Exception reporting in England - all new!

In all of the general excitement(!) of the release of the 2006/7 QOF data it would be quite easy to miss the QOF exception bulletin produced by the Information Centre for England for the same year. Not perhaps the most gripping of documents but very useful none the less. It is rather dry with plenty of statistics but relatively little comment and no exploration of the reasons behind individual indicators. If you are not familiar with exception reporting in QOF it may be worth looking back at past exception articles.

I am not going to repeat any of the data there, rather to try to provide a little background to help understand what is going on. Page 11 (and to their credit the page numbered 11 is also the 11th page of the PDF - certainly not universal) shows a table of the top ten excepted indicators. There is also the bottom ten but I will concentrate, as I imagine most people will, on the highest figures.

Top of the list is CKD 3 (CKD and hypertension with BP less than 140/85) which has an exception rate of nearly 30%. The equivalent indicator for hypertension alone (BP5) does not even reach the top ten. What is going on here? Well firstly hypertension is very difficult to control in kidney disease so maximum tolerated can quite easily be reached. There is, however, a bigger and more technical issue. Following diagnosis of a condition a patient is automatically excepted for the next nine months if they don't meet the target. This was a new indicator this year and was not really a commonly made diagnosis before. With a simple assumption that practices started work on this QOF a year before (April 2006) then three quarters of the patients could have been excepted if they did not hit the target ( 9/12 ). Suddenly 30% seems fairly good. We can expect to see this drop next year.

Next is CHD 10 (beta blockers in CHD) which has always had a high exception reporting component. Rises a bit this year may be due to the advice that beta blockers are not much use after a year following a heart attack. They are also used much less first line for hypertension than previous due to new research. QOF is looking a bit dated here. Expect a rise again next year.

At third is AF 02 (ECG to diagnose atrial fibrillation) at 21%. Once again this indicator is for quite a short period - looking back over a year. Thus in this case 25% could be excepted automatically. Still fairly high though.

The timescale issue is also true of Asthma 8 (reversibility) at 20%, Stroke 11 (referred for investigation) at 18% and Dep 2 (depression scoring) at 17%. Again these only apply since first of April 2006.

MH 6 (comprehensive care plan) actually seems quite low at 17% due to the mental health register containing everyone who has ever had a psychosis or bipolar disorder - whether they still have the condition or not. MH 9 (annual review) is much the same at 15%.

Finally in the top ten is Epilepsy 8 (fit free for a year) at 17%. This reflects the difficulty in controlling some forms of epilepsy combined with a general lack of problem seen by some patients with occasional fits.

What is interesting is that only Epilepsy and beta blocker indicators have some clinical relevance in the exception reporting. All of the others (eight out of ten) say more about the business rules and the administrative nature of the indicator rather than patients or practices. So the take home message has to be don't place too much importance on exception reporting rates.