Quality And Outcomes Framework Research Articles

Quality Outcome Framework: what's your role?

Quality Outcome Framework: what's your role?

Assessing the uptake of incentivised physical health checks for people with serious mental illness

Background: People with serious mental illness (SMI) are more likely to suffer from physical illnesses. The onset of many of these illnesses can be prevented if detected early. Physical health screening for people with SMI is incentivised in primary care in England through the Quality and Outcomes Framework (QOF). General Practitioners are paid to conduct annual physical health checks (PHCs) on their SMI patients, including checks on body mass index (BMI), cholesterol, and alcohol consumption. Aim: To assess the impact of removing and reintroducing QOF financial incentives on uptake of three PHCs (BMI, cholesterol, and alcohol consumption) for patients with SMI. Design and Setting: Cohort study using UK primary care data from the Clinical Practice Research Datalink between April 2011 and March 2020. Method: We employed a difference-in-difference analysis to compare differences in the uptake before and after the intervention accounting for relevant observed and unobserved confounders. Results: We found an immediate change in uptake after PHCs were removed from, and after they were added back to the QOF list. For BMI, cholesterol, and alcohol checks the overall impact of removal was a reduction in uptake of 14.3, 6.8, and 11.9 percentage points, respectively. The reintroduction of BMI screening in the QOF increased the uptake by 10.2 percentage points. Conclusion: Our analysis supports the hypothesis that QOF incentives lead to better uptake of PHCs.

Targeting malnutrition in patients with COPD in the community.

The number of individuals living with chronic obstructive pulmonary disease (COPD) is increasing, but nutritional care can be inconsistent, especially in those with stable COPD. Historically, poor appetite and weight loss have been considered the norm during the progression of COPD into the later stage. However, it is imperative that nutritional assessment, support and management is undertaken from diagnosis, because malnutrition can lead to exacerbations of COPD and increased hospitalisation. Poor nutrition in individuals with COPD has been shown to predict an increase in mortality and with the care of patients taking place principally in the community, the nutritional aspects of care should be assessed, monitored and managed, in accordance with the latest guidance. The lack of a nutritional Quality Outcome Framework indicator for COPD can leave nutrition overlooked, but evidence shows that screening, assessment and planning can have an overall positive impact.

Targeting patients suffering with long term conditions who smoke on their General Practitioner’s Quality Outcomes Framework (QoF) list, in England

Targeting patients suffering with long term conditions who smoke on their General Practitioner’s Quality Outcomes Framework (QoF) list, in England

Urine ACR uptake in patients with a diagnosis of type 1 and 2 diabetes mellitus in a primary care setting: A cross sectional study

Background and objectivesA recent change in the diabetes Quality and Outcomes Framework (QOF) retired the mandatory testing of urinary ACR. We designed a study demonstrates the impact of this change in a primary healthcare setting. This is relevant as a significant proportion of the NHS budget is spent on managing microvascular and macrovascular complications that result from type 1 and 2 Diabetes mellitus. MethodsOur cross-sectional study collected testing data for 482 patients in a primary care setting. Based on the results seen from the first set of data collection, an intervention was offered to the clinicians by way of clinical presentation that emphasised and refreshed the knowledge of the latest NICE guidelines on urine ACR collection. Subsequently, a second set of data collection was conducted to assess the success, if any, of changes implemented based on the intervention made ResultsOur study demonstrates the drastic decrease in uptake of ACR testing in the primary care setting that took place following the change in the diabetes QOF. ConclusionThe study highlights the need for the reintroduction of such a QOF measure to enable regular monitoring of early signs of nephropathy, thereby allow the timely commencement treatment as deemed appropriate. Furthermore, detecting the development of such complications in diabetic patients, in a timely manner, has the potential to reduce the financial footprint associated with treating the complications resulting from this condition.

