QOF Research

I am always interested to see new and innovative research on the data from QOF and some of the best stuff at the moment is coming from the National Primary Care Research and Development Centre and in particular the team of Dr Tim Doran.

Two papers from this team have been published within a month of each other in two big hitting journals. The first was published in the New England Journal and dealt with the effects of exception reporting (sorry, you or your institution need a subscription to read the whole thing). In one of the more thorough analyses of exception reporting so far there is no association found between exception rates and the points offered in each indicator. Indeed the main association is with the type of indicator with low rates for offering treatment and higher rates for achieving outcomes. No evidence of systematic gaming was found in the QOF data.

In the second paper, this time in the Lancet there is a look at socioeconomic factors on QOF performance (again cash required to read the whole paper). In the early years of QOF practices located in more deprived wards tended to have more problems with attaining higher levels of achievement than those in more affluent areas. There were, however, areas of high achievement in every type of area but low achievement was concentrated in more deprived areas. Things tended to become a lot more even by year three.

There are a couple of interesting points about this second paper. Firstly there appears to be some meaningful outcome despite the fairly poor results that you get with practice based social profiling rather than patient based profiling (no cash required to read - hooray!). i.e. where patients live is more important than where the practice is located.

The second interesting factor is that points are not used for the analysis. Overall mean achievement by each practice is used. This tends to give undue prominence to lithium prescribing and patient referrals and it seems likely that most of the variation between practices is concentrated in a small number of highly variable indicators. It is still, however, much the best method of analysis so far seen in any QOF study. Clearly a team to watch!

Fat maps? Fat chance.

It comes to quite something when the best source that I can find for information about QOF analysis comes from GMTV. The big story is the "Fat Map" of the UK apparently produced by Dr Foster and sponsored by Roche. I say apparently but the actual map and report don't seem to feature on the web sites of either.

The data they appear to be using is the QOF obesity register size at PCT level for April 2007 which has been available on this site for ten months now. When you come down to the business rules level this is a measure of the number of patients over sixteen years old who have had a BMI measured (or technically weight measured and BMI calculated) between January 2006 and April 2007 and that BMI was greater than or equal to 30.

A BMI of 30 is not that high these days. For those of you who don't deal with BMIs on a daily basis (basically front line clinicians) Flickr hosts a rather wonderful range of illustrated BMI catagories.

The prevalence has then been calculated by dividing this number by the total registered patient population.

There are thus quite a number of confounding factors.

Firstly and probably most significantly is the enthusiasm of the GP practice for weighing lots of people. If people were not weighed they did not count. For instance a huge patient would not be counted as obese if they did not have a BMI recorded. Getting a high prevalence involved weighing everyone who came through the door who looked like they may have a BMI over 30. There was no incentive to weigh patients with a BMI of less than 30 so it was just not done much - GPs have a pretty good eye for rough BMIs. For this reason even if we could know how many BMIs were measured it would be a bad measure of the obesity prevalence due to the skewed population at the measurement level.

Secondly we have the dodgy denominator. Remember the definition above? It applied only to patients of 16 or over - which is fair enough. BMIs don't really work with children. However to get the prevalence it was divided by the whole population. So if you have a lot of under 16s then your obesity prevalence will tend to be diluted. Similarly if you have a generally aging population then your obesity levels would appear artificially high.

Finally we have areas such as coding which are probably pretty minor.

Wales in general seems to stick out on the map, or at least the bits I could see on news.sky.co.uk Now I don't know a lot about Wales other than what I see on Torchwood but it seems rather odd that the whole of Wales is high (from North to South) and that obesity starts right on the border. Was there a LES or other country specific reason for practices to be incentivised to check BMIs a lot?

So this is a pretty dubious set of statistics on a map. Could it be better? Well perhaps a little. I mentioned the problem of the dodgy denominator above. Is there a better figure that we could use? Certainly there is. Records 22 (recording of smoking status) applies to all patients over 15 and uses that population as its denominator. We could at least correct that error although practice rates of measurement will still be a significant factor. I will try to put the figures together and if Roche or anyone else want to sponsor it they are very welcome!

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.

Who has two?

This morning Ben Bradshaw announced in an interview with the BBC News website that he had found a practice with only two patients. It is, apparently, in Southern England.

