The role of cost-effectiveness analysis in the development of indicators to support incentive-based behaviour in primary care in England.

Nadeem Qureshi,Stephen Weng,Nick Hex

doi:10.1177/1355819616650912

Abstract

In England, general practitioners are incentivized through a national pay-for-performance scheme to adopt evidence-based quality improvement initiatives using a portfolio of Quality and Outcomes Framework (QOF) indicators. We describe the development of the methods used to assess the cost-effectiveness of these pay-for-performance indicators and how they have contributed to the development of new indicators. Prior to analysis of new potential indicators, an economic subgroup of the National Institute for Health and Care Excellence (NICE) Indicator Advisory Committee is formed to assess evidence on the cost-effectiveness of potential indicators in terms of the health benefits gained, compared to the cost of the intervention and the cost of the incentive. The expert subgroup is convened to reach consensus on the amounts that could potentially be paid to general practices for achieving new indicators. Indicators are also piloted in selected general practices and evidence gathered about their practical implementation. The methods used to assess economic viability of new pilot indicators represent a pragmatic and effective way of providing information to inform recommendations. Current policy to reduce QOF funding could shift the focus from national (QOF) to local schemes, with economic appraisal remaining central.

Highlights

The Quality and Outcomes Framework (QOF) is a financial incentive scheme for UK general practices to improve quality of care
Research has shown that financial incentive schemes have the potential to improve the quality of primary care, though longer-term effects are still unknown.[1,2,3]
Indicator costs include unexpected consequences such as an increase in referrals resulting from more intensive monitoring. This may lead to increased health service usage costs in the short-term, as in the case of chronic kidney disease (CKD), where the introduction of estimated glomerular filtration rate as a prognostic indicator led to a 61 per cent increase in new patient referrals in a National Health Service (NHS) Trust.[13]

Summary

Introduction

The Quality and Outcomes Framework (QOF) is a financial incentive scheme for UK general practices to improve quality of care. These practices’ performance is measured against a set of quality indicators. The scheme was introduced in 2004/05 and is a component of the revised General Medical Services contract between the UK Government and general practice. Research has shown that financial incentive schemes have the potential to improve the quality of primary care, though longer-term effects are still unknown.[1,2,3] In addition, there is some evidence to suggest that these incentives have the potential to improve delivery of clinical care in underserved populations.[4, 5]

Findings

Discussion

Conclusion