- This study evaluated the impact of the 2004 UK Quality and Outcomes Framework (QOF) on clinical quality in primary care over time using longitudinal data from 42 practices between 1998-2005. - The results showed that quality of care was already improving before QOF, but the rate of improvement was significantly higher than predicted for diabetes and asthma under QOF. - There was no significant difference found between incentivized and non-incentivized quality indicators under QOF, suggesting it improved care broadly rather than just for incentivized areas. - Overall, QOF was found to improve the rate of increase in quality for some conditions, but did not damage professional values as some had feared.

1. Improvements in clinical quality in
English primary care
A longitudinal study of the Quality
and Outcomes Framework
Evan Kontopantelis
NPCRDC, University of Manchester

2. Timeline
• 80’s: Determinism
– Quality can’t be measured
– There’s no such thing as a bad doctor
• Early 90’s: Wind of change
– Government: improving health care became a priority. Care is too
variable but can be expensive to improve
– Academics: developed methods for measuring Q
– Doctors: cultural shift towards accepting that Q needs to be
measured and improved.
• By 1997: Reversal of perception, guidelines & standards
– Quality can be measured
– Care is too variable and can improved
– Providing high Q care is expensive
– Doctors want to be rewarded for providing high Q care

3. QuIP
• Design
– Longitudinal time series, 4 time points
– Sample: 42 representative English practices
• Aim
– Evaluate the impact of the 2004 GMS contract and QOF on
the quality of care provided in general practice, with attention
to both the losses and gains
1998 2003 2005 2007
NGMS/
QOF
QUASAR QuIP
1998 2003 2005 2007
NGMS/
QOF
QUASAR QuIP

4. 1998-2003: pre QOF
• Quality was already
improving
• How will the new
contract affect quality of
care…
– No change
– Change in level not slope
– Change in level & slope
– Change: quality fall
59%
62% 60%
76%
70% 70%
0%
10%
20%
30%
40%
50%
60%
70%
80%
CHD Diabetes Asthma
1998
2003P<0.01 P<0.01 P<0.01
newcontract

5. 2004: Quality and Outcomes
Framework introduced
• What is it?
– A complex set of 146 quality indicators that relates
to 25% of GPs’ income
• Costs
– Additional funding of £1.8 billion
• What might its effects be?
– Improved care
– Un-incentivised areas get worse care
– Change in professional values

6. 1998-2005: QOF in the middle
• Quality is still improving
• But: Is the rate of improvement significantly more than
what was expected from previous trends?
• In other words: is there a QOF effect?
59% 62% 60%
76%
70% 70%
85% 84%81%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
CHD Diabetes Asthma
1998 2003 2005

7. Method
• Data Structure
– Longitudinal time series
– Data extracted from medical records of random cross-sectional
samples of patients with asthma, CHD and diabetes registered with
42 English family practices
– 2300 patients in 1998, 1495 in 2003 and 1882 in 2005
• Problems
– Ceiling effect
– Time-series with only 3 time points
• Method
– Performance in 2005 was compared to that predicted by a logit
model, based on observed trends between 1998 and 2003
– Comparison for both overall scores and individual indicators
– Sensitivity analysis with the more conservative linear model
produced the same results

8. Did QOF improve care?
• Mean practice achievement scores for 2005, in our
sample of 42 English practices:
CHD Diabetes Asthma
Actual score 85.0 81.4 84.3
Predicted* 80.7 73.2 72.3
Significance of difference 0.066 0.002 <0.001
*on logit model using the 98-03 trend
• Performances for incentivised vs non-incentivised
indicators were compared
• No significant difference found for any condition

9. 3.0%
1.0% 1.8% 2.6% 3.7%
6.1%
10.5%
21.7%
49.5%
0.6% 0.4% 0.3% 0.8% 1.2% 2.2%
5.0%
12.1%
77.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 to <650 650 to < 700 700 to < 750 750 to < 800 800 to < 850 850 to < 900 900 to < 950 950 to < 1000 1000 to 1050
No. of points
Percentageofpractices
2004/05
2005/06
The big picture: post QOF achievement
across all English practices
2004-5
Median
2005-6
Median
Overall 83.4% 87.1%
CHD 85.7% 88.7%
Diabetes 80.1% 83.7%
Asthma 80.5% 83.6%
• Data extracted automatically from clinical computing
systems for 7935 English practices in 04/05 & 05/06:

10. Overall weighted achievement

11. Overview
• QOF improved the rate of increase in quality of
care for certain conditions
• There is no evidence that quality improved more
for incentivised indicators compared to non-
incentivised ones
• QOF could be corrosive for professional values but
“internal motivation has not been damaged by
external incentives” (McDonald, Harrison, Checkland,
Campbell, Roland. BMJ, In Press)

12. Thank you for listening