NICE Quality Standards & Performance Measures: QOF & COF Tim Stokes Consultant Clinical Adviser General Practitioner, Ashby de la Zouch, Leicestershire [email protected] Overview • Performance measures • Quality Standards • Quality and Outcomes Framework (QOF) – Overview of the NICE Managed QOF • Experience to date (2009-2011) • Commissioning Outcomes Framework (COF) – Overview Performance Measures Performance Measures (1) Institute of Medicine, US, 2002 • Patient perspectives – patient assessment and satisfaction with their access to and interactions with the care delivery system • Patient outcomes – mortality, morbidity, and physical and mental functioning • Clinical quality measures Performance Measures (2) Institute of Medicine, US, 2002 • Clinical quality measures – specific quantitative indicators • to identify whether the care provided conforms to established treatment goals and care processes for specific clinical presentations – consist of a descriptive statement or indicator – Have a list of data elements that are necessary to construct and/or report the measure – Have detailed specifications that direct how the data elements are to be collected – may also include thresholds, audit standards, or other benchmarks of performance A performance measure – QOF QOF 2012-13 Indicator wording Points Threshold ID (%) OST1 The practice can produce a register of 3 patients: 1. Aged 50-74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan, and 2. Aged 75 years and over with a record of a fragility fracture after 1 April 2012 OST2 The percentage of patients aged 3 between 50 and 74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, who are currently treated with an appropriate bone-sparing agent - 30-60 Where do NICE Quality Standards fit in? What are NICE Quality Standards? Quality Standard: set of specific, concise statements and measures, developed from evidence-based guidance, that act as markers of high-quality and cost-effective care or services in a specific area. NICE quality standards (17) Registration requirements Proportion of services Standard of services Unsafe Substandard Adequate Good Excellent How will quality standards be used? • NHS White Paper Equity and Excellence: Liberating the NHS – “To achieve our ambition for world-class healthcare outcomes, the service must be focused on outcomes and the quality standards [developed by NICE] that deliver them” • Health and Social Care Bill – Secretary of State and National Commissioning Board have a duty to improve quality of services and in discharging this duty they ‘must have regard’ to NICE quality standards – Commissioning guidance for clinical commissioning groups will include NICE quality standards Where quality standards fit in the measurement pathway Clinical Guideline Recommen dations Quality Standard statements Quality Standard measures - Audit Criteria Performance measures for: QOF COF QOF: paying GPs to perform … Tim Hunkin Under the Pier Show Southwold , Suffolk, UK The QOF • Incentive scheme (2004) – Open to all primary medical care providers – rewards GP practices for implementing systematic improvements in quality of care for patients • Contains sets of clinical, organisational and patient experience indicators • Practices are assessed against the indicators – score points according to their achievement • Points generate income for the practices (P4P) – £1bn ($1.5bn; €1.1bn) spend each year (15% of primary medical care costs) – £76 ($114; €84) per point (1000 points in total) • 25% of GP practice income (2009-10 data) NICE led QOF process (2009 – date) • Independent body with transparent processes – should be clear to all stakeholders why certain clinical areas have been prioritised for development as QOF indicators – Independent Advisory Committee – Indicators published on NICE menu ahead of negotiations • Considers cost effectiveness as well as clinical effectiveness – Net benefit approach used • Indicators are piloted • QOF as a vehicle for quality improvement – existing indicators will be retired – new indicators introduced when certain criteria are met Who does what? • NICE – Manchester and London based – Primary Care QOF Indicator Advisory Committee • The External Contractor – Primary Care Group in the School of Health and Population Sciences at the University of Birmingham in collaboration with the York Health Economics Consortium - YHEC • The NHS Information Centre • Key partners, including UK devolved administrations What is NICE’s role? • √ Managing the process of developing and reviewing the QOF clinical and health improvement indicators – Ensure consultation with individuals and stakeholder groups – Publish an annual “menu” of new, evidence-based indicators – Make recommendations about existing indicators • X Deciding