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Michael Caley Samantha Burn Tom Marshall Andrew Rouse 《The British journal of general practice》2014,64(618):e54-e59
Background
General practices in the UK receive incentive payments for managing patients with selected chronic conditions under the Quality and Outcomes Framework (QOF) scheme. Payments are made when a negotiated threshold percentage of patients receive the appropriate intervention.Aim
From 2013–2014 in England the Department of Health has proposed that this negotiated threshold is replaced with a value equal to the 75th percentile of national performance to attract maximum payments. This is an investigation of the potential impact of this change on practice income and workload.Design and setting
Analysis of 2011–2012 QOF dataset (the latest available) which covers 8123 GP practices and 55.5 million patients in England.Method
The 75th percentile of performance was calculated for 52 clinical indicators and applied to 2011–2012 performance. Estimations were made of financial and workload impacts on practices, and whether practices with different characteristics would be disproportionately affected.Results
The proposed changes will result in an increase in the upper payment threshold of each clinical indicator by a mean of 7.47% (range 2.16–38.87%). If performance remains static practices would lose a mean of 47.68 (0–108.33) QOF points, equivalent to a mean financial change of −£279.60 (−£35 352.50 to +£19 957.78) per practice for these 52 indicators.Conclusion
Increasing the QOF upper payment threshold to the 75th percentile of national performance will, if clinical performance remains static, substantially reduce the mean number of QOF points achieved per practice. However, this translates into only a small mean loss of income per practice. 相似文献5.
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Geraldine M Leydon Christopher F Dowrick Anita S McBride Hana J Burgess Amanda C Howe Pamela D Clarke Susan P Maisey Tony Kendrick 《The British journal of general practice》2011,61(583):117-123
Background
Since 2006 the Quality Outcomes Framework (QOF) has rewarded GPs for carrying out standardised assessments of the severity of symptoms of depression in newly diagnosed patients.Aim
To gain understanding of GPs'' opinions and perceived impact on practice of the routine introduction of standardised questionnaire measures of severity of depression through the UK general practice contract QOF.Design of study
Semi-structured qualitative interview study, with purposive sampling and constant comparative analysis.Setting
Thirty-four GPs from among 38 study general practices in three sites in England, UK: Southampton, Liverpool, and Norfolk.Method
GPs were interviewed at a time convenient to them by trained interviewers. Interviews were audiorecorded and transcribed verbatim in preparation for thematic analysis, to identify key views.Results
Analysis of the interviews suggested that the use of severity questionnaires posed an intrusion into the consultation. GPs discursively polarised two technologies: formal assessment versus personal enquiry, emphasising the need to ensure the scores are used sensitively and as an aid to clinical judgement rather than as a substitute. Importantly, these challenges implicitly served a function of preserving GPs'' identities as professionals with expertise, constructed as integral to the process of diagnosis.Conclusion
GP accounts indicated concern about threats to patient care. Contention between using severity questionnaires and delivering individualised patient care is significantly motivated by GP concerns to preserve professional expertise and identity. It is important to learn from GP concerns to help establish how best to optimise the use of severity questionnaires in depression. 相似文献8.
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Reviewing long-term antidepressants can reduce drug burden: a prospective observational cohort study
Chris F Johnson Hector J Macdonald Pauline Atkinson Alasdair I Buchanan Noreen Downes Nadine Dougall 《The British journal of general practice》2012,62(604):e773-e779
Background
Antidepressant prescribing continues to rise. Contributing factors are increased long-term prescribing and possibly the use of higher selective serotonin re-uptake inhibitor (SSRI) doses.Aim
To review general practice patients prescribed the same antidepressant long-term (≥2 years) and evaluate prescribing and management pre and post-review.Design and setting
Prospective observational cohort study using routine data from 78 urban general practices, Scotland.Method
All patients prescribed antidepressants (excluding amitriptyline) for ≥2 years were identified from records November 2009 to March 2010. GPs selected patients for face-to-face review of clinical condition and medication, December 2009 to September 2010. Pre- and post-review data were collected; average antidepressant doses and changes in prescribed daily doses were calculated. Onward referral to support services was recorded.Results
8.6% (33 312/388 656) of all registered patients were prescribed an antidepressant, 47.1% (15 689) were defined as long-term users and 2849 (18.2%) were reviewed. 811 (28.5%) patients reviewed had a change in antidepressant therapy: 7.0% stopped, 12.8% reduced dose, 5.3% increased dose, and 3.4% changed antidepressant, resulting in 9.5% (95% CI = 9.1% to 9.8% P<0.001) reduction in prescribed daily dose and 8.1% reduction in prescribing costs. 6.3% were referred onwards, half to NHS Mental Health Services. Pre-review SSRI doses were 10–30% higher than previously reported.Conclusion
Almost half of all people prescribed antidepressants were long-term users. Appropriate reductions in prescribing can be achieved by reviewing patients. Higher SSRI doses may be contributing to current antidepressant growth. 相似文献10.
