Changes to QOF - details available

The BMA has moved faster than I have ever seen in getting details of the new QOF indicators out. After a rather vague press release this morning this afternoon produced a letter from Lawrence Buckman with a link to the details of the QOF changes.

It is only three pages and well worth a read. Highlights include the addition of a requirement for albumin:creatinine ratio in all patients on the chronic kidney disease register. This may raise a few eyebrows in biochemistry labs around the country who may not know what is going to hit them. (If they want to know what is going to hit them then a quick browse around the CKD register on the site may be useful. Around 1.8 million urine samples are headed their way.)

The current contraception indicators have gone and are replace by 8 points - six of which are for plugging coils and implants. It will be interesting to see the evidence base for this one. This will be at least a small crumb of comfort to university practices likely to be hit hard by the loss of the square root formula.

There is a bit about primary prevention in those newly diagnosed with hypertension - which should be a manageable number. In essence this boils down to finding out if they smoke, eat badly, drink alcohol and take no exercise and telling them not to do these things. I am really trying not to be cynical but very few patients are under any illusions about any of these things and it always seems a little lame.

There is a tidy up in diabetes with three thresholds including a tough 7% HbA1c (again evidence will be interesting to see). Inhaler technique is out and the MRC assessment - which is purely function is in. Actually quite a usable scale and much easier than finding an inhaler and watching them use it.

Finally depression. There is a new indicator for the reassessment of depression severity after 5-12 weeks using PHQ-9 or whatever. The patients aren't free of the questionnaires yet!

The last word has to go to Laurence Buckman - chair of the General Practitioners Committee and now Youtube star.

QOF changes 2009 onwards

Results of negotiations on next year's contract have been released last night. There is quite a bit of information although the final details are not absolutely clear.

First off there is a bit about money. There is agreement on how uplift for 2009/10 will be allocated. This may prove to be a bit academic in the current climate as it is not entirely clear whether there will be any extra cash on the table. This will be up to the DDRB. The cash will be divided up with 37% going to the Global Sum - 11% to the correction factor (to maintain MPIG) - 26% to QOF and 26% to Enhanced Services.

The effect of the above is likely to allow the Global Sum and MPIG to rise roughly together but a larger percentage increase in QOF and even large in Enhanced Services. Thus QOF is going to be a more significant income source to practices than it was before.

So what of the QOF itself? Well the big thing to go is the survey. The Department of Health has decided to do its own, by post. This is probably a relief to practices, to whom the administration was a hassle, and to those patients who feel bombarded by surveys. It may be a bit of a kick in the teeth for the nice people at GPAQ but there is of course nothing to stop people from continuing to pass them out anyway.

This will free 55 points from PE 2 and PE 6. There are also another 17 points being shaved off other (undisclosed) indicators. There is probably an interesting bit of work to show the effects of shaving points on overall achievement in those areas. These 72 points are going into new clinical indicators for which we have some vague suggestions. Official(ish) bits in bold.

• Helping to prevent the development of cardiovascular disease in people diagnosed with high blood pressure (13 pts) - other than controlling their blood pressure I assume. Possibly cholesterol measurement but this does not seem enough points for this - just measuring BP currently gets 20 points.
• Advice on long term contraception(10 pts) - for whom? Is this to combat teenage pregnancy. Long term contraception tends to be used in the over 30s - aiming to change this?
• A new indicator for depression to reduce early cessation of treatment (20 pts) - no idea how this might work.
• Beta blockers for heart failure (9 pts) - which is one of this year's new DESs
• Improvements to the indicators for chronic kidney disease (11 pts), diabetes (7pts) and chronic lung disease (2pts) - or at the very least changes.

In addition the square root formula has gone from next year, and with the uplift for those practices with less than 5% of the maximum prevalence will go in 2010/11. These changes turn things into a much simpler item of service payment once over the 40% threshold.

Developments awaited.

Updated 12:45 with points data and square root stuff.

Prevalences for 2008 (minus Wales)

	2005	2006	2007	2008
Atrial Fibrillation			1.30%	1.30%
Asthma	5.82%	5.83%	5.79%	5.72%
Hypertension	11.37%	12.03%	12.56%	12.77%
Cancer	0.51%	0.72%	0.91%	1.08%
Coronary Heart Disease	3.71%	3.71%	3.67%	3.60%
Chronic Kidney Disease			2.34%	2.92%
COPD	1.42%	1.44%	1.49%	1.51%
Dementia			0.41%	0.43%
CHD and/or Diabetes			6.40%	6.44%
Diabetes	3.35%	3.55%	3.65%	3.83%
Epilepsy	0.61%	0.63%	0.62%	0.61%
Heart Failure	0.45%	0.46%	0.80%	0.76%
Learning Disabilities			0.28%	0.28%
Mental health (05-06)	0.55%	0.72%
Mental health (07-08)			0.72%	0.74%
Obesity			7.51%	7.66%
Smoking with chronic disease			18.21%	17.30%
Stroke	1.52%	1.61%	1.66%	1.66%
Hypothyroidism	2.27%	2.46%	2.63%	2.76%

Most of this should be fairly self explanatory. The Welsh data for 2008 is not included as there is no data yet available. Mental health features in two separate rows as the definitions changed after the first two years.

There are a couple of made up prevalences in there. First is the screening population for depression which is made up of all those patients with either diabetes or heart disease or both. The smoking indicator is also based on many of the other areas. Included here is the proportion of patients with chronic diseases who smoke.

2007/8 QOF data (mostly) available now!

Another year has passed and there is a new set of QOF data to pore over. Northern Ireland published first this year about a fortnight ago whilst Scotland and England both published last Tuesday. All of the data for these countries is now online at the QOF Database. You can search for or browse the data.

I will publish the Welsh data when it becomes available. Database download will also be available soon as will overall prevalences.

Palliative care data is not visible yet either. This is due to differences in the way that this has been reported. England gives a prevalence, the other countries just give a yes or no to the presence of a register. This will take a couple of tweaks to display sensibly and I will do this soon. In any case the prevalence is difficult to make a lot of sense of. These tend to be small numbers which inevitably vary quite considerably over time.

In other site news I have removed the links to the QOF changes pages as these have become out of date as well as the extended hours calculator. In the latter case the national directed enhanced service is much less relevant as many local enhanced services filled the gap caused by its tardy arrival.

For the future I am working on ways of keeping practice data up to date, particularly addresses. I also hope to bring in links to practice websites. As I am a one man band and there are about ten thousand practices automation is going to be essential and this is taking a little time to code. It is likely to come in gradually.

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.