GPPAQ not as fiddly as they would have you believe

Updated with correction 17th May

In this new QOF year there are two indicators added the the hypertension area about the assessment of physical activity. You can see the argument here - physical activity is generally good for the cardiovascular systems and specifically can have a beneficial effect on the blood pressure. There is a second indicator for a brief intervention to encourage exercise.

The chosen method to do this by the GPPAQ form with associated guidlines. The method of calculating this in the paper through that link is a bit fiddly. It involves cross referencing across two tables and is simply slow to do. There is an online version of the questionnaire at Patient.co.uk. Only the first three questions are used, the answers to rest are ignored, which seems a poor repayment of effort.

On closer inspection it appears that this is a needlessly complicated way of working out the result and that it is much easier to just allocate each answer a numerical value and calculate the result at the end. It should be no more complicated than working out the result of one of the "Smash Hits" personality analyses of my youth.

Is your occupation :

• None or sedentary (0 points)
• Standing (1 point)
• Physical Handling (2 points)
• Heavy lifting work (3 points)

How much physical exercise (jogging/gym/football/swimming but not cycling) do you do weekly?

• None (0 points)
• Less than an hour (1 point)
• One to three hours (2 points)
• More than three hours (3 points)

Home much cycling do you do a week?

• None (0 points)
• Less than an hour (1 point)
• One to three hours (2 points)
• More than three hours (3 points)

Just add up the points

• Zero points - inactive
• 0.5 to one point - moderately inactive
• 1.5 to two points - moderately active
• 2.5 points or more -active

Simple! Of course you may be thinking to yourself that you are sitting in front of a computing device of such power that it would have you burnt as a witch as late as the 1990s and you should not be asked to add up numbers yourself. In that case I have a javascript GPPAQ calculator which is no more or less accurate than the Patient.co.uk on but is less cluttered and I am happy for you to use the code in your own systems under BSD license.

If you use EMIS PCS I have written a protocol (with thanks to EMIS Support for squashing the bug) which asks you the questions and inserts the Read code automatically. You can download it here and then import it through protocol designer.

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.

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.

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).

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!

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.

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!

New Business Rules (v12) for 2008/9

We are now about a third of the way through the QOF year and I have just come back from my holidays to find that the new version of the QOF business rules has arrived. It is a no more gripping read than it was before and fortunately the changes are fairly minor this year. Most of the obvious changes seem to be in the area of smoking - both the clinical area and Records 22. This is the area that has received most attention this year - at least in terms of the coding areas. Just a reminder of what the guidance says:

The guidance has also been updated and in particular we would draw your attention to amendment to non-smokers and ex-smokers. Non-smokers should be recorded as such up until the age of 25 while the smoking status of ex-smokers should be for 3 years and only thereafter if their smoking status changes.

Now this has been implemented almost exactly as you see it here (for the one problem see below). Arguably there is a degree of ambiguity, and a missing bracket, in the way that the rule about three years is written but I am sure that the system suppliers can be relied on to implement it sanely. There is, however, an interesting anomaly in the way that the text above specifies the criteria. If a young man were never to have smoked by the age of 24 this would still have to be coded on an annual basis. If, however he had smoked when he was 15 and then became an ex smoker this would only have to be recorded from the ages of 18 - 20 and can then be stopped. Ex-teenage smokers are thus less work than those who have never smoked.

There are not that many young people in the smoking clinical indicators - they just don't feature in the chronic diseases that much with the possible exception of asthma and for asthmatics the smoking indicator only starts at age 20 (there is another indicator for younger asthmatics at Asthma 3). However around 80% of the practice population is also covered in Records 22, including all of the 18-25 year olds. For a typical practice this represents about 4742 patients. There are only 11 points here, around £1370 equivalent to just 58 pence for each patient in the "scoring zone" from 40-90%. It is likely that annually chasing young people who don't often attend the surgery to check that they have not started smoking will simply be uneconomic. That is not to say that nobody will do it though. For 2006/7 practices achieved 82% overall.

The recording of ex smokers for three years is however rather fragile. This may cause problems in the future although the effect should be limited this year. The problem is that the rules look only at the most recent codes and this could trip practices up. If a patient had given up smoking you could record this in years one, two and three. They would then not need a record again - ever. However if you recorded in years one, two and three - missed year four and then recorded again in year five another code would be needed in year six. The rules would see the code in year five and missed the previous year and not the three codes in the years before.

