More on QOF contract changes

The full details of the English government's enforced contract changes were released today. You can read my annotated version of the letter. Most of the changes were what was expected, certainly in relation to the QOF. There is plenty in the medical media about the changes as well. Here are a couple of bits you may have missed.

There is a plan to renumber the indicators to make them neater. So this years diabetes 31 may be next years diabetes 5. Seems a recipe for confusion and generating extra work at the Commissioning Board to me. Actually seems like a bit of work reprogramming the website to me too!

More serious is the CPI in QOF. For practices with average prevalence there is a certain amount of cash per patient for each point. When the QOF was originally devised this was not really a headline amount so it became £120 or so per typical practice of 5891 patients (5885 in Wales, 5095 in Scotland and 4937 in Northern Ireland)

£120 per 5891 patient is simply a way of saying 2p(ish) per patient. As the value of points rose over the years so did this payment per patient. Practices got bigger on average (whatever the pros and cons, smaller practices are simply not in fashion) but that did not matter. It was still 2p per patient. The government was paying no more, and no less than it planned to for each registered patient.

In the letter the government plans to increase the average list size by 16% and the payment per point by 16%. They say this will be cost neutral in 2013/14, and it will. They are still paying 2p per patient.

In each future year the average will likely rise again. However the value per
point will be by negotiation. Essentially there is not guarantee that the payment per patient will not fall as the average practice size rises. It will depend on negotiations producing a similar rise in point value.

I can see no reason to change this other than as a little time bomb in the future (but then I can't see why you would want to renumber all the indicators. I may not be in the DH mindset.)

This is an obscure part of the calculation although it can't really be said to be hidden - it is there three times- it is easily missed.

2012 English data now on the site.

I am happy to be able to say that the English 2012 QOF data has now been uploaded to the QOF Database website. It joins the Scottish and Welsh data which has been there for a couple of weeks.
There is currently no indication when the data for Northern Ireland will become available.

I still have a couple of tweaks to do, mainly around the organisational area at PCT level and higher to give a good overview of how practices are doing. There is also quite limited data about QP3-5. In these the targets were different for each practice.

There will be one more update this year, when the Northern Ireland data is released and once that is done then I should get the data to download - subject to my copy of Access on the laptop coping with 14 million rows of data!

2012 Wales and Scotland data now online

I am delighted to be able to say that the 2012 data for Wales and Scotland is now on the site. Some of the virtual indicators and registers (mostly around depression incidence and smoking) have not yet been calculated. The site still defaults to 2011 until England data is on (it is 80% of the site) but 2012 is available in the left side menus.

So the English don't feel left out there is also a recalculation of the 2011 data at CCG level. In many cases the composition of the CCG is so similar to the PCT that it makes no difference but it may prove interesting. Either search for the CCG or drill down from England page or up from an English practice.

It is likely to be about three weeks before the English data is available on the site and I have no firm date for Northern Ireland.

Overdiagnosis and Chronic Kidney Disease

Last week's Inside Health on BBC Radio 4 was the first of two editions discussing over diagnosis. The suggestion is that we are creating diseases which are, at best, risk factors. Chronic Kidney Disease (CKD), which has been part of the QOF for a few years now, was given as an example.

It is well worth downloading and listening to. Particular focus was placed on the MDRD formula for calculating the estimated glomerular filtration rate. This is the basis for entry to the register.

The formula (taken from Wikipedia) is

There are only two variables for any given person (race and gender are pretty constant). I see a lot of low eGFRs in older patients and wondered how the formula works. I downloaded Gnuplot and, after a bit of reading the manual, plugged the formula in. I have plotted for non black men but the chart would simply be moved a bit to the left or right in other patients.

For those that don't see that many of these things this is a not untypical range for creatinine. 125 is about the top of the normal range in my lab. You can see how the threshold for CKD (and eGFR of 60 or below) drops from a creatinine of 125ish in a 30 year old to 100ish at 90.

This is actually a smaller effect than I thought it would be but it does give some idea of the shape of the formula. What a low eGFR actually means for individuals remains under some debate.

Smoking indicators

The business rules for the QOF are rather murky place and I am grateful to a couple of people who have pointed out some odd things happening in the smoking cessation areas

Just as a reminder smoking cessation advice now applies to all patients in the practice who are over 15 years old and smoke. There is a difference between those with chronic disease and those without that those with chronic disease should have the advice annually (well, within 15 months of the end of the QOF year) and those without within two years (27 months). So for this year the smoking cessation advice requirements applied since January 2011, or 14 months before the business rules actually came out.

Despite fairly minimal change to the wording the actual smoking cessation indicator has changed. Two codes are now needed to pass this indicator. One code from each of the two following groups. The fist group is basically the same codes as before. The patient should receive advice or be referred or pointed to self referral to a smoking cessation clinic.

8CAL	Smoking Cessation Advice
8HTK	Referral to stop smoking clinic
8HkQ	Referral to NHS stop smoking service
8H7i	Referral to smoking cessation advisor
8IAj	Smoking cessation advice declined
8IEK	A declined code
9N2K	Seen by smoking cessation advisor
13p50	Practice based smoking cessation programme start date
9Ndf	Consent given for follow up by smoking cessation team
9Ndg	Declined consent for follow up by smoking cessation team

This is all pretty sensible. Most of the evidence points to a good smoking cessation clinic improving quit rates. However there is now a second part that requires a prescription to be issued. Note in both these areas there is a declined code. I use EMIS PCS at work and the declined codes are not yet available on the system. That is 17 months after they could first require to be entered.

745H	Smoking cessation therapy (and all its subtypes)
8B3f	Nicotine replacement therapy provided free
8B2b	Nicotine replacement therapy
8B3Y	Over the counter nicotine replacement therapy
8IEM	A declined code
Rx	Smoking cessation product prescription

Quite how this helps anything is beyond me. We have a local smoking cessation clinic that does not (or nor does it need to) inform me every time they advice someone to get some patches at the chemist. Logically the most sensible thing for me to do would be to throw patches at patients like confetti. This is likely expensive for my PCT/CCG and, in the curse of QOF, it seems that nicotine therapy may actually reduce quit rates.

Even the evidence quoted in the official guidelines is confused and muddled.

It would be nice if these retrospective changes were corrected in the next ruleset although past experience suggests that this is policy and not error and change is unlikely.

QOF indicators for 2013-14

NICE is currently consulting on the potential new QOF indicators for 2013-14. These are the indicators that could be put forward to the negotiators in the summer for consideration of the following year's contract. There is certainly no guarantee that they would go forward. This year rather fewer than half of the suggestions in the menu actually made it into practice.

As this is a consultation then the more responses the better. My response to the QOF consultation is on the web in the interests of openness. In generally the aims seem laudable although there are some significant practical problems that may arise with the implementation of these indicators. Some clearly need more work but your view may differ and I would encourage you to put them forwards.

Access Databases to download

The access databases are now available on the download page. These are actually version two. If you have downloaded before Saturday night (21st January) there were some errors in the indicator descriptions and some practice codes - basically a lack of 'N's due to over vigorous removal of null values.

You can download this years data or the data for all QOF years. The latter is a very large download and it makes Access run like an asthmatic sloth but that could all be the way I have set it up. I am no Access guru.

You may also have noticed the new timelines on the site. You can see how achievement for an indicator has changed over time. This is something that would not have been possible on the old site - the new database structure makes it much easier.