So does QOF really reduce emergency hospital admissions?

What should you make of our latest paper suggesting that QOF reduced emergency admissions? There have now been over 20 systematic reviews of pay for performance (P4P) and even a systematic review of systematic reviews. A reasonable summary would be that P4P seems to improve the processes of care somewhat (and with the potential for unintended consequences). However (apart from a few studies like ours suggesting that P4P in hospitals cut mortality), there are precious few studies suggesting that P4P has any impact on health outcomes. So what to make of this most recent paper?

The results look at first sight to be clear cut. Against two sets of controls (ambulatory care sensitive conditions which were not incentivised, and conditions not regarded as being ‘ambulatory care sensitive’), admissions for conditions in QOF clearly bucked an inexorably rising trend of admissions. But bearing in mind the modest short term changes in process measures which we showed previously, it seems hardly likely that the reduction in admissions was just due to improvements in the incentivised process measures.

In an accompanying editorial Bruce Guthrie and Tobias Dreischulte find our suggestion that introducing pay for performance may lead to important changes in the organisation of care beyond the intended effect on incentivised processes “plausible”. This begs a much bigger question of what contribution primary care is making to improved health. We know for example that coronary heart disease mortality has dropped dramatically during a decade when the quality of chronic disease management in primary care has also improved dramatically. It’s hard to know whether there’s a link. Simon Capewell and colleagues reckon that about half the drop in UK coronary mortality is due to medical care (see papers here and here), and it would be good to think that at least some of that was due to improvements in primary care. Back in 2003 Denis Pereira Gray suggested that the role of hospitals and GPs was becoming reversed – with GPs now responsible for saving lives8 (e.g. by detection and management of high blood pressure, helping people stop smoking and good chronic disease management) with the role of the hospital being to reduce disability (e.g. with hip and corneal replacements).

It would be good to really understand what’s making us all live longer.

Further reading

  1. Harrison M, Dusheiko M, Sutton M, Gravelle H, Doran T, Roland M. Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study. www.bmj.com/content/349/bmj.g6423

 

  1. Eijkenaar F, Emmert M, Scheppach M, Sch.ffski O. Effects of pay for performance in health care: a systematic review of systematic reviews. Health Policy 2013;110:115-30.

 

  1. Sutton M, Nikolova S, Boaden R, Lester H, McDonald R, Roland M. Reduced mortality with hospital pay for performance in England. New England Journal of Medicine 2012; 367: 1821-28 www.nejm.org/doi/full/10.1056/NEJMsa1114951

 

  1. Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of pay-for-performance on the quality of primary care in England. New England Journal of Medicine 2009; 361: 368-78 www.nejm.org/doi/full/10.1056/NEJMsa0807651

 

  1. Guthrie B, Dreischulte T Quality in Primary Care www.bmj.com/content/349/bmj.g6485

 

  1. Unal B, Critchley JA, Capewell S. Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000. Circulation. 2004 Mar 9;109(9):1101-7. http://circ.ahajournals.org/content/109/9/1101.full

 

  1. Hotchkiss JW, Davies CA, Dundas R, Hawkins N, Jhund PS, Scholes S, Bajekal M, O’Flaherty M, Critchley J, Leyland AH, Capewell S. Explaining trends in Scottish coronary heart disease mortality between 2000 and 2010 using IMPACTSEC model: retrospective analysis using routine data. BMJ. 2014;348:g1088 http://www.bmj.com/content/348/bmj.g1088

 

  1. Pereira Gray D Role reversal between primary and secondary care. Med Educ. 2003;37(9):754-5

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