Identifying potential biases in code sequences in primary care electronic healthcare records: a retrospective cohort study of the determinants of code frequency

ObjectivesTo determine whether the frequency of diagnostic codes for long-term conditions (LTCs) in primary care electronic healthcare records (EHRs) is associated with (1) disease coding incentives, (2) General Practice (GP),...

The relationship between Quality and Outcomes Framework scores and socioeconomic deprivation: a longitudinal study.

The Quality Outcomes Framework (QOF) is a pay incentive scheme in England designed to improve and standardise general practice. QOF attainment has been used as a proxy for primary care quality in previous research. To investigate whether there is a relationship between socioeconomic deprivation and QOF attainment in primary care in England. Retrospective longitudinal study of primary care providers in England. QOF scores were obtained for individual general practices in England from between 2007-2019 and linked to practice-level Indices of Multiple Deprivation (IMD) scores derived from census data. Beta regression analyses were used to analyse the relationship with either percentage of total QOF attainment or of domain-specific attainment with multivariate analyses, adjusting for additional practice-level demographics. QOF attainment in the most affluent quintile was used as the reference group. General practices in less deprived areas have consistently outperformed those in more deprived areas in terms of QOF achievement. Initially, the gap between least and most deprived practices decreased, however since 2015 there has been relatively little change in comparative performance. The magnitude of inequality was reduced after adjusting for demographic factors. Of the independent variables analysed, the proportion of patients aged >65 years ('over 65s') had the strongest relationship with QOF attainment. There remains an inequality in primary care quality by socioeconomic deprivation in England, even after accounting for demographic differences.

Using the Primary care Academic CollaboraTive to explore the characteristics and healthcare use of older housebound patients in England: protocol for a retrospective observational study and clinician survey (the CHiP study).

Older housebound people are an under-researched group for whom achieving good primary health care can be resource intensive. To describe the characteristics and healthcare use of older (≥65 years) housebound people; explore clinician views on delivery of care to housebound people; and assess the feasibility of using a new network of healthcare professionals to deliver high quality research. Retrospective observational study of electronic GP records and clinician survey in England. Clinical members of a new UK research network called the Primary care Academic CollaboraTive (PACT) will collect the data. For part A, around 20 GP practices will be recruited and clinicians will identify 20 housebound and 20 non-housebound people, matched by age and gender (around 400 total in each group). Anonymised data will be collected on characteristics (age, gender, ethnicity, deprivation decile), long-term conditions, prescribed medicines, quality of healthcare (via Quality Outcomes Framework targets), and continuity of care. Reports with benchmarked practice-level data will be provided to practices to identify areas for quality improvement and to enhance engagement. For part B, 2-4 clinicians will be recruited from around 50 practices in England (around 150 clinicians) to complete a survey about delivery of healthcare for housebound people. For part C, data will be collected to assess the feasibility of using the PACT network to deliver primary care research. Older housebound people are a neglected group both in terms of research and clinical care. Understanding the characteristics and use of primary healthcare of housebound people will help identify how to improve their care.

Prevalence of Chronic Obstructive Pulmonary Disease in England from 2000 to 2019.

There is considerable variation in reported chronic obstructive pulmonary disease (COPD) prevalence internationally, partly due to differing definitions in use. Accurate estimates of disease prevalence are important for allocation of health-care resources, yet UK estimates of COPD prevalence have not been updated for a decade. We calculated yearly COPD prevalence in England between 2000 and 2019 using different definitions of COPD. We used routinely collected primary care electronic healthcare record (EHR) data from the Clinical Practice Research Datalink (CPRD) Aurum database linked with secondary care data from the Hospital Episode Statistics (HES) Admitted Patient Care (APC) database. Mid-year point prevalence was calculated yearly from 2000 to 2019 in English adults aged ≥40 years using 5 definitions: (i) validated COPD, (ii) Quality and Outcomes Framework (QOF) COPD, (iii) COPD symptoms, inhaler prescription, and no asthma diagnosis, (iv) hospitalisation with COPD as any diagnosis, (v) hospitalisation with COPD as primary or secondary diagnosis. Prevalence was further stratified by gender, age group, and region. A total of 12,745,793 people were included over the 20-year period. Annual cohort sizes ranged from 4,373,538 in 2000 to 6,159,496 in 2019. Estimates of COPD prevalence increased every year from 2000 and the difference in estimated prevalence between the validated and QOF definitions has grown over time. In 2019, a COPD prevalence of 4.9% was found using validated events in either primary or secondary care (definition 1 or definition 5). Additionally, including potentially undiagnosed cases (definition 3) in the COPD definition produced an increased prevalence of 6.7%. Common definitions of COPD (eg, QOF codes), may underestimate the true prevalence. The extent of this underestimate has increased over time and could lead to under-allocation of resources where need is estimated based on these definitions. Standardisation of COPD coding in routine EHRs and metrics such as spirometry is key to accurate disease monitoring.

