RESULTADOS EN EL ÍTEM 2

Five modelling articles have been identified, of which three studies are conducted in the UK 226 , 227 , 228, and two in the USA ²²⁹. All these models aim at predicting either the short term financial consequences or the long term health consequences of P4Q programmes.

Kahn et al. (2006) ²²⁹ examine the hospital quality and financial performance under two Pay for Quality programmes in the US, namely the Premier Hospital Quality Demonstration programme with a duration of 3 years and the Medicare Payment Advisory Commission (MedPAC) pay for quality programme. Seventeen clinical quality measures concerning heart attack, heart failure and pneumonia are been taken into account. Under the premier hospital Quality incentive demonstration, hospitals can receive annually bonuses up to 2% (top ten percent performing hospitals). Penalties with a maximum of 2% (hospitals below the 10^th percentile of performance) are only given in the third year and the penalty threshold is established in the first year of the programme. Within the MedPAC P4Q programme hospitals lose 1-2 % of there payment, to create a pool of funds that can be used to pay bonuses. In both the programmes only the top 20 percent of best performing hospitals receive a bonus. The MedPAC approach would redistribute $140 million in payments, the Premier approach would almost pay $10 million more than it collects through penalties. See Table 4.

Table 4 : Winners and losers by Hospital type and by Pay for Quality Program (millions of dollars) by Kahn et al. (2006)

Type of hospital Premier pay for quality

Scenario Medicare Payment Advisory

Commission (MedPAC) pay for quality scenario

Total bonus Total penalty Total bonus Total penalty

All hospitals $39.4 -$30.5 $139.8 -$139.8

Fleetcroft et al. (2006) ²²⁷ explore the link between financial incentives and the likely population health gains within the QOF system. In this study only 38 of the 91 clinical indicators are taken into account. As explained on page 43, the incentives for each indicator rely on a point system, whereby each quality indicator reflects a number of points. Points are then allocated to a GP for a certain indicator, with a related payment that starts above a minimum threshold level of achievement on the indicator. The clinical domain is 550 points (in 2004) out of 1050. The monetary value of one point is estimated at £120 for a general practice of average size.

The potential health gain on the 38 QOF indicators was estimated and expressed in number of lives saved, based on a study by McColl et al. (1998). These authors subdivided these 38 indicators in 8 interventions. As shown in Table 5, the potential health gain ranged from 2.8 lives saved per 100 000 people per year to 308 lives saved per 100 000 people per year. In addition, the potential payments in connection with the pay for quality programme ranges from no payment to £17 280 per year. In conclusion there seems to be no obvious relationship between payment and health gain for these 8 interventions. Some indicators could generate a large amount of health gain against a low payment within the QOF system, others only generate a minimal improvement in health gain against large payments within the QOF system.

Table 5: Relationship between potential health gains and potential payments within the QOF system by Fleetcroft et al. (2006)

Quality indicator Maximum lives saved per 100000 people per year (% of total)

Maximum payment for a typical practice per year (% of total)

ACE in heart failure 308.0 (41%) 2 400 (6%)

Influenza immunization in over 65s 146.0 (20%) 3 600 (10%) Smoking cessation advice and

nicotine replacement 120.0 (16%) 10 440 (28%)

Screening and treatment of hypertension

71.0 (10%) 17 280 (46%)

Aspirin in ischemic heart disease 48.0 (6%) 1 320 (4%)

Warfarin in atrial fibrillation 33.0 (4%) 0 (0%)

Statins in ischemic heart disease 13.8 (2%) 2 760 (7%)

Statins in primary prevention 2.8 (0%) 0 (0%)

McElduff et al. (2004) ²²⁸ estimated the health gain within cardiovascular patients if a number of QOF quality measures were to be met. Five interventions were taken into account, namely the use of aspirin, a cholesterol lowering treatment, a hypertension management, a treatment with ACE or angiotensin 2 (A2) inhibitors and influenza immunization. The modelling method used incorporates data on clinical effectiveness and the baseline rate (current rate) of performance concerning these interventions.

Consequently, the comparator in this study was current treatment. The health gain in cardiovascular patients is expressed in number of cardiovascular events prevented per 10 000 patients, among which is understood, angina pectoris, myocardial infarction, death from coronary heart diseases (CHD), stroke, congestive heart failure, peripheral vascular disease and death from cardiovascular disease. As shown in Table 6, reaching the cholesterol target (lowering the total cholesterol in patients with values above 5.0mmol/l) will result into a reduction of cardiovascular events among patients with CHD, stroke and diabetes with respectively 15.5, 7.2 and 6.5 cases per 10 000 over a 5 year period. Reaching the targets concerning hypertension management, will prevent cardiovascular events with respectively 3.6, 2.9 and 2.9 cases per 10 000 over a 5 year period for patients with CHD, stroke and diabetes. In addition 15.5 events will be prevented by meeting these targets in other patients (no stroke, no CHD, no diabetes).

With regard to the targets relating to aspirin, ACE inhibitors/A2 antagonists and influenza immunization, achieving these targets will only prevent a small number of events, either due to an already widely spread use of these guidelines (use of aspirin, ACE inhibitor, A2 antagonist), or due to a low baseline risk of death because of a currently already high compliance with the indicator (influenza).

