QOF News: QOF_review

The third thing that the QOF Advisory Committee dealt with was possible changes to the thresholds for existing indicators. These are the triggers for payment in the clinical indicators. Briefly practices start getting paid when their achievement in a given indicator reaches the lower indicator (currently 40% for everything except MH 6 and DEM 2 where it is 25%). They gain points smoothly until the upper threshold at which they gain the maximum points. Maximum thresholds current vary from 50% to 90%.

The committee does not seem to have approached this task with any great enthusiasm. However the the potential changes in thresholds are the most significant aspect of the whole of its recommendations so far. Practices have been excellent at hitting the targets already set. The committee noted that on the only occasion that thresholds have been increased, a couple of years ago, there was an overall increase in exception reporting as practices became more diligent at seeking these out.

There area a lot of caveats and the committee recommend that most of the details need to be worked out in negotiations - it regards the overall effect on practices at beyond its brief. When moving the thresholds the committee has suggested this should be on a historic basis, picking a threshold that would have previously been missed by half or three quarters of practices. This has the strange effect that success will be met by things becoming harder and failure in an indicator will result in it being easier. There will be a disincentive to achieve anything above the upper threshold although I would expect this effect to be mild.

There is also a proposal to change the bottom threshold of indicators (currently 40% for most inductors) to a level that 95-99% of practices have achieved although it is acknowledged that there is little evidence for setting at any particular level.

The practical upshot of all of this for practices is more work to get the same money, or the same work to get less money. I have looked where the centiles (1st,5th,50th and 75th) in the 2008 data are. You can see a full list of where these new thresholds would lie(Excel or Opendocument spreadsheets) . This covers one year only and the committee has suggested looking back over two but I would not expect a huge difference. No indicator gets easier to achieve and many - even at the 50th centile - get much harder. I have not yet modeled the changes at practice level, things are still a little uncertain, but this could be similar to the square root loss in terms of its effects. Even the Advisory Committee notes that the losses are more likely to be concentrated in more deprived areas and may increase health inequalities.

The effects of these changes will not only make many indicators harder but also make the framework more complicated. All of this now passes to the negotiators and we wait to see what is agreed. Personally I think it unlikely we will see much change in the lower threshold. The upper threshold is likely to be much more fluid.

The QOF advisory committee also looked at indicators that might be removed. This makes sense as there is no point in suggesting new areas without trying to free up some cash to pay for them. You can read the full details in the minutes but I will give a summary here.

This was split into two areas. As nobody really knows what happens to service delivery when an indicator is removed they were classified as low risk and higher risk. The low risk areas were:

• CHD 5, Stroke 5 and DM 11 - The measurement of blood pressure in coronary heart disease, stroke/TIA and diabetes.
• DM 5 - The recording of HbA1c in diabetes
• DM 16 - The recording of cholesterol in diabetes

You may have spotted a theme here. These are all about the recording of measurements, or to use the NICE jargon, process indicators. They do not represent outcome. They all have matched outcome indicators. The outcome indicators are not quite a perfect match, of course. Outcome indicators have a much longer exception time after diagnosis or registration (9 months) than the process indicators (three months). They are also much more likely to be affected by other exception reasons such as patient preference for medications and patients having maximum tolerated therapy.

The QOF committee does not currently deal with either the points value of indicators or the thresholds, which is a pity. The effective indicator only works as a combination of criteria, thresholds and points and any division into parts is likely to miss some aspects of the whole. What we can say is that simple removal of these areas would represent a disinvestment in these areas. The degree varies by area. In diabetes the process indicators tend to be about a quarter of the value of the outcomes. The loss of these process indicators is in total about £5 per patient with diabetes. The figures for CHD and stroke are £4.30 and £2.64 respectively (these figures are for the whole register- the amount you gain or lose by performing a blood pressure on a patient already on the register, within the thresholds would be double these figures). To put it another way these indicators are worth £2,282 for an average practice in England.

It is possible to overstate the effects of these losses but there is now no incentive payment for measuring blood pressure in patients unlikely to hit the outcome targets - the patients most at risk.