Mark Ashworth Peter Schofield Tim Doran Richard Cookson Matthew Sutton Paul T Seed Amanda Howe Robert Fleetcroft 《The British journal of general practice》2013,63(609):e291-e299
Background
Health policy in the UK is increasingly focused on the measurement of outcomes rather than structures and processes of health care.Aim
To develop a measure of the effectiveness of primary care in terms of population health outcomes.Design and setting
A cross-sectional study of general practices in England.Method
Twenty clinical quality of care indicators for which there was evidence of mortality reduction were identified from the national Quality and Outcomes Framework (QOF) pay-for-performance scheme. The number of lives saved by 8136 English practices (97.97% of all practices) in 2009/2010 was estimated, based on their performance on these measures, and a public health impact measure, the PHI score, was constructed. Multilevel regression models were used to identify practice and population predictors of PHI scores.Results
The mean estimated PHI score was 258.9 (standard deviation [SD] = 73.3) lives saved per 100 000 registered patients, per annum. This represents 75.7% of the maximum potential PHI score of 340.9 (SD = 91.8). PHI and QOF scores were weakly correlated (Pearson r = 0.28). The most powerful predictors of PHI score were the prevalence of the relevant clinical conditions (β = 0.77) and the proportion of patients aged ≥65 years (β = 0.22). General practices that were less successful at achieving their maximum potential PHI score were those with a lower prevalence of relevant conditions (β = 0.29), larger list sizes (β = −0.16), greater area deprivation (β = −0.15), and a larger proportion of patients aged ≥65 years (β = −0.13).Conclusion
The PHI score is a potential alternative metric of practice performance, measuring the estimated mortality reduction in the registered population. Rewards under the QOF pay-for-performance scheme are not closely aligned to the public health impact of practices. 相似文献11.
Stephen Campbell Kerin Hannon Helen Lester 《The British journal of general practice》2011,61(585):e183-e189
Background
Exception reporting allows practices to exclude eligible patients from indicators or an entire clinical domain of the Quality and Outcomes Framework (QOF). It is a source of contention, viewed by some as a ‘gaming’ mechanism.Aim
To explore GP and practice staff views and experiences of exception reporting in the QOF.Design of study
Qualitative semi-structured interviews.Setting
Interviews with 24 GPs, 20 practice managers, 13 practice nurses, and nine other staff were conducted in 27 general practices in the UK.Method
Semi-structured interviews, analysed using open explorative thematic coding.Results
Exception reporting was seen as a clinically necessary part of the QOF. Exempting patients, particularly for discretionary reasons, was seen as an ‘exception to the rule’ that was justified either in terms of practising patient-centred care within a framework of population-based health measures or because of the poor face validity of the indicators. Rates in all practices were described as minimal and the threat of external scrutiny from primary care trusts kept rates low. However, GPs were happy to defend using discretionary exception codes for individual patients. Exception reporting was used, particularly at the end of the payment year, to meet unmet targets and to prevent the practice being penalised financially. Overt gaming was seen as something done by ‘other’ practices. Only two GPs admitted to occasional inappropriate exception reporting.Conclusion
Exception reporting is seen by most GPs and practice staff as an important and defensible safeguard against inappropriate treatment or over-treatment of patients. However, a minority of practitioners also saw it as a gaming mechanism. 相似文献12.
Narinder Sahota Andrew Hood Anandagiri Shankar Barbara Watt Sam Ramaiah 《The British journal of general practice》2008,58(557):856-861
Background
There has been increasing interest in the development of performance indicators in primary care, especially since the introduction of the Quality and Outcomes Framework (QOF). Public health and primary care trusts collect a range of data from routine or non-routine sources that may be useful for this purpose.Aim
To assess whether performance against the QOF is a robust measure of practice performance when compared with health-inequality indicators and to contribute to the development of a tool to monitor and improve primary care services.Design of study
A retrospective cross-sectional study.Setting
Sixty-three GP practices contracted with Walsall Teaching Primary Care Trust.Method
Correlation analysis and scatter plots were used to identify possible significant relationships between QOF scores and health-inequality data. The study also utilised confidence limit theory and control chart methodology as tools to identify possible performance outliers.Results
Little correlation was found between overall QOF score and deprivation score. Uptake of flu immunisation (r2 = 0.22) and cervical screening (r2 = 0.11) both showed a slight increase with increased QOF score. Benzodiazepine (r2 = 0.06) and antibiotic prescribing levels (r2 = 0.02) decreased slightly with increased QOF scores, although not significantly. An increase in practice-population deprivation score was correlated with a reduction in cervical screening uptake (r2 = 0.27) and an increase in benzodiazepine prescribing (r2 = 0.25). Statistically significant relationships were found between the patient: GP ratio and flu immunisation uptake (r2 = 0.1) and antibiotic prescribing (r2 = 0.1). The majority of GPs found it acceptable to use performance indicator data as part of their annual appraisal.Conclusion
QOF and health-inequality data can be used together to measure practice performance and to develop tools to help identify areas for performance development and the sharing of best practice. 相似文献13.
Peter Griffiths Trevor Murrells Jill Maben Simon Jones Mark Ashworth 《The British journal of general practice》2010,60(570):e36-e48
Background
In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme.Aim
To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.Design of the study
Cross-sectional analysis of routine data.Setting
English general practice in 2005/2006.Method
QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.Results
A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA1C] ≤7.4%, HbA1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).Conclusion
Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets. 相似文献14.
