Depression is not what it seems

This week have been looking at the QOF progress in my own practice and I noticed that the depression figures seemed a little odd. The number of patients needing a second depression assessment (Dep 3) was rather larger than the number of patients needing the first assessement (Dep 2). According to the guidance the former should be a subset of the latter.

Just a reminder of what the indicator says

DEP 3: In those patients with a new diagnosis of depression and assessment of severity recorded between the preceding 1 April to 31 March, the percentage of patients who have had a further assessment of severity 5 – 12 weeks (inclusive) after the initial recording of the assessment of severity. Both assessments should be completed using an assessment tool validated for use in primary care.

Indeed the guidance goes on to say:-

New diagnoses are those which have been made between the preceding 1 April to 31 March.

Clear? There is a slightly odd consequence to this. FIt is difficult to count the need for assessment towards the end of the year. With a first assessment in January the second could be due after all of the data is sent to QMAS. This would tend to work in a practice's favour.

This was not what I actually saw on my practice figures. I looked at the latest version of the business rules (warning - highly geeky) and it seemed all was not well. These are the rules that govern the data that is sent to QMAS for payment and the data that ultimately appears on the QOF Database web site. This year's rule was looking way back past 1st April - back to the start of December 2009 looking for diagnoses.

I got in touch with the NHS Information Centre who are the latest organisation to be in charge of the business rules. It turns out that there is no mistake. The rules were set, in consultation with NHS Employers, to try to fix the issue described earlier. In the process the rules now contradict the wording of the indicator and the guidance.

So what do the rules now say? The "yes" and "no" groups have split slightly so it is worth specifying the numerator and denominator groups separately.

Numerator: Patients who have had a second assessment from the previous 1st April to 31st March. The second assessment must be between 5 and 12 weeks after the first and the first, in turn must be within four weeks after the diagnostic code.

Now the denominator :-

Denominator: Patients in the numerator (i.e. Yes)
and also patients for whom the date of 12 weeks following their first assessment is within the previous 1st April -31 March and who have not had that second assessment (i.e. No)

Those who you failed to get at the end of one year are carried over to the next. The successes are counted in the same year.

What does irk me is not the fact that this was changed - indicators are changed and improved over time - but that this alteration from the original meaning has never been announced anywhere other than the business rules. The description of the indicator, although clearly now misleading, has not been altered. Similarly the guidance remains inaccurate. The business rules are hardly the first port of call for a busy GP.


Anonymous said...

When I asked my software suppliers earlier in the year about this I was advised

"As I have said a number of times on this forum we DO NOT write the rules the
DOH do that, all we do is implement them exactly as written, we do question
nonsense whenever we are able but sometimes this is not listened to and many
times we just have to do as we are told!!!

The only explanation we are given is further down the rule where it states:

Rule 1: The aim of this rule is to identify those patients that have been
diagnosed with depression outside 15 months from the end of the current QOF
Financial year end.
True: If the patient has been diagnosed 15 months outside the end of the
current QOF Financial year end then the patient is disregarded and not
included in the denominator.
False: If the patient has not been diagnosed 15 months outside the end of the
current QOF Financial year end then the patient is further considered.

The indicator was always worded Depression in the last year but this change
came in 2009-10 without any clarification.
This would have to be taken up with your negotiators or the DOH"

Anonymous said...

I think you mean a lack of change in the business rules? You reported on version 16 last year and there is no change in version 17. In fact as QMAS is not live with version 17 yet so you will still be using the same searches as before.

It is the lack of change as you are using 16 which only excludes patients with Hyp before 01/04/09 and not 01/04/10. It is possible that version 17 will never be released on QMAS and they will skip to version 18. Let them know now and they may make a change before the end of the qof year.

As I say thouh, this hasn't changed so is no different if you continued assessing the rules as they were last year.

Karen said...

Something else to be aware of is that Emis PCS contract templates may not be compliant with the contract. A recent QOF validation visit highlighted that our Mental Health Reviews were not compliant with the contract. The MH review should include "cough, wheeze & sputum. In support of our not being aware of the change in contract (despite being told by our PCT there were no changes last year)we are using the fact that Emis PCS contract template doesnt't include this element.

Gavin Jamie said...

Whilst the rules themselves have not changed the way they are designed means that they measure things differently this year to last. So the requirment for practices changes.

Version 17 is out (and has been for nearly five months). It is a 2010/11 version and the IC has stated that this is quite deliberate when I have spoken to them.

The indicator and its guidance are currently wrong (or the business rule is wrong depending on your point of view)

Eva said...

Is DEP3 meant to be a follow of of DEP2?
What I mean by that is that those that have been assessed for DEP2 (the numerator) do they then become the denominator for DEP3? Or is it a different patient group all together?

Gavin Jamie said...

Eva, yes only those who have been assessed for Dep 2 become the denominator for Dep 3. The timing issues above however mean they don't necessarily do so in the same year.