10 Tip for QOF coding.

I have written a guide to coding in QOF for Pulse Magazine. The brief was for 1000 words so it is fairly concise. You can find it here (free registration required).

All four countries' QOF data is now on line at the QOF Database. All of the data is also on the download page in both CSV/SQL format and also as a complete Microsoft Access database.

The publication of the Irish data was a little bit limited so you may notice that there is no palliative care data for Northern Ireland and the patient survey data is limited to the scoring range. Other than this the data is complete.

Wales joined England this year in not including all of the practice names and addresses so these may be a little out of date where practices have moved recently.

Scotland and England data now online 2008/9

I am delighted to be able to announce that the English and Scottish QOF data is now online. The Welsh and Northern Irish data was published by their departments of health today and I hope to have this online by Wednesday or Thursday. Downloads to follow at the end of the week but I will send another email when everything is on.

Results of the QOF seem to be roughly comparable to last year with the loss of points to practices coming from the survey results.

There are a couple of things to note in the data. Quite a lot of the Scottish data, particularly in mental health, has been held back due to small numbers causing a risk of confidentiality breach. Whilst this is right and proper it can be a little frustrating.

England did not release a full address lookup table this year (and later in the week it will become apparent that Wales has not either). I have used addresses for previous years and everything should work fine. Addresses may be a little out of date. If you work at a practice with incorrect details and have and "old style" NHS email address which features your practice code e.g. fred-blogs@gp-X99999.nhs.uk then you can correct this. If you corrected details last year these remain intact.

As you were

In one of the less predicted side effects of swine flu QOF is to be unchanged for 2010/11. In the deal on swine flu vaccination it has been agreed that no changes will be made and the NICE recommendations will be popped into the cupboard until needed again.

Additionally the patient experience thresholds will be moved by an unspecified amount for practices that achieve an unspecified rate of vaccination. A little more work needed there I suspect.

These changes may be worth as much to practices, until 2011 at least, as the actual fee for giving the jab.

Changing the thresholds - shaking it all about

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.

Going out?

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.

Coming in?

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.

Patient survey results out, but not available

My practice received the results of the nation patient survey today. As most practices are probably aware these relate to last year, 2008/9, and apply to two new indicators in the Patient Experience domain. Just as a reminder -

PE7 Patient experience of access (1)
The percentage of patients who, in the appropriate national survey, indicate they were able to obtain a consultation with a GP (in England) or appropriate health professional (in Scotland, Wales and NI) within 2 working days (in Wales this will be 24 hours).
Range 70-90% 23.5 points

PE8 Patient experience of access (2)
The percentage of patients who, in the appropriate national survey, indicate they were able to book an appointment with a GP more than 2 days ahead.
Range 60-90% 35 points

As you can see these command quite a lot of points, more than Stoke, Heart Failure, Cancer and Palliative Care combined.

Now that we have seen our results we are absolutely ... Ah, can't actually tell you how we feel about them. I can tell you other people aren't happy and are questioning the statistical validity due to very small sample sizes, but not if I feel the same. You see it is a secret. It is not, I hasten to ask our secret but instead it is the government's secret - at least until a time of their choosing. The statistics came with this warning:

The data is restricted until full national publication of all survey results by the Department of Health. The data must not be shared with any third parties except where expressly permitted by the Department of Health. This includes giving any indication over the content such as "favourable" or "unfavourable" comparisons of data.

Sharing of individual results with GP practices is permitted. Any communications with GP practices over their individual results should also enforce the confidentiality of the data and the duty not to share the data with any other third party ahead of official publication. A template letter will be available from the Department of Health to help in this regard.

PCTs should also refuse any Freedom of Information requests for this information, given national plans to publish the GP patient survey data. Any wrongful release of data to any other third party should be reported immediately to the Department of Health and may lead to an inquiry.

Now, I would hate to spoil a good press conference (30th June apparently) but we are now in the bizarre situation situation of GPs trying to get a handle on whether there is a systemic problem here without proper information. I personally receive three copies of the survey, all with different ID numbers and returned them all!. It is impossible to see if there is a problem or not without the data. Emails going around are a little cryptic as they can't disclose the data. All in the name of a stage managed press release. Expect to see a lot of argument about this over the next couple of weeks.