which indicators are included in the QOF – this will continue to be negotiated by NHS Employers on behalf of the DH and the BMA GP Committee How QOF indicators are developed Characteristics of Performance Measures: judgement or improvement? Indicators for Judgement Indicators for Improvement Unambiguous interpretation Variable interpretation possible Unambiguous attribution Ambiguity tolerable Definitive marker of quality Good data quality Screening tool Poor data quality tolerable Good risk-adjustment Partial risk-adjustment tolerable Statistical reliability necessary Statistical reliability preferred Cross-sectional Time trends Used for punishment/reward Used for learning / changing practice For external use Mainly for external use Data for public use Data for internal use Stand-alone Allowance for context possible Risk of unintended consequences Lower risk of unintended consequences Raleigh VS, Foot C. Getting the measure of quality opportunities and challenges. London: The King’s Fund, 2010 Key points in QOF process NICE Quality Standards Review of current QOF areas Indicator development, piloting and consultation Review by QOF Advisory Committee and publication DH, GPC and NHS employers Changes to QOF indicators negotiated using the NICE menu 24 Months NICE Managed Prioritisation of evidence-based recommendations by QOF Advisory Committee NICE and the QOF: experience to date (2009-11) Overall (2009-2011) 42 new QOF indicators developed using NICE process 29 (69%, 29/42) approved by QOF AC 22 (76%, 22/29) negotiated into QOF 2011/12 (9) 2012/13 (13) Retirement (2009-11) 22 QOF indicators have been recommended for retirement by the AC Just under half (45%, 10/22) have been retired from QOF by the negotiators Just under half (45%, 10/22) of the indicators recommended for retirement are “paired” indicators, where they relate to a health care process that will still be required to occur for another QOF indicator following any retirement of the indicator (CHD5; CHD6; BP) The future of QOF? Moving from activity to outcomes Paying for Activity Paying for improved health care processes - drug or nondrug interventions - Diagnosis - Review Paying for improved health outcomes - Intermediate outcomes - true health outcomes TO IMPROVE THE QUALITY OF CARE Types of QOF Indicators Category Number (%) QOF Points (%) Average points Points achieved per Achieved as % practice of Available Health Outcome* 1 (1.2) 6 (0.9) 5.3 89.1% Intermediate Outcome° 12 (14.0) 173 (24.8) 167.3 96.7% Process measure directly 14 (16.3) linked to Health Outcomes+ Process measure 42 (48.8) indirectly linked to Health Outcomes≈ Disease Register 17 (19.8) 116 (16.6) 113.5 97.8% 331 (47.5) 311.5 94.1% 71 (10.2) 70.5 99.3% Total 697 (100) 668.2 95.9% 86 (100) * epilepsy – seizure free in past 12 months ° e.g., BP target; cholesterol target; HbA1c target +delivery of drug therapy or other interventions that directly improve health outcomes; ≈ where the link between process and improvement in health outcomes is less direct (e.g. use of a diagnostic test, clinical measurement, clinical review, advice) The Commissioning Outcomes Framework (COF) Commissioning Outcomes Framework (COF) • The purpose of the Commissioning Outcomes Framework will be to: – drive local improvements in quality and outcomes for patients – hold Clinical Commissioning Groups (CCGs) to account for their progress in delivering these outcomes • Include some proxy indicators of outcomes that are good predictors of improvement – ‘intermediate’ outcome indicators – processes that are shown to have a strong link to outcomes What is a COF indicator? (1) • NICE Quality Standards – Will form the basis of quality indicators that can be used to measure the quality of specific aspects of clinical care achieved through clinical commissioning groups – The focus of NICE’s work will be measuring health care processes that are linked to health outcomes – COF indicators developed by NICE are intended to be indicators for judgement • Working definition: • An indicator used to assess the quality of the services commissioned locally by CCGs, that translate the NHS Outcomes Framework, and other outcomes or proxies for outcomes into indicators that are meaningful at local level. What is a COF indicator? (2) NHS Commissioning Board Clinical commissioning groups COF indicators: • measure quality • NHS CB to hold CCGs to account •CCGs to hold providers to account •“outcomes” bit of COF Providers Key points in COF process NICE Quality Standard Development of draft COF indicators NHS IC COF Advisory Committee - Prioritisation of draft COF indicators Indicator field testing NHS Commissio ning Board COF Advisory Committee - Approval of final COF indicators Recommends COF indicators 12 Months NICE Any questions?