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Research article:

Withdrawing Performance Indicators: Retrospective Analysis of General Practice Performance Under the UKs Quality and Outcomes Framework


Kontopantelis, Evangelos; Springate, David; Reeves, David; Ashcroft, Darren; Valderas, Jose M; Doran, Tim(2014) Withdrawing Performance Indicators: Retrospective Analysis of General Practice Performance Under the UKs Quality and Outcomes Framework. British Medical Journal, doi:

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Objectives: To investigate the effect of withdrawing incentives on recorded quality of care, in the context of the UK Quality and Outcomes Framework pay-for-performance scheme. Design: Retrospective longitudinal study. Setting: Data for 644 general practices, from 2004/5 to 2011/12, extracted from the Clinical Practice Research Datalink. Participants: All patients registered with any of the practices over the study period, 13,772,992 in total. Intervention: The removal of financial incentives for aspects of care for patients with asthma, coronary heart disease, diabetes, stroke and psychosis. Main outcome measures: Performance on eight clinical quality indicators withdrawn from a national incentive scheme: influenza immunisation (asthma) and lithium therapy monitoring (psychosis), removed in April 2006; blood pressure monitoring (coronary heart disease, diabetes, stroke), cholesterol level monitoring (coronary heart disease, diabetes) and blood glucose monitoring (diabetes), removed in April 2011. Multilevel mixed effects multiple linear regression models were used to quantify the effect of incentive withdrawal. Results: Mean levels of performance were generally stable after the removal of the incentives, both short- and long-term. For the two indicators removed in April 2006/7, levels in 2011/12 were very close to 2005/6 levels, although a small but statistically significant drop was estimated for influenza immunisation. For five of the six indicators withdrawn in from April 2011/12, there was no significant impact on performance in that year following removal and differences between predicted and observed scores were small. Performance on related outcome indicators retained in the scheme (e.g. blood pressure control) was generally unaffected. Conclusions: Following the removal of incentives, levels of performance across a range of clinical activities generally remained stable. This indicates that health benefits from incentive schemes can potentially be increased by periodically replacing existing indicators with new indicators relating to alternative aspects of care. However, most of the aspects of care we investigated remained indirectly incentivised and further work is required to assess the generalisability of the findings when incentives are fully withdrawn.
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Evangelos Kontopantelis
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Asthma_drugs Download this codelist
Influenza_immunisation Download this codelist
Smoking_status Download this codelist
Coronary_Heart_Disease Download this codelist
Neuropathy Download this codelist
HbA1C_testing Download this codelist
Proteinuria Download this codelist
Spirometry Download this codelist
Angina Download this codelist
Exercise_testing Download this codelist
Asthma_clinicals Download this codelist
Body_mass_index Download this codelist
Serum_Creatine_testing Download this codelist
Thyroid_function Download this codelist
Lithium_therapy Download this codelist
Lithium_drugcodes Download this codelist
Micro-albuminuria_testing Download this codelist
Retinal_screening Download this codelist
Epilepsy_clinicals Download this codelist
Chronic_obstructive_pulmonary_disease Download this codelist
Epilepsy_drugs Download this codelist
Diabetes Download this codelist
Stroke Download this codelist

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