Targeting patients suffering with Long Term Conditions who smoke on their General Practitioner’s Quality Outcomes Framework (QoF) list, in England

Targeting patients suffering with Long Term Conditions who smoke on their General Practitioner’s Quality Outcomes Framework (QoF) list, in England

Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis

ObjectiveTo determine whether the withdrawal of the Quality and Outcomes Framework (QOF) scheme in primary care in Scotland in 2016 had an impact on selected recorded quality of care, compared...

Consequences of the closure of general practices: a retrospective cross-sectional study.

Two general practices close every week in the UK. Given the pressure on UK general practices, such closures are likely to persist. Yet little is known about the consequences. Closure refers to when a practice ceases to exist, merges, or is taken over. To explore whether practice funding, list size, workforce composition, and quality change in surviving practices when surrounding general practices close. A cross-sectional study of English general practices was undertaken, using data from 2016-2020. The exposure to closure for all practices existing on 31 March 2020 was estimated. This is the estimation proportion of a practice's patient list that had been through a closure in the preceding 3 years, between 1 April 2016 and 3 March 2019. The interaction between the exposure to closure estimate and the outcome variables (list size, funding, workforce, and quality) was analysed through multiple linear regression, while controlling for confounders (age profile, deprivation, ethnic group, and rurality). A total of 694 (8.41%) practices closed. A 10% increase in exposure to closure resulted in 1925.6 (95% confidence interval [CI] = 1675.8 to 2175.4) more patients in the practice with £2.37 (95% CI = £4.22 to £0.51) less funding per patient. While numbers of all staff types increased, there were 86.9 (95% CI = 50.5 to 123.3), 4.3%, more patients per GP. Increases for other staff types were proportionate to increases in patients. Patient satisfaction with services declined across all domains. No significant difference in Quality and Outcomes Framework (QOF) scores was identified. Higher exposure to closure led to larger practice sizes in remaining practices. Closure of practices changes workforce composition and reduces patient satisfaction with services.

Prevalence of co-morbidity and history of recent infection in patients with neuromuscular disease: A cross-sectional analysis of United Kingdom primary care data.

People with neuromuscular disease (NMD) experience a broader range of chronic diseases and health symptoms compared to the general population. However, no comprehensive analysis has directly quantified this to our knowledge. We used a large UK primary care database (Clinical Practice Research Datalink) to compare the prevalence of chronic diseases and other health conditions, including recent infections between 23,876 patients with NMD ever recorded by 2019 compared to 95,295 age-sex-practice matched patients without NMD. Modified Poisson regression estimated Prevalence Ratios (PR) to summarise the presence of the disease/condition ever (or for infections in 2018) in NMD patients versus non-NMD patients. Patients with NMD had significantly higher rates for 16 of the 18 conditions routinely recorded in the primary care Quality and Outcomes Framework (QOF). Approximately 1-in-10 adults with NMD had ≥4 conditions recorded (PR = 1.39, 95%CI 1.33-1.45). Disparities were more pronounced at younger ages (18-49). For other (non-QOF) health conditions, significantly higher recorded levels were observed for rarer events (pulmonary embolism PR = 1.96 95%CI 1.76-2.18, hip fractures PR = 1.65 95%CI 1.47-1.85) as well as for more common primary care conditions (constipation PR = 1.52 95%CI 1.46-1.57, incontinence PR = 1.52 95%CI 1.44-1.60). The greatest co-morbidity burden was in patients with a myotonic disorder. Approximately 1-in-6 (17.1%) NMD patients had an infection recorded in the preceding year, with the risk of being hospitalised with an infection nearly double (PR = 1.92, 95%CI 1.79-2.07) compared to non-NMD patients. The burden of chronic co-morbidity among patients with NMD is extremely high compared to the general population, and they are also more likely to present in primary and secondary care for acute events such as infections.