The committee also suggest three indicators for removal which they state have a higher level of risk.

• DM 22 - eGFR or creatinine testing in patients with diabetes.
• MH 4 - Creatinine and TSH testing in patients on lithium
• Thyroid 2 - Checking TSH in patients on thyroxine - the committee also noted this would leave Thyroid 1 (the register) on its own with no other indicators. They did not actually write "so what would be the point?" but I'm sure I heard them in my head.

Diabetes would still require enough blood tests that the renal function box is virtually bound to be ticked at some point. It was, however, at least a nod to the importance of renal function in diabetes, especially in patients taking metformin.

I am no psychiatrist but lithium certainly seems to be yesterday's drug these days. Around 5% of practices have no patients at all taking lithium. I personally would drop all the lithium indicators.

There really does seem to be little point in keeping the thyroid register if the indicator goes. It is automatically generated. Could we see the first clinical area to be dropped from QOF since its introduction?

Next time - the possibility of changing the thresholds.

The QOF Advisory Committee at NICE has published the minutes of its first couple of meetings which took place in June and July. I must admit that I have quite high hopes of this committee. In fact I have to declare that I applied to sit on it myself although was not selected. The very fact that its minutes have been published is a sign of some improvement in the whole process. We can all see the indicators being proposed and developed. In this posting I will look at the new indicators that they have put on what they describe as the "menu".

On a really very busy day in June they looked at a lot of proposed indicators, and found most of them wanting. The majority were sent back for more work. This has had the unfortunate result of leaving their menu looking somewhat bare. Additionally the committee has not suggested the number of points or ranges that should be attached to each indicator. In fact there is so little detail that these seem more like a list of raw ingredients than fully prepared dishes. These proposed indicators will go on to the negotiators and may possibly become part of QOF.

First the good news. A proposal for staged indicators for blood pressure in diabetes at 150/90 and 140/80. It has long been a perverse part of the QOF that it was much more lucrative to deal with mild disease than more significant disease and this would both reward tighter control and extend the reach of the QOF. Much will depend on the points awarded to each area - no details are given.

Much lower on the practicality scale is the suggested annual thyroid blood tests for patients with Down's syndrome who are over 18. The clinical and financial case for this in the briefing papers is somewhat thin at best. Even worse is the practicality of this indicator. A rough calculation (based on a birth prevalence of 1 in 1000 and a life expectancy of 50) suggests that a typical practice would have around three patients to check annually. Small practices would have fewer and, as we are dealing with such small numbers, many are likely to have none at all. These practices would not be eligible for the points at all in a similar way to that seen already with the lithium indicators. In 2007-8 579 practices (out of ten thousand or so) gained no points for these as they had no patients taking lithium.

The final indicator on the menu proposes the mentioning of contraception and conception advice to women of reproductive age currently treated for epilepsy. It seems to assume that they are quite forgetful and suggests they should be reminded annually. It is difficult to argue that this is a bad thing to do but there is little evidence for any positive effect either. Even the economic experts say that there is so little evidence that assessment is impossible.

It is a rather disappointing menu with little that is new and exciting and little that seems likely to be of significant clinical benefit. The committee sent many other potential indicators back as "must do better" and we wait to see if they can. Next time - what might be going out.

Back in January the I posted the first What To do Now article. Basically a reminder of which new QOF indictors "went live" back then. If you have not read that then I would suggest giving it a look before coming back here.

I did miss one thing off the January post which was the requirement for everyone on the CKD register to have either an albumin:creatinine or protein:creatinine ratio recorded in the notes. Actually the protein:creatinine ratio is not officially recommended but it is all that some laboratories will do and will still count for the QOF.