Eric Robinson Helen Parretti Paul Aveyard 《The British journal of general practice》2014,64(628):e703-e708
Background
Guidelines suggest that GPs should intervene on patients’ weight, but to do so GPs must first recognise that a patient may have a weight problem and weigh them.Aim
To examine whether GPs and trainee GPs can identify overweight and obese body weights by sight, and if this influences whether they would discuss weight with a potential patient.Design and setting
Study of GPs and trainee GPs on the lists of the UK NHS Workforce West Midlands Deanery and NHS Sandwell and West Birmingham Clinical Commissioning Group.Method
Participants viewed 15 standardised photographs of healthy-weight, overweight, and obese young males, and estimated their BMI, classified their weight status, and reported whether they would be likely to make a brief intervention for weight loss with that person.Results
The sample of GPs and trainee GPs correctly classified a mean of 4.0/5.0 of the healthy weight males, a mean of 2.4/5.0 of the overweight, and a mean of 1.7/5.0 of the obese males. For each 1 kg/m2 increase in actual BMI, participants underestimated BMI by −0.21 (95% CI = −0.22 to −0.18), meaning that participants would underestimate the BMI of a man of 30 kg/m2 by approximately 2.5 kg/m2, but were more accurate for lower body weights. Participants were more likely to intervene with those with a higher estimated BMI (OR 1.53, 95% CI = 1.49 to 1.58).Conclusion
This sample of predominantly trainee GPs perceived overweight and obese weights as being of lower BMI and weight status than they actually are, and this was associated with a lower intention of discussing weight management with a potential patient. This was found to be true for trainee and fully qualified GPs who participated in the study. Healthcare professionals should not rely on visual judgements when identifying patients who may benefit from weight management treatment. 相似文献15.
RESPECT trial team S Richmond V Morton B Cross I Chi Kei Wong I Russell Z Philips J Miles A Hilton G Hill A Farrin S Coulton H Chrystyn P Campion 《The British journal of general practice》2010,60(570):e10-e19
Background
The pharmaceutical care approach serves as a model for medication review, involving collaboration between GPs, pharmacists, patients, and carers. Its use is advocated with older patients who are typically prescribed several drugs. However, it has yet to be thoroughly evaluated.Aim
To estimate the effectiveness of pharmaceutical care for older people, shared between GPs and community pharmacists in the UK, relative to usual care.Design of study
Multiple interrupted time-series design in five primary care trusts which implemented pharmaceutical care at 2-month intervals in random order. Patients acted as their own controls, and were followed over 3 years including their 12 months'' participation in pharmaceutical care.Setting
In 2002, 760 patients, aged ≥75 years, were recruited from 24 general practices in East and North Yorkshire. Sixty-two community pharmacies also took part. A total of 551 participants completed the study.Method
Pharmaceutical care was undertaken by community pharmacists who interviewed patients, developed and implemented pharmaceutical care plans together with patients'' GPs, and thereafter undertook monthly medication reviews. Pharmacists and GPs attended training before the intervention. Outcome measures were the UK Medication Appropriateness Index, the Short Form–36 Health Survey (SF-36), and serious adverse events.Results
The intervention did not lead to any statistically significant change in the appropriateness of prescribing or health outcomes. Although the mental component of the SF-36 decreased as study participants become older, this trend was not affected by pharmaceutical care.Conclusion
The RESPECT model of pharmaceutical care (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) shared between community pharmacists and GPs did not significantly change the appropriateness of prescribing or quality of life in older patients. 相似文献16.
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Background
The Quality and Outcomes Framework (QOF) includes indicators for patient experience, but there has been little research on whether the indicators identify practices that deliver good patient access.Aim
To determine whether practices that achieved high QOF patient experience points in 2005/2006 or 2006/2007 also delivered good patient access.Design of study
Use of publicly available data to investigate two hypotheses: practices with more positive access survey findings in 2006/2007 will be more likely to have achieved maximum QOF patient experience points in the same year; and practices with maximum QOF patient experience points in 2005/2006 will have higher access survey findings in 2006/2007.Setting
Two-hundred and twenty-four East Midlands general practices.Method
For hypothesis one, binary logistic regression was used, with achievement of maximum QOF points as the dependent variable, and access survey findings, responder variables, and practice variables as independent variables. For hypothesis two, general linear models were used, with access survey findings as the independent variables, and achievement of maximum QOF points and the responder and practice variables as dependent variables.Results
The findings did not support the first hypothesis. For the second hypothesis, achievement of maximum QOF points was only significantly associated with patient satisfaction with opening hours (positive correlation). QOF points were not associated with any other aspect of access.Conclusion
The QOF patient experience indicators do not reward practices that offer good patient access. A standard patient survey with financial incentive may be more effective in identifying and rewarding practices that offer better access, including opportunity to book appointments with a particular doctor. 相似文献18.
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Isobel M Cameron Kenneth Lawton Ian C Reid 《The British journal of general practice》2009,59(566):644-649