Quality And Outcomes Framework Research Articles

GP incentives to design hypertension and atrial fibrillation local quality-improvement schemes: a controlled before-after study in UK primary care.

Financial incentives in the UK such as the Quality and Outcomes Framework (QOF) reward GP surgeries for achievement of nationally defined targets. These have shown mixed results, with weak evidence for some measures, but also possible unintended negative effects. To look at the effects of a local intervention for atrial fibrillation (AF) and hypertension, with surgeries rewarded financially for work, including appointing designated practice leads, attendance at peer review workshops, and producing their own protocols. A controlled before-after study comparing surgery performance measures in UK primary care. This study used published QOF data to analyse changes from baseline in mean scores per surgery relating to AF and hypertension prevalence and management at T1 (12 months) and T2 (24 months) for the intervention group, which consisted of all 58 surgeries in East Lancashire Clinical Commissioning Group (CCG), compared to the control group, which consisted of all other surgeries in north-west England. There was a small acceleration between T0 (baseline) and T2 in recorded prevalence of hypertension in the intervention group compared to the controls, difference 0.29% (95% confidence interval [CI] = 0.05 to 0.53), P = 0.017, but AF prevalence did not increase more in the intervention group. Improvement in quality of management of AF was significantly better in the intervention group, difference 3.24% (95% CI = 1.37 to 5.12), P = 0.001. This intervention improved diagnosis rates of hypertension but not AF, though it did improve quality of AF management. It indicates that funded time to develop quality-improvement measures targeted at a local population and involving peer support can engage staff and have the potential to improve quality.

Paediatric asthma care in the UK: fragmented and fatally fallible.

The National Review of Asthma Deaths (NRAD) report entitled Why Asthma Still Kills ,1 published on World Asthma Day in May 2014, concluded that only one of the 28 children and young people (CYP) who died had been adequately managed by health professionals. Of the 19 NRAD recommendations only one has been initiated nationally in the UK, namely setting up a National Asthma Audit, which has yet to report after nearly 5 years. Care for children with asthma in the UK is mainly provided in primary care, and is often limited to the few tasks set out in the Quality and Outcomes Framework (QOF)2 to provide data to qualify for payments. Currently the QOF requires a recorded asthma diagnosis confirmed by measures of airflow reversibility, smoking status, and evidence of an asthma review in the preceding 12 months that includes an assessment of asthma control using the Royal College of Physicians’ three questions (RCP 3 Questions); the latter are not validated and nor are they recommended for children aged <16 years by the UK Asthma Guidelines.3 The aim of the NRAD was to identify potentially preventable factors related to care preceding these tragic (and often preventable) deaths. The confidential inquiry identified a number of key themes associated with potentially preventable asthma deaths, which included: lack of objective evidence for the diagnosis of asthma and certification of death due to asthma; excess prescriptions and overreliance on reliever medication; insufficient prescriptions (and collection) of preventer (controller) medications; lack of provision of education for patients (in the form of personal asthma action plans [PAAPs]); and, importantly, a marked failure by health professionals, patients, and their carers to recognise risk of poor outcome in those who have already had at least one asthma attack. All these factors were previously known from …

Workload impact of the Quality and Outcomes Framework for patients with diabetes: an interrupted time series in general practice.

There are substantial concerns about GP workload. The Quality and Outcomes Framework (QOF) has been perceived by both professionals and patients as bureaucratic, but the full impact of the QOF on GP workload is not well known. To assess the impact of the QOF on GP consultation rates for patients with diabetes mellitus. This study used interrupted time series of 13 248 745 general practice consultations for 37 065 patients with diabetes mellitus in England. Clinical Practice Research Datalink general practice data were used from 2000/2001 to 2014/2015, with introduction of the QOF (1 April 2004) as the intervention, and mean annual GP consultation rates as the primary outcome. Mean annual GP clinical consultation rates were 8.10 per patient in 2000/2001, 6.91 in 2004/2005, and 7.09 in 2014/2015. Introduction of the QOF was associated with an annual change in the trend of GP clinical consultation rates of 0.46 (95% confidence interval [CI] = 0.23 to 0.69, P = 0.001) consultations per patient, giving a post-QOF trend increasing by 0.018 consultations per year. Introduction of the QOF was associated with an immediate stepped increase of 'other' out-of-hours and non-clinical encounters, and trend change of 0.57 (95% CI = 0.34 to 0.81, P<0.001) per year, resulting in a post-QOF trend increasing by 0.27 other encounters per year. Introduction of the QOF was associated with a modest increase in clinical GP consultation rates and substantial increase in other encounters for patients with diabetes independent of changes in diabetes prevalence. National prevalence of diabetes increased by 90.7% from 2004/2005 to 2014/2015, which, combined with this study's findings, means GPs would have provided nearly double the number of consultations for patients with diabetes over this timescale.

