Abstract
Executive Summary
Background
The new General Medical Service (GMS) contract was introduced into UK primary care in April 2004. The contract was supported by a significant investment, estimated to be £8 billion by the Department of Health (DoH) in the first 3 years(4). It includes payment for performance against criteria in 4 areas: clinical, organisational, patient experience and additional services. There were 10 clinical domains in the original contract, and this was revised to include a further 8 clinical domains in 2006.(4, 5) Points are allocated on the basis of expected workload and quality of care.(4) Practices achieved a high standard of performance, with practices in England scoring an average of 959 points out of a possible 1050 in 2004/5, rising to 1011 points out of a possible 1050 points in 2005/6 excluding exception reported patients(6). The revision to the contract in 2006 has increased the points allocated to clinical indicators to 665.(5)
Remit agreed with the Department of Health
This research formed a larger part of the project with the University of York and the University of Manchester. The University of York have estimated the cost effectiveness of a subset of clinical indicators, and the University of Manchester are exploring the trends in the performance in a subset of indicators inside and outside the Quality Outcomes Framework (QOF). Our research aims to estimate the potential population health gain of the full implementation of the interventions in the new GMS contract, both in its original form (2003)(4) and its revised form (2006).(5) The number of lives saved is the chosen measure of health gain, as many of the clinical interventions in the new GMS contract have potential to save lives. The “potential” health gain is based on the difference between 100% indicator achievement and zero achievement; however this will be greater than the actual health gain as there was a substantial indicator achievement before the contract was introduced. Secondly, we aimed to construct the aggregate of the number of lives saved per 100,000 populations per year at two levels namely; an aggregate at the domain level and an overall aggregate of all clinical indicators. The research was conducted in the following way:
1. A search was made for the most robust level of evidence for lives saved in terms of risk reduction. Sources used were the supporting documentation for the GMS contract(4, 5), The National Institute for Health and Clinical Excellence (NICE)(7), Clinical Evidence (CE) database(8) and the Cochrane Library(9). Where the absolute risk reduction (ARR) was not reported in a clinical trial, then this was calculated where possible from other measures of health gain such as relative risk reduction (RRR) and odds ratio (OR). This is combined with the UK population prevalence data to calculate the baseline risk.
2. The risk reduction in mortality was approximated to a standardised year, with the assumption of a linear relationship between mortality and time. An adjustment was made for the prevalence of each condition to estimate the maximum health gain across a standardized population of 100,000 in terms of lives saved per year.
Methods
The research includes four stages that mirror the aims of this project, these being search strategy, inclusion and exclusion criteria, sensitivity analysis and strategies for combining data.
1. Search Strategy
Two researchers (RF and SP) independently reviewed four sources for the highest level of evidence for lives saved in terms of absolute risk reduction for all cause mortality for each clinical indicator in the GMS contract 2003 and 2006 versions(4, 5). The sources for evidence were as previously described. A detailed search strategy has been defined in Appendix A. The level of evidence was determined by using the classic “hierarchy of evidence” grading scale designed by the US Agency for Health Care Policy and Research (AHCPR 1992)(10) and adopted by the Cochrane Library(9).
2. Inclusion and exclusion of studies
Studies included have the following characteristics:
Clinical interventions were compared with a placebo control arm.
Studies had clinical interventions that closely matched the clinical indicators.
Studies had all cause mortality as an outcome.
Evidence for effectiveness for each clinical indicator in the new GMS contract was sought in each of the 4 sources independently by each author. Each study that had been identified by this process was then again reviewed by two researchers against the inclusion and exclusion criteria in developing the final list of appropriate studies. 28 studies were included in the final analysis.
3. Sensitivity analysis
Where several studies of similar level were identified for a particular clinical indicator, then the upper and lower risk reductions estimated by these studies were used to estimate an upper and lower limit to the population health gain. The 95% confidence intervals were given for each study included where this has been reported.
4. Results
Evidence for lives saved was found for 19 indicators in the 2006 revised contract.. A further 23 indicators were indirectly linked to a reduction in mortality, as they are necessary processes to deliver results for the directly linked 19 indicators. The number of potential lives saved by the 19 directly linked indicators ranged from 1.0 to 62.8 per 100,000 people per year.
In the 2003 GMS contract(4) the potential lives saved per 100,000 populations per year aggregated at the domain level are: 163.2 lives in coronary heart disease, 105.2 lives in diabetes, 51.5 lives in hypertension, 49.7 lives in stroke, 27.0 lives in chronic obstructive pulmonary disease, 11.9 lives in left ventricular dysfunction, and 8.8 lives in asthma.