Now this is not really the fault of the rules writers. The structure of the rules is not that flexible and they have done their best within these limits. The rules have a very linear structure and there is no option for looping or iteration. The designers of QOF at the DH and the BMA are getting more ambitious with much more complex targets; the smoking rules are probably the most complex in the whole of the framework so far. Many people have big plans for new QOF areas in the future and it may be time to look at an overhaul of the way the rules are set and the systems that implement them. We are likely to see an increasing number of problems of this nature unless ambitions are reigned in a bit - and personally I don't see that happening.

New Business Rules (v10)

There is presumably some schedule behind the production of new business rules for QOF. These are the rules that govern the data extraction from practice systems and are negotiated across all four countries. For this reason they tend to be a bit of a camel.They pop up every six months or so, and the version numbers seem to increase by 0.5 each time. Counter intuitively it is the ones ending in .5 that are the big ones but with version ten of the business rules being recently released what is new?

Well not a lot. This has its downsides. Mental health is still a bit of a mess with its Hotel California register (once you are on it you can never leave). For the most part this will be something of a relief to practices who don't fancy changing all of their codes again.

There are a few changes worth noting. Firstly smoking exception codes have disappeared, but only for Records 22. The exception codes (for informed dissent and unsuitability) are still there for high risk groups counted in the smoking indicators.

Also in relation to smoking patients under 20 with asthma are no longer in the high risk group. I don't know why, especially as patients of that age with diabetes, heart disease or strokes are still in there, but there you go.

More important changes have been made to dementia assessment. There is now a specific code for annual review ( 6AB ) and the old, vaguer, codes no longer count.

In a similar vein the old LVD exception codes no longer apply (those starting 9h1 ) and have been superseded with 9hH codes.

My suggested action plan for practices would be

• Check the review codes for dementia (especially on templates) since April and make sure they are 6AB
• Check the exception codes for heart failure (templates again) and make sure you are using 9hH codes

Happy coding!

QMAS trips up

Now if there was one thing that seemed to be reliable in the new work of NHS IT it was the QMAS computer. It was hailed as a great success by Connecting For Health. It was an early win. Yes, it wasn't in their original brief and it was not an especially complex system, but it did have over 10,000 users and it worked well. Until today.

There have been no problems for the last two years but today it has failed under load for much of the day. Nine thousand practices are trying to sign off their data. All this has snowballed for the simple reason that the more error reports that are sent, the more people press OK. Users are also managing to lock themselves out of the system.

In terms of getting data published there should not be a significant delay, but the timetables for payment are a lot tighter. We can hope for a better day tomorrow and perhaps an explanation of why it worked well for two years and then went wrong today. Now if I can just get my Glastonbury tickets..

The Crazy World of Mental Health

For the vast majority of practices the clinical data on this site has been automatically extracted from their computer systems. There are various ways that this is done but it is all under the control of the business rules. These determine which codes indicate success or failure in each area and are thus crucial to practices. The original set of rules had a few quirks but these were fairly quickly ironed out and gave two good years of service. With the new, more complex, items in 2006/7 some more rules were needed. Nowhere was the change and complexity greater than in the mental health area. The diagnostic criteria changed from merely having a "severe and enduring" mental health problem to being exclusively psychotic and bipolar disorders. Also the individual criteria became quite involved - the worst being

MH7: The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who do not attend the practice for their annual review who are identified and followed up by the practice team within 14 days of non-attendance.

There have been three sets of rules this year. Version 8.0 - in which the rules for MH7 were completely incomprehensible. Version 8.5 still had problems which I listed at some length and version 9.0 which was released shortly before Christmas. There is no doubt that version 9.0 is much better and solves many of the previous problems, albeit sometime in a somewhat cumbersome way. It does, however still have some problems and has introduced a new challenge to practices. Perhaps the most dramatic change is the abolition of the explicit mental health register. In the original QOF patients were given the option of 'opting out' of the mental health register. Under the new rules entry to the register will be coded on diagnosis rather than an explicit code. This is arguably a better way of doing things - in fact this is the way that the rest of QOF does things. But this is a very late rule change. Systems suppliers and central systems are not yet upgraded. Practices may have a very short time to make sure their data fits the new rules. Finally there is still no provision for the recovery from mental illness. Whilst much illness is lifelong there is a considerable amount that is short lived. Read code 212T means "Psychosis, schizophrenia + bipolar affective disorder resolved" which seems to suggest that active follow up would not be needed. Unfortunately the rules do not look for this code so some of my patients who only had a brief period of postnatal psychosis in the 1970s are included on the register. The solution has been to code them as 9h91 "Excepted from mental health quality indicators: Patient unsuitable". An ugly bodge maybe, and one that will possibly need repeating annually, but it does illustrate the use of exception reporting as a pressure valve for problems in the business rules. I await version 9.5 with interest.