Read codes for new indicators

With impressive speed version 19 of the business rules has been released. This is likely because rules are developed alongside the indicators at the NICE committee stage. The sign off date for this set of rules is given as December last year. This certainly makes things easier for practices and, perhaps because of the extra time, the rules seem pretty well put together and well annotated.

So what is new this time? It is of little surprise that it is in mental health where the biggest changes are. Most of the other changes to indicators were fairly simple. Where there are lots of new indicators here there are also lots of codes.

There is, however, some chance of patients getting off the mental health register for the first time. Strangely this is not through the 212T resolved code but through remission codes for individual diagnoses. These are spread around read codes and all state remission rather than resolved. The implication that once you have mental illness it is never really gone remains. Use of these codes does not reduce disease prevalence for a practice.

First up is recording of alcohol consumption. In general codes starting 136 count but there are some odd exceptions to this. Code 136 on its own with a quantity would be fine. Anything which says unknown does not count. There is a list of "bad" codes and some good equivalents below.

Codes not counted	Codes which are counted
136W Alcohol misuse	136T Harmful alcohol use
136M Current non drinker	1361 Teetotaler
1369 Suspected alcohol abuse - denied	136S Hazardous alcohol use
136Y Drinks in morning to get rid of hangover
136b Feels should cut down on drinking	136K Alcohol intake above recommended sensible limits

The guidance states that lipids test must be for a TC:HDL ratio - this is certainly not the routine in my area. Even worse the only code currently allowed is 44PG HDL:TC ratio. This is the inverse of what the guidance asks for. Our lab certainly reports 44PF which would be the correct code here. This is clearly silly and I would hope that this would be corrected in the next version.

The codes for other areas of mental health are fairly routine. Glucose testing is not required for patients who have a diagnosis of diabetes although the test is still counted if they are diagnosed during the year. The sample can be fasting or random.

Another complex area is advice to women who are having advice about epilepsy and fertility. This applies to women who are between ages 18 and 55 inclusive at the end of the year. They require separate codes for contraception 6110, pre-conceptual 67IJ0 and pregnancy 67AF counselling. All three codes or their exception codes must be entered every year. Useful information available from Epilepsy Action including a pdf leaflet (top right corner). Beware the "printer friendly" is a tree unfriendly 61 pages long!

Diabetes foot risk assessment is fairly straightforward using codes 2G5E-L. The rules are made a little more complex as they exclude bilateral amputees but this should not cause too much concern to practices. Just remember that they still need sensation testing (29B4-9 or 29H4-B) as well.

CHD 13 is the indicator that says new angina patients should be referred for specialist assessment. Excercise testing is not longer required, or counted. Referral codes 8H44, 8H4R, 8HTJ and 8HVJ count. Unfortunately NICE says that barn door angina does not need specialist assessment so exceptions will apply. There is no specific exception code so they would need 9h01 (excepted from CHD indicator, patient unsuitable) to be used. This is less than satisfactory. I would hope this would be sorted on the next release or they will requiring excepting from the whole of the CHD section every year.

Effectively the referral needs to be within 3 months before or after the diagnosis although within the same QOF year following diagnosis is also fine.

That is about the most I can spot at the moment. Most of the other indicators have changed in fairly minor or predictable ways. It is to be hoped that the obvious errors will be corrected soon, indeed it may be that version 19 is never actually implemented if version 20 comes out soon. The real message at the moment is to get cracking on the mental health checks and the epilepsy advice.

(Apologies if you have seen this post up and down over the last couple of days. Blogger crashed in a fairly major way and they had to get this from backup.)

Things to do now

GP Business magazine asked me to write a couple of articles which they have now put up on their website. The first gives some hints on what to do now to maximise your QOF achievment this year. It is important not just to get the points but to maximise prevalence. Adding one patient with diabetes can add over £50. Much more from the link above.

The second is a first guide to the QOF changes for this year. There are quite a lot of smaller changes and many are worth getting on with now.

Some of my points are missing

Yesterday the changes to the GMS contract for the year from the first of April came out. there are quite a few of them and the full details are on the BMA contract page. Of course I turned to the QOF changes first of all. You can read the full QOF changes here.

You can almost feel the negotiations behind them. Raising the upper threshold on three indicators from 70% to 71% seems likely the result of a very long and banal meeting. Other areas have other minor differences and some, such as mental health see big changes. There is also a lot of "to be announced" around prescribing and referral audits.

I am trying to write and article for a trade magazine about the changes but I have hit a problem. The numbers just don't add up.

Page one goes pretty much as billed with 92.5 points being removed. Page two then gets a little odd. CHD11 (ACEi after MI)become CHD14 with 3 extra points. DM9 (foot pulses) gains a point but also does most of what DM 10 currently doing. Is this duplicated or is there another three points lost here? So at the end of page two we have lost 92.5 or possibly 95.5 points and gained 4.

Page three - MH 9 gains four points in its split up but depression loses 20. So total 8 gained and 112.5 (or 115.5) down.

Page four has lots of new indicators so gains 40. Now 48 up.

Page five gains 48.5 but loses another 4. Final total 96.5 gained with at least 116.5 lost. 20 points have gone adrift somewhere. Even worse there may be another 3 if they don't want to pay twice for foot checks. And actually I wonder whether they will really want to have two indicators for aspirin and beta blockers in CHD which would lose another 14.

So where are my 20 points?

Updated 14/3/11 They have been found and it seems to have been the slip of a keyboard. QP9-11 which relate to reviewing emergency admissions should have 47.5 rather than 27.5 points. That is a lot of points, nearly 5% of QOF - more than all of asthma.

QOF error in your favour - receive £???

This statement has appeared on the Primary Care Contracting site

An error has been identified within the QMAS system which calculates payments to GP contractors under QOF and which has resulted in GP practices being underpaid for achievement under the QOF additional services indicators since 2004/05. The Department of Health will provide PCTs with resources to make good these underpayments.

... and that is all we have. There is no detail of what the error is. The additional service domain contains Child Health Surveillance, Cervical Cytology and Contraception/Sexual Health. There is a prevalence adjustment here and I would guess that that is where the problem is.

It is worth noting that this seems to have purely been an underpayment and some practices could be due six years of back pay.

QMAS is used to calculate the QOF in England and Scotland although PCC only deals with England as far as I know.

A notice on QMAS says the system will be off for a couple of days from the 11th February. I have no idea if this is connected.

Does QOF work?

There is quite a bit of publicity today for a paper in the BMJ asking whether hypertension targets have any effect on outcomes. Neither blood pressure or cardiovascular morbidity seem to have been affected.

It was with a sense of dread that found the paper. QOF has had more than its fair share of thinly disguised rants appearing as research. I was however very pleasantly surprised to find a well constructed piece of research with tightly defined methods and considerably clarity of thought. Maybe it takes researchers in the USA (Harvard to be exact) to look at these things objectively.

There is considerably debate about performance related pay and very variable evidence about how effective it is. There has been some research in the USA where schemes tend to make up a much smaller proportion of practice income than in the NHS.

It is of course disappointing although not particularly surprising to see a lack of observable effect. QOF is not, of course, a controlled intervention and it is possible to argue that we will never know what would have happened without it but this is pretty weak.

Now for the political bit. The cash for the QOF came, to a large extent, from a transfer from the old capitation payments. So the pay which previously went to practices and was used for treatment of hypertension was paid, in a different way, to practice for the same treatment of hypertension.

So little change but I am strangely cheerful that it has been demonstrated in such a high quality piece of research. More please.

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!