Impact of an enhanced intervention for quality improvement for AF and hypertension: a controlled before-after study

Abstract

Problem: Evidence in favour of using financial rewards to bring about quality improvement in primary care is generally poor. The few benefits which have been demonstrated are inconsistent, often short-lived, and come from data with unreliable control comparisons. The biggest and best known reward scheme is the Quality Outcomes Framework (QOF), which has proved unpopular with surgeries, and has also resulted in some negative effects on care. East Lancashire CCG introduced a local quality framework for general practice for 2016/7 designed to improve standards and diagnosis in AF and hypertension, for a set amount per head of population, rather than the unpopular sliding remuneration scale used by QOF for hitting specific outcome targets. Participating surgeries appointed surgery leads for AF and hypertension, produced their own protocols, and attended quarterly workshops where they reflected with peer groups on protocols and data. This study set out to analyse whether the framework improved the numbers of patients diagnosed, and the quality of care they received.
Approach: This study used published QOF data to compare those surgeries taking part in the intervention (n=57) to controls in the rest of England (n=7243). It adopted a controlled before-after approach, which looked at the primary outcome measures of change in mean recorded prevalence of AF and hypertension at surgery level after 12 months, compared to before the intervention. Secondary measures looked at additional outcomes as indicators of quality of management of patients with AF and hypertension.
Findings: In primary outcome measures, independent T tests showed a significant benefit for the intervention group in the mean increase in prevalence of AF (0.19%) compared to the controls (0.12%), p=0.024, although the mean increase in prevalence of hypertension (0.29%) compared to controls (-0.01%) was non-significant, p=0.141. The mean increase in percentage of patients with optimal anticoagulation management (previous/current CHA2DS2-VASc≥2 and anticoagulated, or CHA2DS2-VASc<2 in past 12 months), was significantly more in the intervention group (5.82%) than in the controls (3.31%), p=0.005. There was no significant increase in patients with hypertension being treated to target ≤150/90mmHg, or in patients ≥45 years having an up to date BP in the past 5 years, although repeated measures ANOVA analysis of the intervention group using local data not available for the control group, showed the rate of new diagnoses of hypertension to be increasing with time, p<0.001.
Consequences: This study demonstrates how a financial incentive as part of quality improvement framework designed to meet local needs, can potentially engage local primary care providers and improve outcome measures for patients, without the need for financial incentives for hitting specific targets. Preliminary analysis of subsequent 12-month data suggests continued improvement in management of both conditions, however a longer time frame to review impact may be necessary.