Can a local intervention for quality improvement for AF and hypertension work better than QOF? A controlled before-after study

Problem

Evidence in favour of using financial rewards to bring about quality improvement in primary care is generally inconsistent, often short-lived, and comes from data with unreliable control comparisons. The biggest and best-known reward scheme is QOF, which has proved unpopular with surgeries, and has some negative effects on care. East Lancashire CCG has run a local quality framework for general practice since 2016/7 designed to improve standards and diagnosis in AF and hypertension, for a fixed amount per head of population, rather than the sliding remuneration scale used by QOF. 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. The first year’s data presented at last year’s conference showed a significant increase in recorded prevalence of AF and optimal anticoagulation management but no significant benefit in hypertension measures. We have analysed the second year’s data to see whether they showed the same effects.

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 24 months, compared to before the intervention. Secondary measures looked at additional outcomes as indicators of quality of management.

Findings

In primary outcome measures, independent T tests showed a significant benefit for the intervention group in the mean increase in recorded hypertension prevalence (0.59%) compared to the controls (0.20%), p=0.004, although the mean increase in AF prevalence (0.26%) compared to controls (0.20%) was non-significant, p=0.168. There was a significant increase in patients ≥45 years having an up-to-date BP in the past 5 years in the intervention group (0.55%) compared to controls (0.23%), p=0.002. 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 (9.58%) than in controls (5.99%), p<0.001.

Consequences

There have been ideas in recent times about what alternatives or accompaniments to QOF might best improve outcomes for patients. This study demonstrates how a funded quality framework designed to meet local needs, can engage local primary care providers and improve patient outcome measures, without the need for financial incentives for hitting specific targets. Potentially, it offers an alternative, more successful method for funding quality improvement within existing services. However, similar to findings of some earlier quality-improvement schemes that demonstrated only short-lived benefits, there are suggestions that long-term benefits can be difficult to maintain, as the significant increase in recorded AF prevalence seen after 12 months was not continued by 24 months.