What is new is a second assessment of the severity of depression - 5 to 12 weeks after the first one. Despite evidence that these assessments are of minimal use at best there will be twice as many of these this year. The timing here is quite crucial and will make a lot of difference to how it will work in practice. To put it simply following a diagnosis of depression you will have 28 days to code the first assessment. From the time of the first assessment you will have to complete the second between five and twelve weeks after that. Why is this significant? Well any patients who have their first assessment after 7th January 2010 and then miss their second will not be counted. If they do have their second but had their first before 25th February 2010 they will be counted. After that they never will be counted. There is a short window of potential catch up time in the new year. For this year you will need to start on the second assessments from the 7th of May (for those patients with their first assessment on the first of April just gone).

Finally there are two primary prevention indicators. PP1 is simply the calculation of a Framingham risk score (or ASSIGN score for readers in Scotland) for all patients diagnosed with hypertension since April the first who have not had CHD, Diabetes or stroke in the past. Patients already on statins or similar will also not be expected to have a score although this may need an exception code. You have three months before (?) or after the date of diagnosis to do this.

PP2 asks that all patients who have been diagnosed with hypertension since the start of April have advice about diet, exercise, smoking and drinking sometime this year. There are already separate codes for each and these may be used for the rules although how they deal with non smokers and tee totallers remains to be seen. Templates would be useful here and if you have any I would be delighted to publish them to a wider audience.

You can find the full rules and regulations at the BMA site, although I'm not sure for how long as they tend to shuffle their links without warning.

Good Luck!

Monday is the last day for responses to the Department of Health consultation on changes to the process of review of indicators in the QOF.

I have sent in my own response to the consultation. It is proposed to move the development of indicators across to NICE although there is no terribly good reason given why this should be done. In any case their economic model is just a bit muddled - a pity as this is the major new innovation in the process. We await the results!

The BMA has moved faster than I have ever seen in getting details of the new QOF indicators out. After a rather vague press release this morning this afternoon produced a letter from Lawrence Buckman with a link to the details of the QOF changes.

It is only three pages and well worth a read. Highlights include the addition of a requirement for albumin:creatinine ratio in all patients on the chronic kidney disease register. This may raise a few eyebrows in biochemistry labs around the country who may not know what is going to hit them. (If they want to know what is going to hit them then a quick browse around the CKD register on the site may be useful. Around 1.8 million urine samples are headed their way.)

The current contraception indicators have gone and are replace by 8 points - six of which are for plugging coils and implants. It will be interesting to see the evidence base for this one. This will be at least a small crumb of comfort to university practices likely to be hit hard by the loss of the square root formula.

There is a bit about primary prevention in those newly diagnosed with hypertension - which should be a manageable number. In essence this boils down to finding out if they smoke, eat badly, drink alcohol and take no exercise and telling them not to do these things. I am really trying not to be cynical but very few patients are under any illusions about any of these things and it always seems a little lame.

There is a tidy up in diabetes with three thresholds including a tough 7% HbA1c (again evidence will be interesting to see). Inhaler technique is out and the MRC assessment - which is purely function is in. Actually quite a usable scale and much easier than finding an inhaler and watching them use it.

Finally depression. There is a new indicator for the reassessment of depression severity after 5-12 weeks using PHQ-9 or whatever. The patients aren't free of the questionnaires yet!

The last word has to go to Laurence Buckman - chair of the General Practitioners Committee and now Youtube star.

Results of negotiations on next year's contract have been released last night. There is quite a bit of information although the final details are not absolutely clear.

First off there is a bit about money. There is agreement on how uplift for 2009/10 will be allocated. This may prove to be a bit academic in the current climate as it is not entirely clear whether there will be any extra cash on the table. This will be up to the DDRB. The cash will be divided up with 37% going to the Global Sum - 11% to the correction factor (to maintain MPIG) - 26% to QOF and 26% to Enhanced Services.

The effect of the above is likely to allow the Global Sum and MPIG to rise roughly together but a larger percentage increase in QOF and even large in Enhanced Services. Thus QOF is going to be a more significant income source to practices than it was before.

So what of the QOF itself? Well the big thing to go is the survey. The Department of Health has decided to do its own, by post. This is probably a relief to practices, to whom the administration was a hassle, and to those patients who feel bombarded by surveys. It may be a bit of a kick in the teeth for the nice people at GPAQ but there is of course nothing to stop people from continuing to pass them out anyway.