Update your address, possibly

I am delighted to announce a new feature on the site about which I am quite excited although I must admit may disappoint a lot of you.

Over the past couple of years I have received a steady trickle of emails about practices with incorrect details on the database. This can because practices have moved, merged, or changed hands. Commonly it is due to not terribly good details in the first place. It can be impossible to tell one practice from another within the same building in some cases.

Other emails have pointed out that this site appears rather higher in the rankings of search engines than their own website which caused confusion amongst users.

The answer is to allow practice to update their own details. This can be more easily said than done however. It required quite a bit of messing around in the entrails of the site although the same process has given a more intelligent search form.

The really difficult bit is trying to unsure that only practices can change their details. Somewhat to my surprise the NHS IT people have not yet provided a reliable way of making sure that a GP's identity on-line is who they say they are. The closest I can come is the old style email addresses in England which contained the practice id as part of the address. For many practices, even with nhs.net addresses this old address will still work. For practices outside England so such system has ever existed to my knowledge.

So please have a go if you can, and my apologies if you cannot. Suggestions for an on-line verification scheme for other practices gratefully received!

What to do now - part two

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!

Evidence in diabetes and depression

Medical evidence is always changing. The QOF is meant to be based on robust evidence. Problems arise when new evidence arrives between the decisions being made to include something and their actual implementation. We are now a week away from several new indicators coming on line and the evidence for two of them is starting to look less than great.

Most seriously an editorial in the BMJ(paying customers only) suggests that the new targets for diabetes are unlikely to improve the lot of patients with the condition. In a review of the editorial even the NHS Nation Prescribing Centre is concerned by these indicators. The tighter indicators come in on the 1st of April.

A research paper, again in the BMJ, looked at the use of depression questionnaires in practice (free to read!). It found them to be inconsistent with each and having little bearing on treatment. All rather troubling as the number required to be administered under QOF is to double next month.

Now things certainly do change but the evidence for either of these interventions was previously weak and yet they were still included. It is to be hoped that there will be a more robust attitude to evidence when NICE takes over the assessment of possible indicators. There is little that is dramatic in the government response to the QOF consultation but it was rather good to see just how many GPs took the time to respond to the consultation. My response is here. Unfortunately we will now have at least a year incentivising GPs to do some things that are not really supported by good evidence.

Smoking recording - don't panic

It is only two weeks until the final collection of data for payment for this year. However it seems that this will not be collected correctly, at least in the case of smoking status. Appearing in the less than grippingly titled QMAS End of Year Communication is the revelation that the business rules have been incorrect this year and that there is not enough time left to correct them.

Don't panic though. There will be new searches put in by the GP computer system suppliers and put into QMAS (and presumably the separate systems in Wales and Northern Ireland) at some unspecified point in the future. This will inevitably increase the number of points to each practice. No practice will lose due to these changes. Practices need to make sure they look out for when to correct this data and that their PCTs remember to give them the opportunity.

QOF indicators review consultation

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!

What to do now

Happy New Year. 2009 is upon us and there is three months left for practices to polish those QOF figures. The really organised practices will be look towards the changes to QOF 2009/10.

Two of these indicators start from now (well yesterday actually). Firstly is the COPD annual review which must now include the MRC Dyspnoea scale. This is a five point scale and is listed below with byte Read codes.

  1. Not troubled by breathlessness except on strenuous exercise 173H
  2. Short of breath when hurrying or walking up a slight hill 173I
  3. Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace 173J
  4. Stops for breath after about 100 m or after a few minutes on the level 173K
  5. Too breathless to leave the house, or breathless when dressing or undressing 173L

We use the EMIS PCS system in my practice and you can download our MRC Dyspnoea Template.

The second new indicator that has started is the requirement to give women seeking emergency contraception, routine contraceptive pills or patches information about long acting reversible contraceptives (LARCs) - basically coils, injections and implants. NICE guideline. I can't find a good read code for this so I am making up a local code under 611 (5 byte - contraceptive advice) which I will block change when the rules come out (September most likely).

Best of luck!