PS-P02-3: DIETARY RISK FACTORS FOR HYPERTENSION- INSIGHTS FROM THE TESCO 1.0 DATASET

Background: Tesco published an open-source dataset containing area-aggregated product purchase information from 420m transactions across 16m individual Clubcard users in the Greater London area, at a borough level. This dataset is presented as a typical product purchase for each borough, divided into 220 individual datapoints. Purpose: We wanted to explore dietary correlates with the prevalence of hypertension, utilising the London Borough wide Quality and Outcomes Framework (QOF) for GP reported hypertension diagnoses. Methods: The Tesco 1.0 dataset (2015) was accessed on 1/11/21 and all data downloaded. Hypertension data was accessed from the QOF reporting database (gpcontract.co.uk) for the last year available presented by Borough (2017). HYP001: the number of established hypertension patients as a total of registered patients, and HYP006: the % of hypertensive patients with a reading < 150/90 mmHg were selected, representing the prevalence and control of hypertension respectively. To explore for relevant associated factors, the average deprivation index (IMD) for each borough was accessed from Public Health England, and demographic data accessed from the Greater London Authority database. Univariable correlation using Spearmans Rho was calculated in using scipy in Python (3.0) and significance value of < = 0.01. Results: Highly significant risk factors for hypertension were the consumption of sugar, carbohydrate and sweets. Diabetes mellitus and obesity prevalence were also highly correlated with hypertension. Salt consumption was not a significant risk factor. Highly significant protective factors included consumption of eggs, fish, fruit and vegetables. Conclusions: The Big Data approach of utilising supermarket data allows a unique insight into dietary habits at a population level. We have demonstrated here an unexpected finding, the consumption of sugar and carbohydrate are highly significant risk factors for hypertension prevalence, while salt consumption is not. While not the first time the sugar versus salt question has been asked, this is the first time it has been answered in this manner.

Pay-for-performance for primary health care in Brazil: A comparison with England's Quality Outcomes Framework and lessons for the future

Pay-for-performance (P4P) has been widely applied in OECD countries to improve the quality of both primary and secondary care, and is increasingly being implemented in low- and middle-income countries. In 2011, Brazil introduced one of the largest P4P schemes in the world, the National Programme for Improving Primary Care Access and Quality (PMAQ). We critically assess the design of PMAQ, drawing on a comparison with England's quality and outcome framework which, like PMAQ, was implemented at scale relatively rapidly within a nationalised health system. A key feature of PMAQ was that payment was based on the performance of primary care teams but rewards were given to municipalities, who had autonomy in how the funds could be used. This meant the incentives felt by family health teams were contingent on municipality decisions on whether to pass the funds on as bonuses and the basis upon which they allocated the funds between and within teams. Compared with England's P4P scheme, performance measurement under PMAQ focused more on structural rather than process quality of care, relied on many more indicators, and was less regular. While PMAQ represented an important new funding stream for primary health care, our review suggests that theoretical incentives generated were unclear and could have been better structured to direct health providers towards improvements in quality of care.

