives per 100,000 of the population. This equates to a possible saving of approximately 18,000 additional lives per year in England.

Lead researcher Dr Robert Fleetcroft, a lecturer in general practice at the University of East Anglia, concluded in the September issue of the British Journal of General Practice that would be sensible to consider using measures of health gain for selecting indicators ‘as the framework evolves'.

‘It may not be cost-effective to leave the same indicators in a pay-for-performance scheme from year to year as performance improves.

‘Information on baseline performance and health gain could be used to inform decisions about retiring less-effective indicators, and weighting the size of financial incentives in order to maximise potential health gain for the population.

‘Targets for full payment may need to be revised upwards over time as performance improves — and arguably could simply be set at 100% as long as appropriate procedures for exception reporting are in place.'

British Journal of General Practice 2010; 60: 649-654.

Clinical indicators and domains with greatest reduction in mortality

Clinical indicators with the greatest potential for mortality (reduction if all eligible patients were to receive) treatment:
- Primary prevention for hypertension (12 lives in 2006)
- Influenza immunisation (6 lives in 2006)

Domains with the largest potential reduction in mortality: -- Heart disease,
- Diabetes and
- Primary prevention for hypertension, which accounted for 4/5 of the total reductions in 2006.

British Journal of General Practice 2010; 60: 649-654.

The QOF has led to variable population health gains