Longitudinal evaluation of a countywide alternative to the Quality and Outcomes Framework in UK General Practice aimed at improving Person Centred Coordinated Care

ObjectivesTo evaluate a county-wide deincentivisation of the Quality and Outcomes Framework (QOF) payment scheme for UK General Practice (GP).SettingIn 2014, National Health Service England signalled a move towards devolution of...

Multimorbidity and emergency department visits by a homeless population: a database study in specialist general practice.

Estimating healthcare needs of the homeless is associated with challenges in identifying the eligible population. To explore the demographic characteristics, disease prevalence, multimorbidity, and emergency department visits of the homeless population. EMIS electronic database of patient medical records and Quality and Outcomes Framework (QOF) data of all 928 patients registered with a major specialist homeless primary healthcare centre based in the West Midlands in England, from the period of October 2016 to 11 October 2017. Prevalence data on 21 health conditions, multimorbidity, and visits to emergency departments were explored and compared with the general population datasets. Most homeless people identified were male (89.5%), with a mean age of 38.3 (SD = 11.5) years, and of white British origin (22.1%). Prevalence of substance (13.5%) and alcohol dependence (21.3%), hepatitis C (6.3%), and multimorbidity (21.3%) were markedly higher than in the general population. A third (32.5%) had visited the emergency department in the preceding 12 months. Emergency department visits were associated with a patient history of substance (odds ratio [OR] = 2.69) and alcohol dependence (OR = 3.14). A high prevalence of substance and alcohol dependence, and hepatitis C, exists among the homeless population. Their emergency department visit rate is 60 times that of the general population and the extent of multimorbidity, despite their lower mean age, is comparable with that of 60-69-year-olds in the general population. Because of multimorbidity, homeless people are at risk of fragmentation of care. Diversification of services under one roof, preventive services, and multidisciplinary care are imperative.

Evaluation of a countywide alternative to QOF, aimed at improving person-centred coordinated care

BackgroundThe Quality Outcomes Framework (QOF) for general practice is one of the largest pay-for-performance schemes in the world. The scheme, however, is sometimes viewed as anachronistic, with recent proposals for a slimmed down QOF. Over the last few years, Somerset have been trialling a system with national implications: 55 GP practices in Somerset established the Somerset Quality Practice Scheme (SPQS) — a de-incentivisation of QOF — with the goal of redirecting resources towards improved Person Centred Coordinated Care (P3C), especially for those with long-term conditions.AimAn evaluation of the SPQS scheme to establish benefits (for example in provision of P3C) or disbenefits (for example in emergency admissions).MethodA longitudinal evaluation from 55 SPQS practices and 17 regional controls. Patient experiences (2363 patients), staff experiences (127 professionals), and organisational data (for SPQS and control practices) were collected. Emergency admission data was analysed for ambulatory-sensitive conditions across Somerset.ResultsDiscretion from QOF resulted in time savings in the majority of practices. Organisational data revealed a significant increase in P3C. Care delivery was improved via stronger federation-level agreements and informal networks, increased multidisciplinary working, reallocation of resources for other healthcare professionals and changes to the structure and timings of GP appointments. Patient and practitioner experiences were similar in SPQS versus control practices. No disbenefits were detected in admissions data.ConclusionThe SPQS scheme leveraged time savings and reduced administrative burden via discretionary removal of QOF, enabling participating practices to engage in a number of schemes aimed at improving care for people with LTCs.