This will free 55 points from PE 2 and PE 6. There are also another 17 points being shaved off other (undisclosed) indicators. There is probably an interesting bit of work to show the effects of shaving points on overall achievement in those areas. These 72 points are going into new clinical indicators for which we have some vague suggestions. Official(ish) bits in bold.

• Helping to prevent the development of cardiovascular disease in people diagnosed with high blood pressure (13 pts) - other than controlling their blood pressure I assume. Possibly cholesterol measurement but this does not seem enough points for this - just measuring BP currently gets 20 points.
• Advice on long term contraception(10 pts) - for whom? Is this to combat teenage pregnancy. Long term contraception tends to be used in the over 30s - aiming to change this?
• A new indicator for depression to reduce early cessation of treatment (20 pts) - no idea how this might work.
• Beta blockers for heart failure (9 pts) - which is one of this year's new DESs
• Improvements to the indicators for chronic kidney disease (11 pts), diabetes (7pts) and chronic lung disease (2pts) - or at the very least changes.

In addition the square root formula has gone from next year, and with the uplift for those practices with less than 5% of the maximum prevalence will go in 2010/11. These changes turn things into a much simpler item of service payment once over the 40% threshold.

Developments awaited.

Updated 12:45 with points data and square root stuff.

We are now about a third of the way through the QOF year and I have just come back from my holidays to find that the new version of the QOF business rules has arrived. It is a no more gripping read than it was before and fortunately the changes are fairly minor this year. Most of the obvious changes seem to be in the area of smoking - both the clinical area and Records 22. This is the area that has received most attention this year - at least in terms of the coding areas. Just a reminder of what the guidance says:

The guidance has also been updated and in particular we would draw your attention to amendment to non-smokers and ex-smokers. Non-smokers should be recorded as such up until the age of 25 while the smoking status of ex-smokers should be for 3 years and only thereafter if their smoking status changes.

Now this has been implemented almost exactly as you see it here (for the one problem see below). Arguably there is a degree of ambiguity, and a missing bracket, in the way that the rule about three years is written but I am sure that the system suppliers can be relied on to implement it sanely. There is, however, an interesting anomaly in the way that the text above specifies the criteria. If a young man were never to have smoked by the age of 24 this would still have to be coded on an annual basis. If, however he had smoked when he was 15 and then became an ex smoker this would only have to be recorded from the ages of 18 - 20 and can then be stopped. Ex-teenage smokers are thus less work than those who have never smoked.

There are not that many young people in the smoking clinical indicators - they just don't feature in the chronic diseases that much with the possible exception of asthma and for asthmatics the smoking indicator only starts at age 20 (there is another indicator for younger asthmatics at Asthma 3). However around 80% of the practice population is also covered in Records 22, including all of the 18-25 year olds. For a typical practice this represents about 4742 patients. There are only 11 points here, around £1370 equivalent to just 58 pence for each patient in the "scoring zone" from 40-90%. It is likely that annually chasing young people who don't often attend the surgery to check that they have not started smoking will simply be uneconomic. That is not to say that nobody will do it though. For 2006/7 practices achieved 82% overall.

The recording of ex smokers for three years is however rather fragile. This may cause problems in the future although the effect should be limited this year. The problem is that the rules look only at the most recent codes and this could trip practices up. If a patient had given up smoking you could record this in years one, two and three. They would then not need a record again - ever. However if you recorded in years one, two and three - missed year four and then recorded again in year five another code would be needed in year six. The rules would see the code in year five and missed the previous year and not the three codes in the years before.

Now this is not really the fault of the rules writers. The structure of the rules is not that flexible and they have done their best within these limits. The rules have a very linear structure and there is no option for looping or iteration. The designers of QOF at the DH and the BMA are getting more ambitious with much more complex targets; the smoking rules are probably the most complex in the whole of the framework so far. Many people have big plans for new QOF areas in the future and it may be time to look at an overhaul of the way the rules are set and the systems that implement them. We are likely to see an increasing number of problems of this nature unless ambitions are reigned in a bit - and personally I don't see that happening.