“We don’t routinely check vaccination background in adults”: a national qualitative study of barriers and facilitators to vaccine delivery and uptake in adult migrants through UK primary care

ObjectivesExplore primary care professionals’ views around barriers/facilitators to catch-up vaccination in adult migrants (foreign-born; over 18 years of age) with incomplete/uncertain vaccination status and for routine vaccines to inform development...

Key updates to the management of type 2 diabetes in adults: how to embrace and embed the new NICE guidance

Key updates to the management of type 2 diabetes in adults: how to embrace and embed the new <scp>NICE</scp> guidance

The impact of a clinical review of people with active epilepsy not under shared care by a GP with special interest

PurposeTo review clinical outcomes of a single face-to-face review of people with epilepsy (PWE) not under shared care, and any recommendations following a notes review of non-attendees and those under shared care, by a GP with Special Interest in epilepsy (GPwSIe). MethodOne hundred and eighty one PWE, not under shared care were invited for a review. In addition, fifty six people under shared care had a notes review. Interventional outcomes were reviewed after 12 months. ResultsThere had been ten deaths (all non-attributable to epilepsy), and six people had left the area, leaving 221 people who completed the audit. Fifty one percent attended for review, and were more likely to be in documented remission (p = 0.01). The frequency of annual GP epilepsy reviews in the following year did not rise significantly. There was a significant rise in vitamin D prescriptions (p < 0.001). Thirty seven DEXA scans were arranged, 76% were abnormal. There was reluctance by patients to withdraw medication, change multi dose, or subtherapeutic anti-seizure medication (ASM) regimes, even in the context of long-term seizure remission or inadequate seizure control. Three people achieved remission from changes made to ASM as a result of the review. ConclusionReview of PWE in primary care remains poor. Attitudes from both GPs and PWE to their condition needs evaluation in order to plan future care. Bone health is an issue easily addressed in primary care and should be promoted through education or the re-introduction of a specific QOF (Quality and Outcomes Framework) target. Guidance on bone health for ASM needs clarification. This study adds to the evidence of the effectiveness of a GPwSIe.

Association of environmental and socioeconomic indicators with serious mental illness diagnoses identified from general practitioner practice data in England: A spatial Bayesian modelling study.