Trends in reported incidence of erectile dysfunction, hypogonadism, PDE5i prescriptions and TRT in patients with type 2 diabetes in primary care

BackgroundErectile dysfunction (ED) and testosterone deficiency (TD) are complications of type 2 diabetes mellitus (T2DM), and predictors of cardiovascular disease. Guidelines recommend that men with T2DM are assessed and treated for ED/TD, which was included into the Quality and Outcomes Framework (QOF) from 2013–2014 only.AimExplore the effects of QOF on ED/TD diagnoses and management in T2DM patients.MethodThe study population included males (≥18 years) with T2DM and contributing to UK GP electronic health records from 1999–2016. Adjusted incidence rate ratios (IRRs) were estimated using multivariable Poisson regression.ResultsIn total 135 342 adult males (mean age 60 years) with T2DM were included. During follow-up, 60 819 (45%) had a recorded ED assessment, 23 834 (18%) an ED diagnosis and of these 73% received a phosophodiesterase-5 inhibitor (PDE5i). ED assessments increased from 7.6 per 1000 PYAR in 2012 (95% confidence interval [CI] = 7.0 to 8.3) to 620 in 2013 (95% CI = 614 to 626) when included into QOF but dropped to 59.4 (95% CI = 56 to 63) in 2016. Compared with 2012, the adjusted incidence of recorded ED diagnoses and PDE5i prescriptions doubled in 2013 (incidence rate ratio [IRR] 2.0; 95% CI = 1.8 to 2.1) before falling to below pre-QOF levels in 2016 (IRR 0.89; 95% CI = 0.82 to 0.97). Of 1187 diabetic men diagnosed with ED or receiving a PDE5i in 2015, 213 (18%) had minimum one testosterone measurement, of which 45 (21%) met criteria for hypogonadism (testosterone ≤8nmol/l). Nine (20%) subsequently received testosterone replacement therapy (TRT).ConclusionTo improve diagnosis and management of ED/TD in T2DM patients and thereby (cardiovascular) health and quality of life, incorporation of guidelines into a GP framework and/or financial incentives may be required alongside GP education.

Routine health monitoring and preventative care for people with dementia in UK primary care

BackgroundUK National Dementia Strategies prioritise fair access to dementia treatment for all. It has been shown that people from black and minority ethnic (BME) groups are diagnosed later and those are less likely to receive anti-dementia medication.AimIt is hypothesised that access to primary care services post diagnosis is also reduced in ethnic minority groups.MethodThe Health Improvement Network (THIN) database of UK primary care records was analysed between 2015 and 2016, all patients with dementia were identified, and health service use was compared. Annual GP consultations, blood pressure (BP), weight/body mass index (BMI), Quality and Outcomes Framework (QOF) dementia review, and flu vaccination recordings were compared between ethnic groups.ResultsOver 20 000 individuals with a dementia diagnosis aged 50–105 years were included. There was no significant difference between white, black, and Asian groups across all outcomes. Overall 80% received an annual BP check, 86% received at least one annual GP consultation, 68% received an annual dementia review, and 48% had a weight/BMI recorded. People with dementia who did not have cardiovascular risk factors were less likely to have their BP checked (59%) and be seen by a GP.ConclusionThere do not appear to be ethnic inequalities in primary care service use post-dementia diagnosis. The overall proportion receiving an annual dementia review and weight check was low, despite recommendations that a care plan should be reviewed annually (including nutrition as a key priority). Post-diagnosis support and preventative care should be prioritised in general practice for all people living with dementia.

