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Research article:

Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework


Doran, Tim; Kontopantelis, Evangelos; Valderas, Jose M; Campbell, Stephen; Roland, Martin; Salisbury, Chris; Reeves, David(2011) Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework. British Medical Journal, doi: 10.1136/bmj.d3590

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Objective: To investigate whether the incentive scheme for UK general practitioners led them to neglect activities not included in the scheme. Design: Longitudinal analysis of achievement rates for 42 activities (23 included in incentive scheme, 19 not included) selected from 428 identified indicators of quality of care. Setting: 148 general practices in England (653 500 patients). Main outcome measures: Achievement rates projected from trends in the pre-incentive period (2000-1 to 2002-3) and actual rates in the first three years of the scheme (2004-5 to 2006-7). Results: Achievement rates improved for most indicators in the pre-incentive period. There were significant increases in the rate of improvement in the first year of the incentive scheme (2004-5) for 22 of the 23 incentivised indicators. Achievement for these indicators reached a plateau after 2004-5, but quality of care in 2006-7 remained higher than that predicted by pre-incentive trends for 14 incentivised indicators. There was no overall effect on the rate of improvement for non-incentivised indicators in the first year of the scheme, but by 2006-7 achievement rates were significantly below those predicted by pre-incentive trends. Conclusions: There were substantial improvements in quality for all indicators between 2001 and 2007. Improvements associated with financial incentives seem to have been achieved at the expense of small detrimental effects on aspects of care that were not incentivised.
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Tim Doran
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4 comments have been posted.

Jan. 31, 2014, 6:32 a.m. - David Springate

From Supplementary material ( Identification of patients for quality indicators For indicator denominators, patients with the relevant conditions were identified using diagnostic Read codes. The Quality and Outcomes Framework reporting rules for practices list acceptable codes for identifying patients with relevant conditions,1 but we included additional codes to avoid underestimating prevalence and to control for changes in coding behaviour following the introduction of the scheme.2 As practices might not have attached diagnostic codes to all relevant patients, we conducted sensitivity analyses by identifying additional patients using relevant management, referral, admission and prescription codes and terms. For example, for the main analysis patients with diabetes were identified using codes beginning C10 (diabetes mellitus), excluding non-diabetic specific codes (e.g. C10F811 – metabolic syndrome). Additional patients for sensitivity analyses were identified using codes relating to diabetic management (e.g. 66A – diabetic monitoring), referral (e.g. 8H4F.00 – referral to diabetologist), complications (e.g. 2BBF – retinal abnormality, diabetes related) or treatment (e.g. repeat prescriptions for insulin). The numbers of additional patients identified were generally small, and the results of the sensitivity analyses did not differ substantially from those of the main analysis. Patients for whom targets were met were identified using relevant Read codes and free-text terms.

Jan. 31, 2014, 6:34 a.m. - David Springate

Codes used for the main and sensitivity analyses are marked in the 'analysis' column in the row lists.

Jan. 31, 2014, 6:35 a.m. - David Springate

If codes are included in the QOF business rules (2009), this is indicated in the 'QOF' column

Jan. 31, 2014, 6:39 a.m. - David Springate

Codes used to define indicators are detailed in page 7 of the full text article.

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