BackgroundThe evidence is sparse regarding the associations between serious mental illnesses (SMIs) prevalence and environmental factors in adulthood as well as the geographic distribution and variability of these associations. In this study, we evaluated the association between availability and proximity of green and blue space with SMI prevalence in England as a whole and in its major conurbations (Greater London, Birmingham, Liverpool and Manchester, Leeds, and Newcastle).Methods and findingsWe carried out a retrospective analysis of routinely collected adult population (≥18 years) data at General Practitioner Practice (GPP) level. We used data from the Quality and Outcomes Framework (QOF) on the prevalence of a diagnosis of SMI (schizophrenia, bipolar affective disorder and other psychoses, and other patients on lithium therapy) at the level of GPP over the financial year April 2014 to March 2018. The number of GPPs included ranged between 7,492 (April 2017 to March 2018) to 7,997 (April 2014 to March 2015) and the number of patients ranged from 56,413,719 (April 2014 to March 2015) to 58,270,354 (April 2017 to March 2018). Data at GPP level were converted to the geographic hierarchy unit Lower Layer Super Output Area (LSOA) level for analysis. LSOAs are a geographic unit for reporting small area statistics and have an average population of around 1,500 people. We employed a Bayesian spatial regression model to explore the association of SMI prevalence in England and its major conurbations (greater London, Birmingham, Liverpool and Manchester, Leeds, and Newcastle) with environmental characteristics (green and blue space, flood risk areas, and air and noise pollution) and socioeconomic characteristics (age, ethnicity, and index of multiple deprivation (IMD)). We incorporated spatial random effects in our modelling to account for variation at multiple scales.Across England, the environmental characteristics associated with higher SMI prevalence at LSOA level were distance to public green space with a lake (prevalence ratio [95% credible interval]): 1.002 [1.001 to 1.003]), annual mean concentration of PM2.5 (1.014 [1.01 to 1.019]), and closeness to roads with noise levels above 75 dB (0.993 [0.992 to 0.995]). Higher SMI prevalence was also associated with a higher percentage of people above 24 years old (1.002 [1.002 to 1.003]), a higher percentage of ethnic minorities (1.002 [1.001 to 1.002]), and more deprived areas.Mean SMI prevalence at LSOA level in major conurbations mirrored the national associations with a few exceptions. In Birmingham, higher average SMI prevalence at LSOA level was positively associated with proximity to an urban green space with a lake (0.992 [0.99 to 0.998]). In Liverpool and Manchester, lower SMI prevalence was positively associated with road traffic noise ≥75 dB (1.012 [1.003 to 1.022]). In Birmingham, Liverpool, and Manchester, there was a positive association of SMI prevalence with distance to flood zone 3 (land within flood zone 3 has ≥1% chance of flooding annually from rivers or ≥0.5% chance of flooding annually from the sea, when flood defences are ignored): Birmingham: 1.012 [1.000 to 1.023]; Liverpool and Manchester: 1.016 [1.006 to 1.026]. In contrast, in Leeds, there was a negative association between SMI prevalence and distance to flood zone 3 (0.959 [0.944 to 0.975]). A limitation of this study was because we used a cross-sectional approach, we are unable to make causal inferences about our findings or investigate the temporal relationship between outcome and risk factors. Another limitation was that individuals who are exclusively treated under specialist mental health care and not seen in primary care at all were not included in this analysis.ConclusionsOur study provides further evidence on the significance of socioeconomic associations in patterns of SMI but emphasises the additional importance of considering environmental characteristics alongside socioeconomic variables in understanding these patterns. In this study, we did not observe a significant association between green space and SMI prevalence, but we did identify an apparent association between green spaces with a lake and SMI prevalence. Deprivation, higher concentrations of air pollution, and higher proportion of ethnic minorities were associated with higher SMI prevalence, supporting a social-ecological approach to public health prevention. It also provides evidence of the significance of spatial analysis in revealing the importance of place and context in influencing area-based patterns of SMI.

What factors influence differential uptake of NHS Health Checks, diabetes and hypertension reviews among women in ethnically diverse South London? Cross-sectional analysis of 63,000 primary care records

SummaryBackgroundUptake of health checks among women has not been examined in relation to patient and General Practitioner (GP) practice level factors. We investigated patient and practice level factors associated with differential uptake of health checks.MethodsPrimary care records from 44 practices in Lambeth for women aged 40-74 years old (N = 62,967) from 2000-2018 were analysed using multi-level logistic regression models. An odds ratio (OR) >1 indicates increased occurrence of no health check.FindingsThe mean age (IQR) of the included female sample (aged 40-74 years) was 52.9 years (45.0-59.0). Adjusted for patient-level factors (age, ethnicity, English as first language, overweight/obesity, smoking, attendance to GP practices, and co-morbidity), the odds of non-uptake of health checks were higher for Other White (OR 1.24, 95% confidence interval 1.17-1.33), and Other ethnicity (1.20, 1.07-1.35) vs. White British. It was also higher for 50-69 year olds (1.55, 1.47-1.62), 70-74 year olds (1.60, 1.49-1.72) vs. 40-49 year olds. These ORs did not change on adjustments for practice level factors (proportion of patients living in deprived areas, proportion of patients with ≥1 chronic condition, ≥3 emergency diabetes admissions annually, GP density/1000 patients, quality outcome framework score of ≥ 95%, and patient satisfaction scores of ≥80%). Non-uptake was lower for Black Caribbeans, Bangladeshis, overweight/obese patients, frequent practice attenders and comorbid patients.InterpretationDifferential uptake in health checks remained after adjustment for patient and practice level factors. Better measures of social determinants of health and of practice context are needed.FundingNIHR Research for Patient Benefit Programme (NIHR202769).