Well I don't know who it is either. This database only lists practices with QOF returns and it contains only nine practices in England with fewer than 300 patients at at April 2007. Of these all are specialist. Most are run by PCTs as access clinics - often these are catering to the homeless or others who may find it difficult to register with conventional practices. These practices will run under PMS contracts which don't attract the MPIG that Mr Bradshaw doesn't like. There are two other specialist practices, one attached to a very large nursing home and another to a school, but both of these latter two have over 150 patients.

So the mystery of the practice with two patients remains.

David Cameron adds some flesh

Nearly a year and a half ago I wrote here about the Conservative "Outcomes Not Targets". Well we have a bit more flesh on the bones with the release of the green paper "Delivering some of the best health in Europe".

Now obviously I come at this from a certain angle. What does it mean for GPs and especially QOF? Well the answer is initially not very much. QOF only gets a single mention in the whole of the Green Paper and even then it is only in passing. Most of the examples related to hospital care. We do get a feeling for the way that thinking is going though.

The paper acknowledges that outcomes are difficult to measure in any objective way and at individual patient level it is almost impossible. There are public health and systematic outcome targets stated in the paper but at the individual patient level the big thing is Patient Reported Outcome Measures or PROMs. It would be over simplistic o liken these to the little cards you get in hotel bedrooms with a chance of winning a free holiday but that would not be a bad place to start thinking about them. How these are to be translated into cash incentives is not clear but this is widely used in industry. When I bought a new car recently the salesman explained that much of their commission was based on these things and they would be very grateful if I could hold back my British reserve and go for excellent rather than very good. They had helpfully laminated an example with the excellent column highlighted. Similar things seem to be happening in education.

The other big thing is that the information will be freely available in a pretty raw form for others to turn into services to patients.

Our policy generates significant value for the NHS that far outweighs any potential cost implications. The NHS will not be expected to do anything other than collect, collate and publish the required information. Experience in other areas and other countries – such as crime mapping in the US – shows that third parties like Dr Foster, Google and others can creatively use this data and turn it into products that are available to patients and commissioners at zero cost to the user.

Well that is why I try to do here! The phrasing certainly plays down the difficulty, complexity and quantity of the work that the NHS will have to do but it is also true that there are several such mechanisms already in place. A lot of data is already generated and opening this up would be very welcome. This struck a chord when reading about suggested architectures for public information. In that architecture the analysis layer can be repeated many times but this seems a pretty good way to open public data to imaginative analysis. This is much more the US model where the government is forbidden from owning copyright on anything coupled with a rather more permissive freedom of information legislation.

But with all of these thing I like to see specifics. There are lots of specific examples in the Green Paper of problems with the target regime. I would love to see just one worked example of a PROM and its consequences for the provider. Another year perhaps?

Supporting Surgeries

If there is one thing that QOF has taught us it is that most GPs respond to a challenge. In the first year the government was surpised at the levels of achievement seen, although this was largely a repeat of the situation with Item of Service payments in the 1992 contract. GPs it seem, will do what is required to meet the contract.

We may have met our match, however. When the requirement is largely that you are not a GP but a large corporation it is an impossible target to meet. With hundreds of individual and different contracts it also become impossible to collect consistent statistics and monitor the performance of the corporate clinics - just when we seemed to be getting started on that problem.

We have seen this already with independent treatment centres. For years there was a persistent rumour of poor outcomes from these centres but no good figures to back these rumours up. There is some data now which suggests that there is little difference in outcome from NHS centres but nobody benefited from a five year delay in collecting the statistics.

We risk a distraction of GPs from the patient sitting in front of them and their needs by the central declaration of needs and solutions from central government. Anything else is a risk to the patients in primary care. This is why I support the Support Your Surgery campain.

Pretty Charts

Since the new indicators appeared on the site last September the chart of prevalence on the practices page has been pretty awful. It was almost impossible to read the key at the bottom. This was a major limitation of the charting app I was using.

Well now there is something new. Thanks to the rather wonderful Fusion Charts there are now simple and clear charts. The downside is that they do need flash. However the way they work means it will be much easier to add new charts to the site in the future without a huge amount of extra work for the server to do.

Enjoy.