A couple of weeks ago the BMA issued its guidance on the QOF changes for this year. Basically some organisational areas were cut and the points transferred to two new areas to be based on surveys of patients.

The survey questions seem likely to be very similar, if not identical, to those asked about appointment booking in the 2007 patient survey.

As we have some data to go on, for England at least, the effect of the changes can be modelled at practice level. In fact I have done this for all practices in the UK, simply the results are likely to be less reliable outside England. In particular the square rooting of the COPD prevalence is based on the English average - slightly overestimating losses outside England.

To find the data for individual practices just use the search or browse pages to find the practice and then select from the menu on the left side.

The BMA has released details of the changes to QOF targets for the year 2008-9. Actually this is more a summary of where the changes are as the detailed guidance is not yet out, and it is in the detail that the interesting details are located.

The headline is probably the removal of fifty eight and a half points largely from the organisational domain but five points have also been take from the COPD spirometry measurement section. The spirometry has also been made more explicit in asking for post bronchodilator spirometry.

There are some other minor changes. They are worth knowing early because they may be difficult to catch up with later in the year. There is now a requirement to refer all patients with stroke or TIA within one month of diagnosis. Along with the spirometry changes this will apply to new diagnoses from the first of April 2008. The reference date for ECG investigation in atrial fibrillation has also been moved to the same date.

One of the changes with widest effect may be the changes to the smoking area - particularly as it affects around one in five patients. As it stands this refers only to the clinical area on smoking which refers to those with diabetes, cardiovascular and lung disease. Patients with psychotic and bipolar disease have now been added to this area (probably a drop in the ocean) and the criteria have changed. Currently if a person had never smoked then you didn't have to ask them again. If they had ever smoked they needed to be asked annually. Now all patients under 27 need to be asked annually and you can stop asking those 27 and over who have never smoked or have not smoked for over three years. My sympathies go to whoever has to write the business rules for that one.

In practical terms this is likely to mean fewer patients needing coding over the course of the year as there are few patients under 27 years old on the chronic disease registers. The BMA guidance seems to suggest that there is to be no change to the organisational smoking indicators which apply to the whole of the practice population over 15 years old. As it stands it would appear that the old rules (if they have ever smoked then you need to ask annually) still apply to RECORDS 22. This would seem to be an odd situation, but I am sure that they have spotted it already!

Finally prevalence day is being moved to March 31st from next year which makes a lot more sense. It takes seconds to do the calculation on a computer and allowing six weeks turned out to be overkill.

Update 1st April

A Department of Health letter landed on my desk today confirming that the smoking rules apply to both the clinical and organisational sections.

Perhaps an old fashioned phrase to describe a significant event but there have been questions in Parliament about the QOF. At health questions this week the Alan Johnson defended of putting cash into extended hours rather than clinical areas. He accused the BMA of propaganda in suggesting the reverse. That suggestion seems to have produced a sharp intake of breath from the Honorouable Members. Ultimately though, like most parliamentary answers, there is more heat than light here.

As many of you are probably aware the site has had information about the potential loss of cash to practices under the government's proposed imposed changes to the QOF in England. If you have not seen this you can click on the link on the left of each of the practice pages. There is also table of the changes effects at PCT level.

Of course now that we have these statistics we can look at the breakdown a little. As I have said before the threshold changes will mostly affect those who have had most problems in meeting the targets. The practices that have tended to have lower score have tended to be those in more deprived areas. A reasonable hypothesis would be that more deprived practices tend to loose out more.

We can go onto test this. Helpfully the deprivation index for most practices was published as part of last year's GP patient survey. We can put all of this together in a spreadsheet and work out the loss per patient for the threshold changes and overall for whole set of changes. Not difficult as we have practice list size from the QOF data as well.

As it turns out there is a correlation between the deprivation and the cash lost through threshold changes at practice level. For the mathematically minded the correlation is 0.13 - not particularly strong but it is there. In practical terms the thousand least deprived practices are to loose 62 pence per patient whilst the thousand most deprived practice will loose 84 pence per patient - a difference of 12 pence. For a "typical" practice of 5891 patient this works out at £1,287 per year between the most and least deprived practices.

