Quality And Outcomes Framework Achievement Research Articles

Patient consultation rate and clinical and NHS outcomes: a cross-sectional analysis of English primary care data from 2.7 million patients in 238 practices

BackgroundPrimary care workload is high and increasing in the United Kingdom. We sought to examine the association between rates of primary care consultation and outcomes in England.MethodsCross sectional observational study of routine electronic health care records in 283 practices from the Clinical Practice Research Datalink from April 2013 to March 2014. Outcomes included mortality rate, hospital admission rate, Quality and Outcomes Framework (QOF) performance and patient satisfaction. Relationships between consultation rates (with a general practitioner (GP) or nurse) and outcomes were investigated using negative binomial and ordinal logistic regression models.ResultsRates of GP and nurse consultation (per patient person-year) were not associated with mortality or hospital admission rates: mortality incidence rate ratio (IRR) per unit change in GP/ nurse consultation rate = 1.01, 95% CI [0.98 to 1.04]/ 0.97, 95% CI [0.93 to 1.02]; hospital admission IRR per unit change in GP/ nurse consultation rate = 1.02, 95% CI [0.99 to 1.04]/ 0.98, 95% CI [0.94 to 1.032]. Higher rates of nurse but not GP consultation were associated with higher QOF achievement: OR = 1.91, 95% CI [1.39 to 2.62] per unit change in nurse consultation rate vs. OR = 1.04, 95% CI [0.87 to 1.24] per unit change in GP consultation rate. The association between the rates of GP/ nurse consultations and patient satisfaction was mixed.ConclusionThere are few associations between primary care consultation rates and outcomes. Previously identified demographic and staffing factors, rather than practice workload, appear to have the strongest relationships with mortality, admissions, performance and satisfaction. Studies with more detailed patient-level data would be required to explore these findings further.

Patient-level and practice-level factors associated with consultation duration: a cross-sectional analysis of over one million consultations in English primary care

ObjectivesConsultation duration has previously been shown to be associated with patient, practitioner and practice characteristics. However, previous studies were conducted outside the UK, considered only small numbers of general practitioner...

92 Primary care prescriptions for statins in england 1998–2015

IntroductionStatins are widely prescribed for the prevention of cardiovascular events. A change in 2014 of the National Institute for Health and Care Excellence (NICE) guidelines for the primary prevention of...

Association between primary care funding and secondary care usage: a cross-sectional health economic analysis

BackgroundGreater investment in primary care yields better population health outcomes. However, in the past decade general practice (GP) funding has reduced, while general practitioner workload has risen and secondary care funding has increased. To date, the impact of broader aspects of GP funding has not been examined. Using newly released GP financial data, we aimed to explore the association between greater investment in primary care and secondary care usage and costs applied at a national level in England. MethodsWe constructed linear regression models to explore the association between practice funding for essential services and quality and outcomes framework (QOF) achievement, secondary care usage (accident and emergency [A&E] attendance, emergency admission, and outpatient attendance rates per 1000 registered patients), and patient satisfaction, adjusted for practice and demographic variables. We then conducted financial modelling to predict the impact of a hypothetical 10% funding increase on secondary care costs, for which we used standard cost estimates. FindingsWe analysed 7767 practices in England. Mean funding per patient was £79·81 (95% CI 67·01–100·67). Funding was lower in General Medical Services (GMS) practices, which hold national contracts, than in Personal Medical Services practices, which have local contracts (£76·00 [66·52–89·20] vs 84·43 [66·68–107·09]). In GMS practices, greater funding was significantly associated with lower emergency admissions (regression coefficient β=–0·22), lower A&E attendances (−1·04), and higher patient satisfaction (overall satisfaction 0·4). We found no significant association with outpatient attendance or QOF performance. In our financial model, a 10% increase in primary care funding would create a return on investment of 78% in GMS practices overall and up to 110% in GMS practices receiving funding above the national capitation formula. InterpretationGMS practices with higher levels of funding had lower secondary care usage and higher patient satisfaction. The lack of association between funding and QOF achievement might be attributable to the different funding stream and incentives for QOF. Our findings support the case for greater investment in primary care where the value of investment is over and above the national capitation formula. FundingNational Institute for Health Research.