Table 6: Potential health gain per indicator within the QOF system by McElduff et al. (2004)

Quality intervention Clinical domain (disease) Number of CVD events prevented over 5 year period Cholesterol lowering

ACE inhibitor /A2 antagonist CHD and HF 1.2

Influenza vaccination CVD 0.003

Fleetcroft et al. (2008) ²²⁶, estimate the potential population health gain of the full implementation of the 8 clinical interventions in both the original and the revised QOF contract. The population health gain is represented by number of lives saved per 100 000 people per year. This research identified evidence for lives saved on 22 indicators in the original contract and 19 indicators in the revised one. The potential of lives saved in the original contract was 415.77 lives per 100 000 in one year. For the revised contract this number raised with 35.73 lives to a potential number of 451.5. In addition, it is important to point out that the comparator in this study was “doing nothing”, whereas there was already a significant baseline activity in primary care before the implementation of the QOF contract. Hence, it should be emphasized that the resulting figures represent a maximum potential. As shown in the table below, influenza immunization (in contrast with the study by McElduff et al (2004) ²²⁸) and primary prevention for hypertension carry the greatest potential for lives saved. It must be noted that influenza immunization was already incentivised before the QOF was introduced, therefore the room for improvement is rather small.

Table 7 : Potential health gain per QOF indicator by Fleetcroft et al. (2008) Clinical

cessation advice/referral 8.8 8.8 See smoking2 - Hypertension BP3: smoking cessation

advice/referral

CHD10: beta blocker 45.9 45.9

CHD11: ACE/ARB 1.5 1.5

CHD12: influenza

immunisation 61.6 61.6

Chronic ChKD3: BP<140/85 - - 26.2 26.2

Kidney disease Chronic obstructive airways disease

COPD5: Smoking

cessation/referral 2.6 27.6 See smoking2 25.0

COPD8: influenza immunization

25.0 25.0

Diabetes DM4: smoking cessation

advice/referral 2.4 109.5 See smoking2 107.1

DM6/DM20: HbA1c<7.4 26.5 26.5

DM7: HbA1c<10 7.4 7.4

DM12: BP<145/85 13.5 13.5

DM15:

Proteinuria/microalbuminu ria on ACE

3.4 3.4

DM18: influenza

immunization 63.7 63.7

Heart failure LVD/HF3: ACE/ARB 11.6 11.6 11.6 11.6

Smoking Smoking2: smoking cessation advice/referral

In domains Included in other domains

10.9 10.9

Stroke Stroke4: smoking cessation

advice referral 1.1 44.9 See smoking2 43.8

Stroke9/Stroke12:

antiplatelet/anticoagulant

15.8 15.8

Stroke10: Influenza

immunization 28.1 28.1

Averill et al. (2006) ⁹⁵ estimate the potential decrease in Medicare payments due to the reduction of post-admission complications in hospital care in a new pay for quality hospital programme in the USA. The Medicare Payment Advisory Commission (MedPAC) recommended an adjustment of the current Medicare Diagnosis-Related Group (DRG) based Inpatient Prospective Payment System (IPPS) under which complications after admission of a patient are being remunerated. Hence when a complication occurs, payment is being increased and thus poor quality of care is being rewarded. The redesign of this DRG system is proposed to reduce those payments due to post-admission complications and requires that present on admission indicators (which specify whether the diagnosis was present at the time of admission) are available for all diagnoses. No explicit financial incentive or penalty is being given, but the system could result in a lower income for hospitals with a large amount of complications in comparison to the current way of remuneration. Currently, hospitals only report discharge diagnoses. Only hospitals in California and New York are required to provide a present on admission indicator for each diagnosis. Data from California are extrapolated to all of Medicare. This results in Medicare payment reductions to hospitals between 0% to 3.29%, with 34.35% of hospitals having a payment reduction below 0.5%, 49.21% having a reduction between 0.5% and 1.5% and 16.43% having a payment reduction between 1.5% and 3.29%. Nationally, the overall reduction amounts to 1.01% of Medicare DRG hospital payments, which corresponds with a reduction in payments of $1.005 billion.

Key points on reported cost effectiveness and modelling effects of P4Q programmes

Cost effectiveness

• One study in the UK and two in the USA focus on cost-effectiveness of P4Q programmes.

• From the twelve QOF-indicators, investigated in the UK study, only one, diabetes retinal screening seemed to be not cost-effective.

• The USA study focussing on P4Q programmes in primary care (diabetic care) showed a positive return on investment ranging between 1.6 and 2.5 per invested US dollar.

• The third study evaluated the cost-effectiveness of hospital P4Q programmes focussing on heart care. Applying a

$

Modelling costs

• Three UK studies, and two USA studies predicted short term financial consequences or long term health consequences of P4Q programmes.

• Concerning the long term financial consequences, one USA study has investigated two P4Q programmes. One programme is break-even, it collects money in a pool of funds that is used to pay bonuses afterwards. The other programme redistributes almost $10 million more than it collects.

• Another US programme estimated the potential decrease in payments due to the reduction of post-admission complications in hospital care. The implementation of such a P4Q programme could result in a payment reduction to hospitals between 0% and 3.29%. The overall reduction equals to 1.01% of hospital payments, with corresponds with a reduction in payments of $1.005 billion.

• One UK study explored the link between financial incentives and likely population health gain within the QOF system. As a result there seems to be no obvious relationship between payment and health gain for these 8

interventions.

• Finally two UK studies estimated the health gain if a number of QOF quality measures were to be met. The first study uses the baseline activity as

comparator, the second study uses no activity as comparator. In the first study reaching the cholesterol target and the targets concerning

hypertension management were the most effective in preventing CHD events in cardiovascular patients. In the second study, influenza

immunization and primary prevention for hypertension carry the greatest potential for lives saved, although is must be noted that influenza

immunization already reaches high achievements. Hence, taking the baseline activities into account, the results of this study are an overestimation of potential life gain.