This all looks pretty bleak but there is another factor that works against this effect. The removed points take more from practices that have gained all of these points in the past. Statistically these tended to be practices in the least deprived areas. If we bring in the removed points then the effect almost disappears. The correlation drops to 0.03 which is small enough to be ignored.

So balance is restored - whether by luck or judgement! It does however give some idea of the less obvious effects of changes to QOF.

It has been a busy few weeks. Just as I was starting to digest a report suggesting the development of the QOF then the negotiations for changes to next year's GMS came crashing to a halt. The report is still worth reading, if only for the summary of research done with QOF data thus far.

There is a pretty good summary of the situation in a letter from Laurence Buckman - chair of the GPC which I would recommend reading. In summary, for the impatient, the government (only in England for now) is imposing changes to the contract to move cash from QOF and Choose & Book and put it towards increased hours of availability. This, we are told, its only priority for primary care this year. Arguably this is a move from quality to quantity

As far as QOF is concerned several indicators are to be removed taking with them a total of sixty points.

• Holistic points (20 of them) - points for consistency - all gone
• Records 3 (1 point) - communication with out of hours service
• Education 4 (3 points) - induction training for new staff
• Management 2 (1 point) - computer back up
• Management 4 (1 point) - instrument sterilisation to national standards
• Management 6 (2 points) - job description for all new posts
• Management 10 (2 points) - employee procedure manual (absence, bulling etc)
• Medicines 4 (3 points) - repeat prescriptions in 72 hours - 48 hour target remains
• Medicines 11 (7 points) - medication review for patients on four or more medications (review for all patients remains)
• CS 5 (2 points) - there is a system for inform women of smear results
• CHD 12 (7 points), Stroke 10 (2 points), DM 18 (3 points) and COPD 8 (six points) - flu jabs in high risk groups

As there are 1000 points in the QOF a rather obvious bit of maths shows a 6% drop already. There is more, however. Initially the scoring area for each of the indicators started at 25%. This was increased two years ago to 40% and this new imposition will increase it to 50%. The top thresholds for payment will also be increased to something around the mean of current achievement. This second part is likely to be more significant for most practices. Pretty much by definition half of practice would be expected not to hit this higher threshold.

The effect of all this remains to be seen. We already know that exception reporting tends to be reactive - i.e. there is more exception reporting when below the threshold than above it. This is largely because practices stop reporting when they get over the threshold. It would not be unreasonable to expect a bit of an explosion in exception reporting with these changes. Of course there will almost certainly some increase in achievement but the extent is uncertain.

We can use the data we already have to try to model the effect of these changes - and apply them to last 2006/7 data although with the caveat above. This should be online in the next day or so.

Waiting, waiting. We are waiting for this years data but just around the corner is also the report from the review group as to what they would like to see in next year's QOF.

Well a rather heavy hint has arrived in the form of Evaluation of standards of care for osteoporosis and falls in primary care commissioned by the Information Centre from the Kings Fund. (it was published co-incidentally with the National Library for Health's Osteoporosis & Fragility Fractures National Knowledge Week which I seem to have missed).

The King's Fund document is a very thorough review of current information in practice systems about osteoporosis (basically not a lot) and the possibilities of generating some useful QOF targets. It seems to be possible. It is however a relentlessly practical document - for which its authors deserve a lot of credit. It is acknowledged that it is very difficult to work out differences in coding from differences in practice. New codes and a proper definition of treatment are required. The huge (and probably undefinable) strain on investigative resources in secondary care are also highlighted. One final conclusion stands out as understanding the problems with QOF.

A preferred set of codes would need to be agreed and disseminated to GPs at least three months before implementation.

You would not normally think that you needed to point out that design needs to come before implementation, but in the wake of last year's mental health mess apparently you do.

Only one problem remains - what goes out for this to come in? No word yet and very little time if it is to be implemented properly next year.