Making RBF Indicators Work for You! The UK Quality and Outcomes Framework Experience
The National Institute for Health and Clinical Excellence (NICE) and University of York share their experiences with the Quality and Outcomes Framework (QOF) with the World Bank Group (WBG). The QOF is a voluntary incentive scheme for general practices in the UK, rewarding them based on how well they care for patients. The QOF contains groups of indicators, against which practices score points according to their level of achievement. Based on their score, practices are fniancially rewarded (up to a maximum amount). This scheme has been in place since 2004, and can provide useful guidance to other countries seeking to implement similar schemes.
NICE has been responsible for managing the development of new clinical and health improvement indicators for the QOF and for reviewing the current QOF clinical indicator set since April 2009. The discussion focused on the NICE-led process for QOF indicator development and experience to date in four key areas: prioritization of clinical guideline recommendations by the QOF advisory committee, development and piloting of quality indicators, cost-effectiveness analysis and retirement of QOF indicators.
The QOF contains 146 indicators which cover secondary prevention for 10 chronic conditions, organization of care, patient experience, and additional services, with each indicator allocated a certain number of points. These data are measured centrally, and achievement scores are publicly reported. The results from the QOF were discussed where incentivized and unincentivized aspects of care were concerned. Incentivized aspects of care saw a significant improvement over projected rates in the first year of incentive, however after the second year, little improvement was observed. The greatest improvements were in the poorest performing practices, often located in more deprived areas, which was promising. Where unincentivized aspects of care were concerned, little effects on quality were observed in the first year, but borderline underachievement was observed by the third year.
Several key lessons were learned from this scheme. First, it is necessary to computerize general practices to enable electronic data collection and measurement. Second, baseline performance levels need to be established, and associated factors need to be identified in order to appropriately design incentives. Indicators should be based on important outcomes or processes with strong evidence of improved outcomes. Third, physician and patient groups should be involved early in the process, and the effects of the scheme on professional behavior and morale need to be monitored. Finally, schemes need to be regularly reviewed, including their effects on unincentivized aspects of care.
This event discusses cost-effectiveness considerations where pay for performance schemes were concerned, and reviews possible methods of calculating the incremental-cost-effectiveness-ratio and their underlying assumptions. The notions of value in health care, cost-effectiveness of treatments, and implementation payments are also discussed.