The combined care clinic: a strategy in improving quality and efficiency related to essential patient reviews in the UK

BackgroundStandardised delivery of patient care remains an essential facet of the NHS. In 2004, the general practice contract for delivering specific primary medical services incorporated a financial payment: Quality Outcomes Framework (QOF). In majority of practices, these reviews are completed by the practice nursing healthcare team.AimTo understand if the combined care (CC) clinic improves the efficiency in delivering patient reviews.MethodThe CC clinic was designed in 2015 inviting patients with diabetes; who may also have other long-term conditions, to be addressed in a ‘one stop’ approach. It is implemented by healthcare assistants (HCAs) supported by apprentices, who perform standard checks such as blood pressures, urine dipstick checks, smoking data, and health promotion that are protocolled. Where there are abnormalities noted, the HCA is able to escalate to the practice nurses who are supported by a GP lead.ResultsQOF diabetes data were reviewed from 2015–2016 (636 patients on register) and 2016–2017 (649 patients on register). Results showed a marked percentage increase between years in the following indicators: DM003 (last blood pressure measurement ≤140/80 mmHg) 7.29%; DM006 (proteinuria/microalbuminuria) 6.20%; and DM009 (foot exam) 3.21%. All other diabetic indicators apart from two showed a percentage increase. The proportion of patients seen between April–October also increased in the subsequent year.ConclusionThe CC clinic provides a method of patient review in an efficient process, without the need for multiple visits, thereby increasing practice capacity to focus on other aspects of patient care and work streams.

Life after QOF

Life after QOF

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.

Incentive schemes to increase dementia diagnoses in primary care in England: a retrospective cohort study of unintended consequences

The UK government introduced two financial incentive schemes for primary care to tackle underdiagnosis in dementia: the 3-year Directed Enhanced Service 18 (DES18) and the 6-month Dementia Identification Scheme (DIS). The schemes appear to have been effective in boosting dementia diagnosis rates, but their unintended effects are unknown. To identify and quantify unintended consequences associated with the DES18 and DIS schemes. A retrospective cohort quantitative study of 7079 English primary care practices. Potential unintended effects of financial incentive schemes, both positive and negative, were identified from a literature review. A practice-level dataset covering the period 2006/2007 to 2015/2016 was constructed. Difference-in-differences analysis was employed to test the effects of the incentive schemes on quality measures from the Quality and Outcomes Framework (QOF); and four measures of patient experience from the GP Patient Survey (GPPS): patient-centred care, access to care, continuity of care, and the doctor-patient relationship. The researchers controlled for effects of the contemporaneous hospital incentive scheme for dementia and for practice characteristics. National practice participation rates in DES18 and DIS were 98.5% and 76% respectively. Both schemes were associated not only with a positive impact on QOF quality outcomes, but also with negative impacts on some patient experience indicators. The primary care incentive schemes for dementia appear to have enhanced QOF performance for the dementia review, and have had beneficial spillover effects on QOF performance in other clinical areas. However, the schemes may have had negative impacts on several aspects of patient experience.

Prevalence of mental illness in primary care and its association with deprivation and social fragmentation at the small-area level in England.

We aimed to spatially describe mental illness prevalence in England at small-area geographical level, as measured by prevalence of depression, severe mental illness (SMI) and antidepressant prescription volume in primary care records, and how much of their variation was explained by deprivation, social fragmentation and sociodemographic characteristics. Information on prevalence of depression and SMI was obtained from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/16 and the national dispensing dataset for 2015/16. Linear regression models were fitted to examine ecological associations between deprivation, social fragmentation, other sociodemographic characteristics and mental illness prevalence. Mental illness prevalence varied within and between regions, with clusters of high prevalence identified across England. Our models explained 33.4-68.2% of variability in prevalence, but substantial variability between regions remained after adjusting for covariates. People in socially cohesive and socially deprived areas were more likely to be diagnosed with depression, while people in more socially fragmented and more socially deprived areas were more likely to be diagnosed with SMI. Our findings suggest that to tackle mental health inequalities, attention needs to be targeted at more socially deprived localities. The role of social fragmentation warrants further investigation, and it is possible that depression remains undiagnosed in more socially fragmented areas. The wealth of routinely collected data can provide robust evidence to aid optimal resource allocation. If comparable data are available in other countries, similar methods could be deployed to identify high prevalence clusters and target funding to areas of greater need.