Association between general practice funding and practice achievement: a cross-sectional study

BackgroundIn the past decade, general practice funding has decreased from 11% to 8% of total National Health Service (NHS) spending, while workload has increased by 19%. To date, the impact of broader aspects of practice funding on performance has not been examined. Using newly released primary care financial data, we aimed to explore the association between NHS payments made to general practices in England that are not part of the quality and outcomes framework (QOF) and primary care performance. MethodsPractice funding data were extracted from the National Health Applications and Infrastructure Services. We confined our analysis to practices with the nationally determined contract, General Medical Services (n=4298); data were not available for the locally determined contracts offered to Personal Medical Services practices. We constructed regression models to explore the association between practice funding and QOF outcomes, secondary care usage (outpatient, accident and emergency [A&E], and inpatient rates per 1000 registered patients), and patient satisfaction, adjusted for practice and demographic variables. We then conducted financial modelling to predict the impact of a hypothetical 10% funding increase on secondary care costs, for which we used standard cost estimates. FindingsThe mean funding was £75·71 per patient (95% CI 66·86–87·58). Higher funding was significantly associated with lower emergency admissions (regression coefficient β=0·24), lower A&E attendances (−1·04), and higher patient satisfaction (overall satisfaction 0·002). We found no significant association with outpatient attendance or QOF performance. In our financial model, a 10% increase in primary care funding would cost an additional £7571 per 1000 registered patients, which would be partly offset by a £5323 reduction in emergency admissions and £1031 reduction in A&E attendances. InterpretationGeneral Medical Services practices with higher levels of funding had lower secondary care usage and higher patient satisfaction. The lack of association between funding and QOF achievement might be attributable to the different funding stream and incentives for QOF. Our findings support the case for greater investment in primary care which would largely be offset by reduced secondary care costs and associated with higher levels of patient satisfaction. FundingVSL is funded by a National Institute for Health Research academic clinical fellowship.

Are primary care factors associated with hospital episodes for adverse drug reactions? A national observational study

ObjectiveIdentification of primary care factors associated with hospital admissions for adverse drug reactions (ADRs).Design and settingCross-sectional analysis of 2010–2012 data from all National Health Service hospitals and 7664 of 8358...

Do higher primary care practice performance scores predict lower rates of emergency admissions for persons with serious mental illness? An analysis of secondary panel data

BackgroundSerious mental illness (SMI) is a set of chronic enduring conditions including schizophrenia and bipolar disorder. SMIs are associated with poor outcomes, high costs and high levels of disease burden. Primary care plays a central role in the care of people with a SMI in the English NHS. Good-quality primary care has the potential to reduce emergency hospital admissions, but also to increase elective admissions if physical health problems are identified by regular health screening of people with SMIs. Better-quality primary care may reduce length of stay (LOS) by enabling quicker discharge, and it may also reduce NHS expenditure.ObjectivesWe tested whether or not better-quality primary care, as assessed by the SMI quality indicators measured routinely in the Quality and Outcomes Framework (QOF) in English general practice, is associated with lower rates of emergency hospital admissions for people with SMIs, for both mental and physical conditions and with higher rates of elective admissions for physical conditions in people with a SMI. We also tested the impact of SMI QOF indicators on LOS and costs.DataWe linked administrative data from around 8500 general practitioner (GP) practices and from Hospital Episode Statistics for the study period 2006/7 to 2010/11. We identified SMI admissions by a mainInternational Classification of Diseases, 10th revision (ICD-10) diagnosis of F20–F31. We included information on GP practice and patient population characteristics, area deprivation and other potential confounders such as access to care. Analyses were carried out at a GP practice level for admissions, but at a patient level for LOS and cost analyses.MethodsWe ran mixed-effects count data and linear models taking account of the nested structure of the data. All models included year indicators for temporal trends.ResultsContrary to expectation, we found a positive association between QOF achievement and admissions, for emergency admissions for both mental and physical health. An additional 10% in QOF achievement was associated with an increase in the practice emergency SMI admission rate of approximately 1.9%. There was no significant association of QOF achievement with either LOS or cost. All results were robust to sensitivity analyses.ConclusionsPossible explanations for our findings are (1) higher quality of primary care, as measured by QOF may not effectively prevent the need for secondary care; (2) patients may receive their QOF checks post discharge, rather than prior to admission; (3) people with more severe SMIs, at a greater risk of admission, may select into practices that are better organised to provide their care and which have better QOF performance; (4) better-quality primary care may be picking up unmet need for secondary care; and (5) QOF measures may not accurately reflect quality of primary care. Patient-level data on quality of care in general practice is required to determine the reasons for the positive association of QOF quality and admissions. Future research should also aim to identify the non-QOF measures of primary care quality that may reduce unplanned admissions more effectively and could potentially be incentivised.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Does the quality and outcomes framework reduce psychiatric admissions in people with serious mental illness? A regression analysis