In the 2006 revised GMS contract(5) the potential lives saved per 100,000 populations per year aggregated at domain level are: 160.9 lives in coronary heart disease, 103.0 lives in diabetes, 48.7 lives in stroke, 46.3 lives in hypertension, 24.4 lives in chronic obstructive pulmonary disease, 19.2 lives in atrial fibrillation, 12.8 lives in chronic kidney disease, 12 lives in smoking cessation and 11.9 lives in heart failure or left ventricular dysfunction.
In the 2003 contract(4) there was potential for 415.0 lives saved per 100,000 per year (406.1-423.9) aggregated across all clinical indicators and domains. In the 2006 contract(5) this increased by 24.3 lives to a potential for 439.3 lives per 100,000 people per year saved (426.1-455.2) aggregated across all clinical indicators and domains.
Conclusions
Full implementation of the quality indicators in the original GMS contract (2003)(4) can be expected to result in a potential 415.0 lives being saved per 100,000 populations per year. However the actual number of lives saved was lower for two reasons. Firstly, there was a significant baseline activity in primary care before the implementation of the new GMS contract.(11-13) Secondly, less than 100% of the target population received the intervention due to exclusions due to exception reporting and less than full implementation of the contract. Full implementation of the revised GMS contract (2006)(5) increases the potential lives saved to 439.3 per 100,000 populations per year. This equates to approximately 262855 lives saved per 100,000 people in one year for the whole of the United Kingdom population.
Lives saved are a direct outcome of 19 of the 2006 GMS contract indicators, and an indirect outcome of a further 23 indicators. Health gain represents a possible additional criterion to be used when allocating points to indicators and conditions in future revisions of the Quality Outcomes Framework (QOF). Limitations of this study include the use of mortality as a relatively narrow measure of health gain, the assumption of linearity between mortality reduction and time, an incomplete evidence base for some interventions in the GMS contract, the changing prevalence of disease and the assumption that patients in the clinical trials are representative of the UK population. Further research includes developing other measures of quality such as QALYs(2) for as many clinical indicators as possible to inform development and weighting of both current and new indicators in future revisions of the GMS contract.
Background
The new General Medical Service (GMS) contract was introduced into UK primary care in April 2004. The contract was supported by a significant investment, estimated to be £8 billion by the Department of Health (DoH) in the first 3 years(4). It includes payment for performance against criteria in 4 areas: clinical, organisational, patient experience and additional services. There were 10 clinical domains in the original contract, and this was revised to include a further 8 clinical domains in 2006.(4, 5) Points are allocated on the basis of expected workload and quality of care.(4) Practices achieved a high standard of performance, with practices in England scoring an average of 959 points out of a possible 1050 in 2004/5, rising to 1011 points out of a possible 1050 points in 2005/6 excluding exception reported patients(6). The revision to the contract in 2006 has increased the points allocated to clinical indicators to 665.(5)
Remit agreed with the Department of Health
This research formed a larger part of the project with the University of York and the University of Manchester. The University of York have estimated the cost effectiveness of a subset of clinical indicators, and the University of Manchester are exploring the trends in the performance in a subset of indicators inside and outside the Quality Outcomes Framework (QOF). Our research aims to estimate the potential population health gain of the full implementation of the interventions in the new GMS contract, both in its original form (2003)(4) and its revised form (2006).(5) The number of lives saved is the chosen measure of health gain, as many of the clinical interventions in the new GMS contract have potential to save lives. The “potential” health gain is based on the difference between 100% indicator achievement and zero achievement; however this will be greater than the actual health gain as there was a substantial indicator achievement before the contract was introduced. Secondly, we aimed to construct the aggregate of the number of lives saved per 100,000 populations per year at two levels namely; an aggregate at the domain level and an overall aggregate of all clinical indicators. The research was conducted in the following way:
1. A search was made for the most robust level of evidence for lives saved in terms of risk reduction. Sources used were the supporting documentation for the GMS contract(4, 5), The National Institute for Health and Clinical Excellence (NICE)(7), Clinical Evidence (CE) database(8) and the Cochrane Library(9). Where the absolute risk reduction (ARR) was not reported in a clinical trial, then this was calculated where possible from other measures of health gain such as relative risk reduction (RRR) and odds ratio (OR). This is combined with the UK population prevalence data to calculate the baseline risk.
2. The risk reduction in mortality was approximated to a standardised year, with the assumption of a linear relationship between mortality and time. An adjustment was made for the prevalence of each condition to estimate the maximum health gain across a standardized population of 100,000 in terms of lives saved per year.