Sub-optimal diagnosis of neurogenic bladder among general practitioners in the United Kingdom—evidence from the Clinical Practice Research Datalink

The diagnosis rate for neurogenic bladder (NGB) in the United Kingdom (UK) is surprisingly low. A lack of a clear diagnosis for patients adds ambiguity to their characterisation, treatment pathways and impedes meaningful research. A correct diagnosis means patients are more likely to have access to appropriate services and the right medical treatments, which subsequently improves their chances of optimal health outcomes as well as reducing healthcare costs. Accordingly, the aim of this research was to speculate the reasons for suboptimal diagnosis in NGB and provide recommendations for improvement. Nine hundred and sixty-seven patients were diagnosed with NGB between 2004–2015 in the Clinical Practice Research Datalink (CPRD) database, which in the context of the literature, seems low. Possible reasons include inadequate medical coding, a lack of awareness of urological symptoms amongst non-urologist healthcare professionals (HCPs), failure to follow clinical guidelines in practice, the exclusion of NGB from the Quality Outcomes Framework (QoF) scheme and an accommodation of urological symptoms. For optimal management in NGB, closing the current diagnosis gap is essential. Deprived of a diagnosis, patients will face an uphill battle in gaining access to services and appropriate medications. Measures such as educational campaigns, financial incentives, better use of clinical decision support systems (CDSS) and fostering better relationships between important stakeholders will be instrumental in achieving optimal diagnosis rates. Furthermore, additional hypothesis testing research is essential to ascertain the actual determinants of referrals.

Evaluating the impact of a community-based social prescribing intervention on people with type 2 diabetes in North East England: mixed-methods study protocol

IntroductionSocial prescribing enables healthcare professionals to use voluntary and community sector resources to improve support for people with long-term conditions. It is widely promoted in the UK as a way...

Inaccurate diagnosis of COPD: the Welsh National COPD Audit.

The diagnosis of chronic obstructive pulmonary disease (COPD) is confirmed with spirometry demonstrating persistent airflow obstruction. To evaluate the clinical characteristics and management of patients in primary care on COPD registers with spirometry incompatible with COPD. A primary care audit of Welsh COPD Read-Coded patient data from the Quality and Outcomes Framework (QOF) COPD register in Wales. Patients on the QOF COPD register with incompatible spirometry (post-bronchodilator forced expiratory lung volume in 1 second/forced vital capacity [FEV1/FVC] ratio ≥0.70) were compared with those with compatible spirometry (FEV1/FVC <0.70). This audit included 63% of Welsh practices contributing 48 105 patients. Only 19% (n = 8957) of patients were post-bronchodilator FEV1/FVC Read-Coded and were included in this study. Of these, 75% (n = 6702) had compatible spirometry and 25% (n = 2255) did not. Patients with incompatible spirometry were more likely female (P = 0.009), never-smokers (P<0.001), had higher body mass index (P<0.001), and better mean FEV1 (P<0.001). Medical Research Council (MRC) breathlessness scores, exacerbation frequency, and asthma co-diagnosis were similar between groups. Patients in both groups were just as likely to receive inhaled corticosteroid (ICS) and long-acting beta-agonists (LABAs), but patients with incompatible spirometry were less likely to receive long-acting muscarinic antagonists (LAMAs) (P<0.001) or LABA/ICS (P = 0.002) combinations. Patients on the COPD QOF register with spirometry incompatible with COPD are symptomatic and managed using significant resources. If quality of care and effective resource use are to be improved, focus must be given to correct diagnosis in this group.

Are there patients missing from community heart failure registers? An audit of clinical practice.

General practitioners in the UK are financially incentivised, via the Quality Outcomes Framework, to maintain a record of all patients at their practice with heart failure and manage them appropriately. The prevalence of heart failure recorded in primary care registers (0.7-1.0%) is less than reported in epidemiological studies (3-5%). Using an audit of clinical practice, we set out to investigate if there are patients 'missing' from primary care heart failure registers and what the underlying mechanisms might be. The design of this study was as an audit of clinical practice at a UK general practice ( n = 9390). Audit software (ENHANCE-HF) was used to identify patients who may have heart failure via a series of hierarchical searches of electronic records. Heart failure was then confirmed or excluded based on the electronic records by a heart failure specialist nurse and patients added to the register. Outcome data for patients without heart failure was collected after two years. Heart failure prevalence was 0.63% at baseline and 1.12% after the audit. Inaccurate coding accounted for the majority of missing patients. Amongst patients without heart failure who were taking a loop diuretic, the rate of incident heart failure was 13% and the rate of death or hospitalization with heart failure was 25% respectively during two-year follow-up. There are many patients missing from community heart failure registers which may detriment patient outcome and practice income. Patients without heart failure who take loop diuretics are at high risk of heart failure-related events.