BackgroundThe Quality and Outcomes Framework (QOF) incentivises general practices in England to provide proactive care for people with serious mental illness (SMI) including schizophrenia, bipolar disorder and other psychoses. Better...

The influence of primary care quality on hospital admissions for people with dementia in England: a regression analysis.

ObjectivesTo test the impact of a UK pay-for-performance indicator, the Quality and Outcomes Framework (QOF) dementia review, on three types of hospital admission for people with dementia: emergency admissions where dementia was the primary diagnosis; emergency admissions for ambulatory care sensitive conditions (ACSCs); and elective admissions for cataract, hip replacement, hernia, prostate disease, or hearing loss.MethodsCount data regression analyses of hospital admissions from 8,304 English general practices from 2006/7 to 2010/11. We identified relevant admissions from national Hospital Episode Statistics and aggregated them to practice level. We merged these with practice-level data on the QOF dementia review. In the base case, the exposure measure was the reported QOF register. As dementia is commonly under-diagnosed, we tested a predicted practice register based on consensus estimates. We adjusted for practice characteristics including measures of deprivation and uptake of a social benefit to purchase care services (Attendance Allowance).ResultsIn the base case analysis, higher QOF achievement had no significant effect on any type of hospital admission. However, when the predicted register was used to account for under-diagnosis, a one-percentage point improvement in QOF achievement was associated with a small reduction in emergency admissions for both dementia (-0.1%; P=0.011) and ACSCs (-0.1%; P=0.001). In areas of greater deprivation, uptake of Attendance Allowance was consistently associated with significantly lower emergency admissions. In all analyses, practices with a higher proportion of nursing home patients had significantly lower admission rates for elective and emergency care.ConclusionIn one of three analyses at practice level, the QOF review for dementia was associated with a small but significant reduction in unplanned hospital admissions. Given the rising prevalence of dementia, increasing pressures on acute hospital beds and poor outcomes associated with hospital stays for this patient group, this small change may be clinically and economically relevant.

Chronic disease detection and access: does access improve detection, or does detection make access more difficult?

The recorded detection of chronic disease by practices is generally lower than the prevalence predicted by population surveys. To determine whether patient-reported access to general practice predicts the recorded detection rates of chronic diseases in that setting. A cross-sectional study involving 146 general practices in Leicestershire and Rutland, England. The numbers of patients recorded as having chronic disease (coronary heart disease, chronic obstructive pulmonary disease, hypertension, diabetes) were obtained from Quality and Outcomes Framework (QOF) practice disease registers for 2008-2009. Characteristics of practice populations (deprivation, age, sex, ethnicity, proportion reporting poor health, practice turnover, list size) and practice performance (achievement of QOF disease indicators, patient experience of being able to consult a doctor within 2 working days and book an appointment >2 days in advance) were included in regression models. Patient characteristics (deprivation, age, poor health) and practice characteristics (list size, turnover, QOF achievement) were associated with recorded detection of more than one of the chronic diseases. Practices in which patients were more likely to report being able to book appointments had reduced recording rates of chronic disease. Being able to consult a doctor within 2 days was not associated with levels of recorded chronic disease. Practices with high levels of deprivation and older patients have increased rates of recorded chronic disease. As the number of patients recorded with chronic disease increased, the capacity of practices to meet patients' requests for appointments in advance declined. The capacity of some practices to detect and manage chronic disease may need improving.

