Bringing QRISK to Facebook

This has nothing to do with QOF. Earlier this year the the good people at QResearch put the QRisk2 formula onto the internet with an open licence. This is freely available to download and use. This is quite something. There have always been problems with trying to apply JBS formulae as, for most people, the data to input is not there. Qrisk2 is based in large part on information that is easily available and the QResearch group provide formula that can estimate some of the other data.

I have put the formula onto Facebook with a fairly simple form. There is a limit to how simple it can be but hopefully it is at least usable.

The results are presented again as simply as seems reasonable. One of the things that can be done with the formula is some "what if" calculations. We can see the effects of stopping smoking or losing weight. There is even data drawn from NHS Choices which gives the closest NHS Smoking Cessation Clinics if you are in England, although this is not currently available due to a bug at NHS Choices.

The app is at http://apps.facebook.com/cvdrisk . Feel free to have a play around. You can change your data as often as you wish and see the effects. All your data is deleted when (or hopefully if) you remove the app from your Facebook account. Facebook will post that you are using the app but none of your data is posted back to Facebook unless you specifically type it in. You can post reviews or questions on the Facebook profile page.

Ooops

Many thanks to the reader who pointed out that, in England, I had transposed the two depression prevalence figures. I have now corrected this on the site. If you have downloaded the data there is now an updated version on the download page.

If you don't fancy downloading it all again you can switch in Access with some queries. I have not worked how to export these. If you are using MySQL the code is

update `achievement` set area='' WHERE `practiceid`regexp '^[ABCDEFGHIJKMLMNOPQRSTUVXYZ][0-9][0-9][0-9][0-9][0-9]$' and area ='DEP Prev 1';
update `achievement` set area='Dep Prev 1' WHERE `practiceid`regexp '^[ABCDEFGHIJKMLMNOPQRSTUVXYZ][0-9][0-9][0-9][0-9][0-9]$' and area ='DEP Prev 2';
update `achievement` set area='Dep Prev 2' WHERE area ='';
update `pcoach` set area='' WHERE `pco`regexp '5[A-Z][A-Z]' and area ='DEP Prev 1';
update `pcoach` set area='DEP PREV 1' WHERE `pco`regexp '5[A-Z][A-Z]' and area ='DEP Prev 2';
update `pcoach` set area='DEP PREV 2' WHERE area ='';

I had also missed the reconfiguration of the PCT in Hertfordshire which is now corrected in the downloads also (there is not a simple patch for that).

Sorry!

CPD+ on QOF Database

I tend to have a few ideas for projects floating around at a time, most of which come to nothing. One of these was an improved method for saving all of the stuff that I read for appraisal. At the time all that was out there was the official Appraisal Toolkit that was too horrible to use. Thankfully this is, if not quite dead, certainly having the curtains pulled around it.

I never actually managed more than about 20 lines of code as a proof of concept on this one but am very excited to find that those good folks at Healthcarerepublic have actually put finger to keyboard and written something very much along the same lines with their CPD+ system. It is also free, which is nice.

It is pretty basic at the moment but crucially it does allow one click to enter data into the log. There are instructions on the CPD + site but to make things even easier you can click on the CPD+ logo after every blog post at at the bottom of every table on the site. There is also a button at the bottom of each blog posting which is a stupidly complex thing to actually get into a Blogger template. Feel free to use the code yourselves.

I hope you find this useful.

2010 QOF data now online

I am delighted to be able to say that the data for 2010 is now available on the site. This is a little later than usual this year. This is a little due to a later publication of the data by the Information Centre and rather more due to my hard drive crashing. I still had the data but getting the system set up around it took a bit of time. I talk a little about that process on E-Health-Insider.

There is still a bit of work to do and I will get the database download going in the next few days.

More business rules strangeness - PP1

My thanks to Dr David Fitzsimons who has pointed out that it is not only depression that has suffered a ruleset that differs from the guidance. PP1 - the assessment of CVD risk in patients newly diagnosed with high blood pressure - features an almost identical change. Whilst the guidance suggests only the patients diagnosed in the past year should be counted the business rules carry forward all of the unassessed patients from the previous year. There is not a lot that a practice can do to avoid this, unless of course their hypertension has resolve (read code 212K ) in the meantime.

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.

What's On the Menu

NICE has published its menu of potential indicators. These indicators will then go to the negotiators for the decision of what goes into the QOF for 2011-12.

There is not a lot of "wow" here. There majority of changes reflect a tidying up of the current indicators with some made more explicit. There are no big ideas or even a unifying style to the indicators. Let's see what is ahead.

NM07: The percentage of patients with a history of myocardial infarction from 1 April 2011 currently treated with an ACE inhibitor (or ARB if ACE intolerant), aspirin or an alternative anti-platelet therapy, beta-blocker and statin (unless a contraindication or side effects are recorded)

A big wrap up here. CHD 9, 10 and 11 are combined with a requirement for a statin, regardless of cholesterol level. In fact CHD 7, the requirement to test cholesterol is also scheduled to go - the outcome measure remains. Actually this is just an assumption as the actual notes only suggest the replacement of CHD 11, but they must mean 9 and 10 as well, surely?

Personally I don't like these big indicators - they end up with horribly complex business rules, particularly when exception reporting comes in to play. Other than being awkward there is not much new here.

