Making exception: 2 - How?

Last week I looked at the reasons for exception reporting. In this entry I will go into some detail about how exception reporting actually works in practice. In particular how the business rules work out the exceptions and how practices decide what codes to enter.

When it comes to the business rules the exceptions fall into three main groups. Firstly there patients who are recently registered with the practice or recently diagnosed are automatically excepted. There is no need for practice intervention in this - the number of potential exceptions are simply dependant on the practice turnover and the number of new diagnoses. The length of the exemption is three months for most 'process' areas (e.g. blood pressure measurement) and nine months for 'outcome' measures (e.g. blood pressure below 150/90)

Secondly are the exceptions which apply to a whole domain. These are generally speaking due to reasons of patient dissent or unsuitability (e.g. hypertension in the terminally ill). Patient dissent is taken as being either actively expressed or a failure to respond to three invitations to review.

Thirdly exceptions may apply to a specific indicator. Patients may decline to have a flu jab or be allergic to a particular drug. Alternatively they may be on the maximum possible dose of treatment drugs and there simply is no further treatment.

To add to the complication each of the exceptions only count if the target is missed. If the patient subsequently makes the target in an area then the exception is ignored in that area. Thus a new patient will only be exempted from a target about having blood pressure measured until they actually have it measured or three months, whichever comes sooner.

In actually applying the codes there are further complications around whether the codes need to be repeatedly entered each year or not, but the above explanation should be enough to understand the basic process.

The latter two types of exception are controlled by the insertion of Read codes by the practice. Now it would be nice to think that the practice sat down in April and worked out who would be inappropriate to test or treat and entered the codes appropriately. They might invite all their patients to the surgery for review and code those who declined.

In reality, of course, it doesn't work like that. Most GPs don't particularly enjoy exception coding - it somehow feels like failure. Well it certainly doesn't in my surgery or any that I know of. Explicit dissent is recorded throughout the year until about January time then the figures are looked at closely. It is then that unsuitable patients are coded and the letters sent out. If the maximum threshold is crossed then we can all relax and stop exception coding.

So much for anecdote, but is there any sign that this is happening over a wide area? The answer is yes, at least in Brighton. A study there showed everyone getting much the same level of achievement in the areas that they looked at. There was a difference in that deprived areas had a much higher level of exception reporting. This could be interpreted as an increased level of exception reporting in reaction to targets being more difficult to reach. The alternative, and less politically correct interpretation, would be that patient in deprived areas are more resistant to treatment.

In the model presented here the two drivers to exception reporting are thus the practice list turnover and the practice's desire to seek out codes - the latter may be driven by likely achievement levels. There is also likely to be a direct population consent effect similar to that we see with immunisation uptake around the country.

Next time I will look a the currently published data and, using what we have explored so far, look at how they can be analysed. I will also look at what level of detail we can look at.