Effects of quality and outcomes framework management model on nursing management for intravenous therapy

Objective To explore the effects of the quality and outcomes framework (QOF) of the UK primary care in nursing management for intravenous therapy. Methods A total of 105 departments from 12 hospitals in Zhuzhou City in September 2015 (before QOF) and March 2017 (after QOF) were selected by convenient sampling. The nursing and management protocol for intravenous therapy was established and implemented with reference to the QOF management model in January 2016. The cross-sectional study results regarding the nursing quality for intravenous therapy in September 2015 and March 2017 were compared, The tool of intravenous puncture, improper use of scalp acupuncture, inappropriate nursing for indwelling catheters and the complications induced by indwelling catheters were compared before and after QOF. Results Totally 902 scalp acupunctures, 916 indwelling needles and 120 central venous catheters were found after the QOF management model was carried out for intravenous therapy, the difference was statistically significant before QOF (χ2=30.84, P<0.001) . Totally 305 improper use of scalp acupunctures, 145 inappropriate nursing for indwelling venous catheters and 90 cases of complications induced by indwelling catheters were found, lower than those before QOF, for which the cases were 563, 327 and 204, respectively (χ2=199.99, 139.13, 82.52; P<0.01) . Conclusions The QOF management model can effectively enhance the specialized nursing ability of nursing staff and improve the nursing quality for intravenous therapy, which is an effective management model for continuous quality improvement. Key words: Nursing administration research; Intravenous therapy; Quality and outcomes framework

Association of guideline and policy changes with incidence of lifestyle advice and treatment for uncomplicated mild hypertension in primary care: a longitudinal cohort study in the Clinical Practice Research Datalink

ObjectivesEvidence to support initiation of pharmacological treatment in patients with uncomplicated (low risk) mild hypertension is inconclusive. As such, clinical guidelines are contradictory and healthcare policy has changed regularly. The...

Modelling the cost-effectiveness of pay-for-performance in primary care in the UK

BackgroundIntroduced in 2004, the United Kingdom’s (UK) Quality and Outcomes Framework (QOF) is the world’s largest primary-care pay-for-performance programme. Given some evidence of the benefits and the substantial costs associated with the QOF, it remains unclear whether the programme is cost-effective. Therefore, we assessed the cost-effectiveness of continuing versus stopping the QOF.MethodsWe developed a lifetime simulation model to estimate quality-adjusted life years (QALYs) and costs for a UK population cohort aged 40–74 years (n = 27,070,862) exposed to the QOF and for a counterfactual scenario without exposure. Based on a previous retrospective cross-country analysis using data from 1994 to 2010, we assumed the benefits of the QOF to be a change in age-adjusted mortality of −3.68 per 100,000 population (95% confidence interval –8.16 to 0.80). We used cost-effectiveness thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY to determine the optimal strategy in base-case and sensitivity analyses.ResultsIn the base-case analysis, continuing the QOF increased population-level QALYs and health-care costs yielding an incremental cost-effectiveness ratio (ICER) of £49,362/QALY. The ICER remained >£30,000/QALY in scenarios with and without non-fatal outcomes or increased drug costs, and under differing assumptions about the duration of QOF benefit following its hypothetical discontinuation. The ICER for continuing the programme fell below £30,000/QALY when QOF incentive payments were 36% lower (while preserving QOF mortality benefits), and in scenarios where the QOF resulted in substantial reductions in health-care spending or non-fatal cardiovascular disease events. Continuing the QOF was cost-effective in 18%, 3% and 0% of probabilistic sensitivity analysis iterations using thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY, respectively.ConclusionsCompared to stopping the QOF and returning all associated incentive payments to the National Health Service, continuing the QOF is not cost-effective. To improve population health efficiently, the UK should redesign the QOF or pursue alternative interventions.