Quality diabetes care comes at a price

By Sally Robertson, B.Sc.Sep 10 2012

Researchers say that the Quality and Outcomes Framework (QOF) that was introduced to UK general practice in 2004 may not be worth the expense of implementing in terms of benefiting patients.

Although the framework has generally helped to improve the quality of diabetes care, the greatest improvements occurred in the first year of the scheme, with only modest improvements achieved in subsequent years, they report.

"The high annual cost of the QOF scheme - over £1 billion (US$1,591,534,938; €1,261,866,168) per year, with almost 10% (£100 million [$159 million; €126 million]) allocated to diabetes care - needs to be assessed in this light," warn Evangelos Kontopantelis (University of Manchester, UK) and colleagues.

The QOF is the largest and most ambitious pay-for-performance scheme ever attempted in healthcare, says the team. An average practice could expect to earn over £ 7500 ($ 11,931; € 9,465) if they achieved all diabetes targets in the first year of the scheme followed by £ 12,500 ($ 19,883; € 15,776) in subsequent years, when incentives were increased.

Using the General Practice Research Database (GPRD), Kontopantelis and team gathered patient-level data from 2000 through 2007 for 23,789 individuals with diabetes from 148 English practices and measured the achievement of the 17 QOF diabetes quality care indicators for each year of the study.

As reported in BMJ Quality & Safety, the recorded prevalence of diabetes across the practices increased from 3.3% to 5.0% between 2000 and 2007.

The recorded quality of care increased for all individual indicators between 2000 and 2007 and a composite quality of care score increased from 46.5% in 2000 to 81.0% in 2007.

In the first year (2004) of the QOF, there was an improvement in composite recorded QOF care that was over and above that expected from the pre-intervention trend, of 14.2%.

By the third year, the difference was smaller, although still significant, at 7.3%.

The team says the decrease in patient gain may first be explained by the fact that achievement for some indicators was close to 100% in 2004 and large improvements beyond this were therefore not possible.

Second, in 2004, most practices exceeded the maximum payment thresholds by reaching the level of achievement required to secure maximum remuneration for most indicators, meaning there was limited financial incentive for further improvement.

"As a result, the QOF may not ultimately have resulted in higher quality of care than would have eventually been achieved in its absence," suggest Kontopantelis et al.

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