Methods
The research includes four stages that mirror the aims of this project, these being search strategy, inclusion and exclusion criteria, sensitivity analysis and strategies for combining data.
1. Search Strategy
Two researchers (RF and SP) independently reviewed four sources for the highest level of evidence for lives saved in terms of absolute risk reduction for all cause mortality for each clinical indicator in the GMS contract 2003 and 2006 versions(4, 5). The sources for evidence were as previously described. A detailed search strategy has been defined in Appendix A. The level of evidence was determined by using the classic “hierarchy of evidence” grading scale designed by the US Agency for Health Care Policy and Research (AHCPR 1992)(10) and adopted by the Cochrane Library(9).
2. Inclusion and exclusion of studies
Studies included have the following characteristics:
Clinical interventions were compared with a placebo control arm.
Studies had clinical interventions that closely matched the clinical indicators.
Studies had all cause mortality as an outcome.
Evidence for effectiveness for each clinical indicator in the new GMS contract was sought in each of the 4 sources independently by each author. Each study that had been identified by this process was then again reviewed by two researchers against the inclusion and exclusion criteria in developing the final list of appropriate studies. 28 studies were included in the final analysis.
3. Sensitivity analysis
Where several studies of similar level were identified for a particular clinical indicator, then the upper and lower risk reductions estimated by these studies were used to estimate an upper and lower limit to the population health gain. The 95% confidence intervals were given for each study included where this has been reported.
4. Results
Evidence for lives saved was found for 19 indicators in the 2006 revised contract.. A further 23 indicators were indirectly linked to a reduction in mortality, as they are necessary processes to deliver results for the directly linked 19 indicators. The number of potential lives saved by the 19 directly linked indicators ranged from 1.0 to 62.8 per 100,000 people per year.
In the 2003 GMS contract(4) the potential lives saved per 100,000 populations per year aggregated at the domain level are: 163.2 lives in coronary heart disease, 105.2 lives in diabetes, 51.5 lives in hypertension, 49.7 lives in stroke, 27.0 lives in chronic obstructive pulmonary disease, 11.9 lives in left ventricular dysfunction, and 8.8 lives in asthma.
In the 2006 revised GMS contract(5) the potential lives saved per 100,000 populations per year aggregated at domain level are: 160.9 lives in coronary heart disease, 103.0 lives in diabetes, 48.7 lives in stroke, 46.3 lives in hypertension, 24.4 lives in chronic obstructive pulmonary disease, 19.2 lives in atrial fibrillation, 12.8 lives in chronic kidney disease, 12 lives in smoking cessation and 11.9 lives in heart failure or left ventricular dysfunction.
In the 2003 contract(4) there was potential for 415.0 lives saved per 100,000 per year (406.1-423.9) aggregated across all clinical indicators and domains. In the 2006 contract(5) this increased by 24.3 lives to a potential for 439.3 lives per 100,000 people per year saved (426.1-455.2) aggregated across all clinical indicators and domains.
Conclusions
Full implementation of the quality indicators in the original GMS contract (2003)(4) can be expected to result in a potential 415.0 lives being saved per 100,000 populations per year. However the actual number of lives saved was lower for two reasons. Firstly, there was a significant baseline activity in primary care before the implementation of the new GMS contract.(11-13) Secondly, less than 100% of the target population received the intervention due to exclusions due to exception reporting and less than full implementation of the contract. Full implementation of the revised GMS contract (2006)(5) increases the potential lives saved to 439.3 per 100,000 populations per year. This equates to approximately 262855 lives saved per 100,000 people in one year for the whole of the United Kingdom population.
Lives saved are a direct outcome of 19 of the 2006 GMS contract indicators, and an indirect outcome of a further 23 indicators. Health gain represents a possible additional criterion to be used when allocating points to indicators and conditions in future revisions of the Quality Outcomes Framework (QOF). Limitations of this study include the use of mortality as a relatively narrow measure of health gain, the assumption of linearity between mortality reduction and time, an incomplete evidence base for some interventions in the GMS contract, the changing prevalence of disease and the assumption that patients in the clinical trials are representative of the UK population. Further research includes developing other measures of quality such as QALYs(2) for as many clinical indicators as possible to inform development and weighting of both current and new indicators in future revisions of the GMS contract.
| Original language | English |
|---|---|
| Publisher | unpublished |
| Number of pages | 130 |
| Publication status | Unpublished - 7 Nov 2007 |
