Objectives To quantify the relationship between a national primary care pay-for-performance programme, the UK's Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework.Design Longitudinal spatial study, at the level of the "lower layer super output area" (LSOA).Setting 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012.Participants 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care.Intervention National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators.Main outcome measures All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality.Results All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality.
ConclusionsHigher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.
IntroductionPrimary care has enormous potential to improve population health outcomes-including mortality from common chronic conditions-through early intervention in the disease process 1 2 and coordinated provision of care. Effective primary care is associated with reduced morbidity, increased longevity, and more equitable health outcomes, 3 4 but quality of primary care varies widely between providers.5 6 Traditional physician payment systems have facilitated this variation, with fee-for-service systems potentially incentivising over-investigation and over-treatment, and capitation systems potentially incentivising under-utilisation. Neither approach directly rewards high quality care or investment in quality improvement. [7][8][9] In order to improve patient outcomes, policymakers worldwide have attempted to link remuneration for providers to quality of care through pay-for-performance programmes. Multiple programmes have been implemented across a range of settings, but clear evidence for improved patient outcomes is yet to emerge. [10][11][12] In the United Kingdom a national primary care incentive scheme was introduced in 2004. The Quality and Outcomes Framework (QOF), one of largest pay-for-performance programmes in the world, links up to 25% of family practitioners' income to performance on o...