NM09: The percentage of patients with a new diagnosis of dementia from 1 April 2011 to have FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded 6 months before or after entering on to the register

My least favourite form of indicator I'm afraid. Miss out in the first six months of diagnosis and you are stuck with that for ages. Depending where they put the threshold a slow start could affect results for years to come. Similarly success will result in several years payments. Much more sensible would be a new diagnosis within the year studied.

NM12: The percentage of patients with diabetes with a record of testing of foot sensation using a 10 g monofilament or vibration (using biothesiometer or calibrated tuning fork), within the preceding 15 months

A tidy up of the wording of DM 10. Nothing new.

NM13: The percentage of patients with diabetes with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer) or 4) ulcerated foot within the preceding 15 months

DM 9 tidied with the risk classification added. Minor changes only.

NM15: The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 15 months

I suspect that the wording here is misleading and they are not going to insist on the mentally ill having a couple of beers. They seem actually mean a record of the amount of alcohol consumed. This is the start of an extensive mental health section.

NM16: The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 15 months

There is little doubt that modern antipsychotics make you put on weight; indeed AstraZenica have just paid out on this. This is probably a large part of their potential to increase the risk of diabetes. I'm sure the guidance will explain what to do with the overweight in this group.

NM17: The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 15 months

Currently MH9 is a general annual MOT for those on these registers. This includes a physical review. Most GPs do a blood pressure as part of this. This group of indicators replaceme MH9. Attentive readers may be wondering why NM07 combined various indicators and MH4 is being unbundled and whether there is any guiding strategy here. I know I am.

NM18: The percentage of patients aged 40 and over with schizophrenia, bipolar affective disorder and other psychoses who have a record of total cholesterol: hdl ratio in the preceding 15 months

I expect some changes to this one in negotiations most likely to the use of total cholesterol rather than the ratio. Certainly our local lab advise HDL measurement sparingly and only once per person. Currently we have only recently agreed for the lab to do HDL measurement when the total cholesterol is low for QOF purposes in new hypertensives. Expect objections from chemical pathologists. This would be a closer monitoring of cholesterol, and particularly HDL than for patients with heart disease, strokes or diabetes. The associated documents don't comment on this.

NM19: The percentage of patients aged 40 and over with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood glucose level or HbA1c in the preceding 15 months

More checks on the mental health register. Worth doing for patients on antipsychotics but for patients with bipolar the evidence base is less clear.

NM20: The percentage of women aged 25-64 (in Scotland from 21 to 60) with schizophrenia, bipolar affective disorder and other psychoses who have a record of cervical screening within the last 5 years

NICE says they don't like double counting but these patients will also count for the main cervical screening indicators. There could be some quite small numbers here. The average number of patients on the mental health register is just over 48. If we assume roughly half are female and some of those are outside the age range then this indicator will apply to less than 20 patients per typical practice. Likely a lot fewer in some practices.

Percentage of patients on the Learning Disability register with Down's Syndrome aged 18 and over who have a record of blood TSH in the previous 15 months (excluding those who are on the thyroid disease register)

I certainly don't want to put down the importance of thyroid function to patients with Down's but I am left wondering how big the problem is at the population level. The economic analysis (which is fairly dire) suggests one in 1000 live births. Down's can be associated with heart problems and other issues which increase childhood mortality and even after that life expectancy, whilst rising, is still reduced. So lets say two thirds are over 18. That would be fewer than four patients in a typical practice and maybe one or even none at all for a small practice. Small numbers make bad indicators and is this really the best use of an indicator?

The percentage of patients with a new diagnosis of dementia from 1 April 2011 to have FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded 6 months before or after entering on to the register.

Simple cheap tests. It is worth mentioning small numbers again. It would be worthwhile practices checking in January whether they have diagnosed someone with dementia in the previous year to get this indicator, if implented. If they have not then they would need to hunt someone out to get the points (tongue slightly in cheek, but only slightly).

The percentage of women with epilepsy under the age of 50 who are taking antiepileptic drugs who have a record of information and counselling about contraception, conception and pregnancy in the previous 15 months

Probably small number here again. Quite how otherwise intelligent women will feel about being told the same thing annually will be seen. There is no lower age limit stated here but the lower limit for the epilsepy register is 18, which is probably too late to start. In reality this will likely become part of the annual review.

And now some more brief points

• The lowest level of HbA1c target for diabetes has been increased from 7% to 7.5% although these are no expressed in mmol/mol.
• The depression assessment indicator changes wording from "the outset of treatment" to "the time of diagnosis". In fact it always was the latter in the business rule. No real change.
• The second assessment moves from 5-12 weeks later to 4-12 weeks later. Probably a little easier
• For patients on lithium the creatinine and TSH must now be measured after the first of July rather than in the previous 15 months.
• For these patients the lithium must now be in the correct range after the First of December rather than July. All blood tests are still only required once a year though, just in more limited months. Unlikely to have the desired effects.
• Risk assessment for new hypertensives has the wording brought up to date with the current practice of only looking at those 30-74. This has been in the business rules for a while.
• CHD 2 is to have the date updated to next April and the emphisis changed from excercise tolerance testing to clinical assessment.