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!

Evidence in diabetes and depression

Medical evidence is always changing. The QOF is meant to be based on robust evidence. Problems arise when new evidence arrives between the decisions being made to include something and their actual implementation. We are now a week away from several new indicators coming on line and the evidence for two of them is starting to look less than great.

Most seriously an editorial in the BMJ(paying customers only) suggests that the new targets for diabetes are unlikely to improve the lot of patients with the condition. In a review of the editorial even the NHS Nation Prescribing Centre is concerned by these indicators. The tighter indicators come in on the 1st of April.

A research paper, again in the BMJ, looked at the use of depression questionnaires in practice (free to read!). It found them to be inconsistent with each and having little bearing on treatment. All rather troubling as the number required to be administered under QOF is to double next month.

Now things certainly do change but the evidence for either of these interventions was previously weak and yet they were still included. It is to be hoped that there will be a more robust attitude to evidence when NICE takes over the assessment of possible indicators. There is little that is dramatic in the government response to the QOF consultation but it was rather good to see just how many GPs took the time to respond to the consultation. My response is here. Unfortunately we will now have at least a year incentivising GPs to do some things that are not really supported by good evidence.

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.

QOF indicators review consultation

Monday is the last day for responses to the Department of Health consultation on changes to the process of review of indicators in the QOF.

I have sent in my own response to the consultation. It is proposed to move the development of indicators across to NICE although there is no terribly good reason given why this should be done. In any case their economic model is just a bit muddled - a pity as this is the major new innovation in the process. We await the results!

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!

Square roots and cut offs

It has been announced that from next year the square root formula for calculating the cash due per point in the clinical areas is to be abandoned. In brief this meant that the cash per point rose as the square root of prevalence rather than linearly with it. The theory was that there would be an economy of scale enjoyed by practices. For more information on this use the search box above to search for square root. Over time thought has moved against this theory.

In the following year the 5% cut off will go. Previously practices with less than five percent of the maximum prevalence would be treated as if they had exactly five percent of the maximum. This could create some bizarre results.

I have been asked by many people over the past couple of weeks what the effect on practices would be. Well after having a short holiday I have looked at modeling these changes based on last year's data. Before I discuss the results a couple of warnings about all that is to follow. It is a model, not a prediction. It is based on applying next year's rules to last year's data. It assumes that all of the indicators will remain the same - which is simply not true. It assumes that practice behaviour is identical which is unlikely. I have also had to make estimates at the prevalences of smoking and depression screening which were not published for England this year. These are likely to be close but not exact. I am not using the Dep 2 indicator at all. This is a model and not a detailed estimate - but it should be close.

So on with some meat. The figures for each practice are available from the left hand menu of each practices page. These are expressed in terms of the equivalence number of points gained and lost. To get the overall picture you can see the spread of practices in the graph above (I have taken eight outlier practices off the top to make the rest of the histogram clear - they tend to be unusual practices and so have unusual patterns of prevalence).

We can also look at practices in groups. Perhaps the most obvious group to look at are University practices. Dealing with younger people they tend to have a lesser incidence of chronic disease - particular cardiovascular and pulmonary diseases which dominate QOF. A rather crude search shows 26 practices in the database with the string "Univ" in their address. On average these practices lose 234 points equivalent from their QOF payments. These were the practices that started from a very low base so to lose this amount is very significant. In fact after these changes their take home points from the entire clinical domain is an average of 93. Their clinical domain is less valuable to them than the patient experience domain. This is likely to have a very significant effect on these practices.

We can also look at the effect at PCT or Health Board level. You can see the PCT level changes online or download a (7k) csv file. The winners and losers are quite dramatic. London is hit hard with both Lambeth and Westminster losing the equivalent of over 100 "full price" points per practice. The clear winners are in the North of England or attractive seaside resorts or, in a couple of cases, both. Two PCTs gain over 100 points per practice. County Durham PCT is going to have to find another one and a half million pounds per year to cover the cost of these changes. Meanwhile in Lambeth eight hundred thousand will be taken from primary care. Of course both of these could be told, more optimistically, the other way around! The message here is that although this change may be cash neutral at the national level the same is not true at the PCT level.

As the graph above shows we have a normal distribution. These changes will be moderate for most, large for some and extreme for a few - a couple of practice gain over a thousand points although they are not large but small and specialist practices.

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.