Abstract
ObjectiveWe aimed to spatially describe hospital admissions for ambulatory care sensitive conditions (ACSC) in England at small-area geographical level and assess whether recorded practice performance under one of the world’s largest primary care pay-for-performance schemes led to reductions in these potentially avoidable hospitalisations for chronic conditions incentivised in the scheme.SettingWe obtained numbers of ACSC hospital admissions from the Hospital Episode Statistics database and information on recorded practice performance from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/2016. We fitted three sets of negative binomial models to examine ecological associations between incentivised ACSC admissions, general practice performance, deprivation, urbanity and other sociodemographic characteristics.ResultsHospital admissions for QOF incentivised ACSCs varied within and between regions, with clusters of high numbers of hospital admissions for incentivised ACSCs identified across England. Our models indicated a very small effect of the QOF on reducing admissions for incentivised ACSCs (0.993, 95% CI 0.990 to 0.995), however, other factors, such as deprivation (1.021, 95% CI 1.020 to 1.021) and urbanicity (0.875, 95% CI 0.862 to 0.887), were far more important in explaining variations in admissions for ACSCs. People in deprived areas had a higher risk of being admitted in hospital for an incentivised ACSC condition.ConclusionSpatial analysis based on routinely collected data can be used to identify areas with high rates of potentially avoidable hospital admissions, providing valuable information for targeting resources and evaluating public health interventions. Our findings suggest that the QOF had a very small effect on reducing avoidable hospitalisation for incentivised conditions. Material deprivation and urbanicity were the strongest predictors of the variation in ACSC rates for all QOF incentivised conditions across England.
Highlights
There were 268 509 ambulatory care sensitive conditions (ACSC) admissions with a primary diagnosis linked to Quality and Outcomes Framework (QOF) incentivised conditions in 2015/2016 alone while admissions for heart disease and chronic obstructive pulmonary disease (COPD) accounted for the majority of admissions for incentivised ACSCs over time
For the whole of England, we present the spatial variability of admissions for ACSCs at the lower super output area (LSOA) level in figure 2 where darker areas had higher ACSC admissions rates
We present the spatial variability of quality of primary care across all conditions, for which we had data on ACSC admissions, at the LSOA level
Summary
Worldwide, unplanned hospital admissions are undesirable for patients, disruptive of Strengths and limitations of this study►► This study uses data from a rich dataset to investigate the association between recorded general practice performance and hospital admissions for Quality and Outcomes Framework (QOF) incentivised ambulatory care sensitive conditions (ACSCs) for the whole of England.►► Previous evidence suggests moderate effects of the QOF on admissions for incentivised ACSCs and our work shows that area characteristics account for more variation in admissions for incentivised conditions than QOF recorded performance.►► There is substantial spatial variation in admissions for incentivised ACSCs at a very low geographical level (ie, lower super output area).►► Hospital admissions for ACSCs are a commonly used measure of system performance, this is sometimes considered problematic and emphasis should be given to databases that have a greater focus on processes of care.►► Even though we cannot rule out the possibility of ecological fallacy our findings are important from a policy perspective due to the high number of potentially avoidable admissions and the associated high cost to the National Health Service.elective care and costly. As such, design and implementation of interventions targeting emergency admissions that are potentially avoidable has become a key priority for the efficiency and effectiveness of health systems. ►► This study uses data from a rich dataset to investigate the association between recorded general practice performance and hospital admissions for Quality and Outcomes Framework (QOF) incentivised ambulatory care sensitive conditions (ACSCs) for the whole of England. The scheme is essentially voluntary, but because the incentives substantially increase practice income around 96% of practices in England participated in the scheme in 2015/2016.8 Evidence from the early years of the scheme suggests that the QOF reduced variations between practices in the delivery of incentivised processes of care, and contributed to progress towards better use of electronic records and nurse-led multidisciplinary care of long-term conditions but had no overall effect on mortality. The UK’s Quality and Outcomes Framework (QOF) was launched as part of a new national contract for general practitioners and in England continues to provide financial rewards to practices for meeting a range of performance indicators, primarily relating to the management of chronic conditions. The scheme is essentially voluntary, but because the incentives substantially increase practice income around 96% of practices in England participated in the scheme in 2015/2016.8 Evidence from the early years of the scheme suggests that the QOF reduced variations between practices in the delivery of incentivised processes of care, and contributed to progress towards better use of electronic records and nurse-led multidisciplinary care of long-term conditions but had no overall effect on mortality.
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