Does general practice reduce health inequalities? Analysis of quality and outcomes framework data

The government set a series of targets to reduce health inequalities in England by 2010. Primary care has an important role in reducing health inequalities. The aim of the study was to assess the impact of general practice on reducing area-based health inequalities. Analysis of differences in achievement on clinical indicators between practices in Spearhead and non-Spearhead Primary Care Trusts (PCTs) using data from the Quality and Outcomes Framework (QOF) for 2004/05 and 2005/06, practice characteristics and Spearhead status of PCTs. The study used data on 8339 primary care practices in England. Unweighted mean reported achievement on subset of 26 clinical indicators was calculated. The study analysed differences in achievement by Spearhead status and deprivation in both years and the change between years. Multiple regression analysis of relationship between Spearhead status, income deprivation, reported achievement and other factors also were carried out. Practices in Spearhead PCTs performed worse than practices in non-Spearhead PCTs in both years but showed greater improvement. Among the most deprived practices, there were no differences in QOF achievement between Spearhead and non-Spearhead PCTs. Previous year's achievement was the strongest predictor of performance. The narrowing in performance between practices in Spearhead and non-Spearhead PCTs may have indirectly contributed to a reduction in area-based health inequalities but the differences are small. The lack of difference between the most deprived practices in Spearhead and non-Spearhead PCTs suggest that area-based initiatives to tackle inequalities have not yet had an observable impact on deprived practices. Unobserved factors explain most of the variation in achievement.

Statin prescribing in Northern Ireland and England pre and post introduction of the quality and outcomes framework

The objective of this research was to examine differences in patterns of statin prescribing between Northern Ireland and England both before and after the introduction of the Quality and Outcomes Framework (QOF). Primary care practices in Northern Ireland and England. Method Northern Ireland practices were matched with practices in England, statin prescribing data and QOF achievement scores (for the first year post-QOF) were obtained. Crude prescribing data from matched practices were manipulated to provide a data set of Defined Daily Doses (DDDs)/1,000 patients and cost/DDD/1,000 patients for each statin drug entity covering 1 year before and after the introduction of QOF. QOF achievements were converted into percentage scores for matched practices. Cost per defined daily dose (DDD) per 1,000 patients. Significantly less statins (DDD/1,000 patients) were dispensed in Northern Ireland compared with the matched region in England both before and after the introduction of QOF (P < 0.001). However, significantly more statins were dispensed in both regions after the introduction of QOF. As a result of the introduction of QOF, the cost/DDD/1,000 patients rose by pound13.17 in NI, but fell by pound3.76 in the matched region in England. Strategies should be considered to educate prescribers on cost-effectiveness by increasing their awareness of the negative budgetary impact resulting from early adoption of new and expensive statins and by encouraging generic prescribing.

Impact of the 2004 GMS contract on practice nurses:

The new GMS contract has led to practice nurses playing an important role in the delivery of the Quality and Outcomes Framework (QOF). This study investigated how practice nurses perceive the changes in their work since the contract's inception. A qualitative approach, sampling practice nurses from practices in areas of high and low deprivation, with a range of QOF scores. Glasgow, UK. Individual interviews were conducted, audiotaped, transcribed, and analysed using a thematic approach. Three themes emerged: roles and incentives, workload, and patient care. Practice nurses were positive about the development of their professional role since the introduction of the new GMS contract but had mixed views about whether their status had changed. Views on incentives (largely related to financial rewards) also varied, but most felt under-rewarded, irrespective of practice QOF achievement. All reported a substantial increase in workload, related to incentivised QOF domains with greater 'box ticking' and data entry, and less time to spend with patients. Although the structure created by the new contract was generally welcomed, many were unconvinced that it improved patient care and felt other important areas of care were neglected. Concern was also expressed about a negative effect of the QOF on holistic care, including ethical concerns and detrimental effects on the patient-nurse relationship, which were regarded as a core value. The new GMS contract has given practice nurses increased responsibility. However, discontent about how financial gains are distributed and negative impacts on core values may lead to detrimental long-term effects on motivation and morale.