Wide variation in the provision of evidence-based care is recognized as a fundamental issue in all health care systems worldwide. The consequences of such variation often impact negatively on patients in terms of health care quality, safety, experiences and increased financial costs (including additional treatments and litigation) associated with sub-optimal clinical practices [1, 2].
It is widely accepted that there is a need to minimize unnecessary variation to improve the reliability of best practice care provision and the associated financial costs [2–4]. Practicing evidence-based medicine and implementing clinical care guidelines are promoted to assist clinical decision making and optimal management of patients, but does not necessarily ensure that patients who should receive all appropriate care actually do so [5–8].
Around 50% of hospital patients may receive the full recommended care and treatments which their clinical condition merits. The difference between the highest and lowest performing health care systems suggests that there is ‘an enormous gap’ in evidence-based (or recommended) care provision [1, 9]. In primary care settings, evidence of wide variation has also been found between individual health care providers . For example, in general medical practice in the United Kingdom (UK) substantial variation in patient care has been described in anxiolytic, hypnotic, antidepressant and antibiotic prescribing [11–13].
The Quality & Outcomes Framework (QOF) is a pay-for-performance (P4P) scheme that was introduced to UK general practice in April 2004 to help address longstanding variation in the quality of primary care provision . Clinical conditions are suitable for QOF inclusion and therefore financial incentivisation if they are common, associated with significant morbidity (and to a lesser extent mortality), and are diagnostically unambiguous. Indicators should be evidence based, achievable by every primary care team, clearly defined and consistently extractable from different computerized information systems .
Since 2009, QOF indicators have been developed through a rigorous National Institute for Clinical Excellence (NICE) led process which includes input from an expert panel and extensive piloting . The Framework consists of a number of incentivized ‘point-in-time’ indicators arranged into four main groups: additional services, patient experience, organizational and clinical sections . Practices ‘earn’ points according to their level of achievement for each indicator, with payment currently starting at a minimum threshold (usually 40%) rising to a maximum (usually 90%).
The average achievement of available QOF points for the period April 2009 to March 2010 was 93.7% in general practices in England and 97.2% in Scotland [16, 17]. The implication is that the quality of care delivered by practices to patients with incentivized disease conditions is very high. However, there is some concern that maximum payment thresholds for QOF indicators are actually too low and that the high performances achieved by most practices may give the inaccurate impression that care quality does not necessarily need to be improved further [18, 19].
There is growing interest in the use of composite – as well as individual - measures of care delivery as an alternative method of describing the quality of clinical care processes and outcomes . The main benefit of the composite (‘all or nothing’) approach is that it may highlight opportunities for further improvement in care provision even when individual measures already indicate that care quality is high.
The care bundle concept is one such composite measure that is promoted as a systematic method of monitoring and improving the reliability and quality of health care [20–22]. A care bundle is simply a number of health care interventions grouped together and which normally have a synergistic relationship that impacts on clinical outcome . Bundles usually contain three to six components which may include clinical interventions such as care processes, procedures, or diagnostic tests, but are not deemed suitable to act as comprehensive lists of all possible care. Selection of appropriate bundle components is based on best evidence, local considerations and may change with time and experiences [24, 25].
Specific care bundles have been implemented in a range of secondary care settings such as paediatric and adult ICU, medical and surgical wards and Accident and Emergency departments in North America and the UK [26, 27]. Related clinical outcomes have included significant reductions in health care acquired infections, condition-specific and all-cause mortality, and reduced re-admission rates of elderly patients, length of ICU stay and number of ventilation days [20, 28–30]. Although higher compliance rates with bundles are associated with improved outcomes , these are difficult to sustain because of a combination of system and human factors which often results in rates below 50% [32–34].
Measuring compliance with bundled interventions on a composite ‘all-or-nothing’ basis may provide the healthcare team with a more accurate indicator of care quality and evidence-based care provision . In essence this means every relevant care component should routinely be delivered (or considered) for every single patient on time and every time. Embracing this rationale may act as a greater prompt to improve patient care than the current method of monitoring data with individual bundle elements, which can give a misleading impression of overall performance.
Evidence of the potential value of composite measures of care quality in general practice – specifically QOF data - is limited [36, 37]. Given the benefits of the bundle approach in acute hospital settings, we aimed to develop care bundles based on those QOF disease areas and indicators in general practice that were judged to be most suitable. We further aimed to measure individual and composite compliance with developed care bundles to highlight the extent of any potential care ‘gaps’ which may point to opportunities for further improvement.