Exception reporting in England - all new!

In all of the general excitement(!) of the release of the 2006/7 QOF data it would be quite easy to miss the QOF exception bulletin produced by the Information Centre for England for the same year. Not perhaps the most gripping of documents but very useful none the less. It is rather dry with plenty of statistics but relatively little comment and no exploration of the reasons behind individual indicators. If you are not familiar with exception reporting in QOF it may be worth looking back at past exception articles.

I am not going to repeat any of the data there, rather to try to provide a little background to help understand what is going on. Page 11 (and to their credit the page numbered 11 is also the 11th page of the PDF - certainly not universal) shows a table of the top ten excepted indicators. There is also the bottom ten but I will concentrate, as I imagine most people will, on the highest figures.

Top of the list is CKD 3 (CKD and hypertension with BP less than 140/85) which has an exception rate of nearly 30%. The equivalent indicator for hypertension alone (BP5) does not even reach the top ten. What is going on here? Well firstly hypertension is very difficult to control in kidney disease so maximum tolerated can quite easily be reached. There is, however, a bigger and more technical issue. Following diagnosis of a condition a patient is automatically excepted for the next nine months if they don't meet the target. This was a new indicator this year and was not really a commonly made diagnosis before. With a simple assumption that practices started work on this QOF a year before (April 2006) then three quarters of the patients could have been excepted if they did not hit the target ( 9/12 ). Suddenly 30% seems fairly good. We can expect to see this drop next year.

Next is CHD 10 (beta blockers in CHD) which has always had a high exception reporting component. Rises a bit this year may be due to the advice that beta blockers are not much use after a year following a heart attack. They are also used much less first line for hypertension than previous due to new research. QOF is looking a bit dated here. Expect a rise again next year.

At third is AF 02 (ECG to diagnose atrial fibrillation) at 21%. Once again this indicator is for quite a short period - looking back over a year. Thus in this case 25% could be excepted automatically. Still fairly high though.

The timescale issue is also true of Asthma 8 (reversibility) at 20%, Stroke 11 (referred for investigation) at 18% and Dep 2 (depression scoring) at 17%. Again these only apply since first of April 2006.

MH 6 (comprehensive care plan) actually seems quite low at 17% due to the mental health register containing everyone who has ever had a psychosis or bipolar disorder - whether they still have the condition or not. MH 9 (annual review) is much the same at 15%.

Finally in the top ten is Epilepsy 8 (fit free for a year) at 17%. This reflects the difficulty in controlling some forms of epilepsy combined with a general lack of problem seen by some patients with occasional fits.

What is interesting is that only Epilepsy and beta blocker indicators have some clinical relevance in the exception reporting. All of the others (eight out of ten) say more about the business rules and the administrative nature of the indicator rather than patients or practices. So the take home message has to be don't place too much importance on exception reporting rates.

English data now online

The English data is now on the QOF database joining the Scottish and Northern Ireland data which has also been tidied up a little. The English data was a little delayed by the postal strike eventually arrived safely.

There are a couple of "virtual" indicators, largely relating to prevalence. I have created two depression indicators relating to the prevalence of people requiring screening for depression and those who have a history of depression recorded in the past. I would avoid putting too much weight on the latter as historical coding may be really quite variable between practices. In fact as practices were not specifically working towards these virtual indicators they should all be used with some caution.

I have also been asked about smoking prevalence. There is therefore a virtual indicator here too. Here it relates to the number of smokers amongst those covered by the smoking area (those with CHD, LVD, stroke, asthma, COPD and hypertension) who have been asked. This is not the only way to do it and is purely a judgement call on my part. In particular it may not correlate with some of the "official" registers and is not the one used for payment.

You may also notice that I do not put prevalence information for the palliative care domain on the main prevalence list. For one thing this prevalence is not used for payment. Secondly the numbers are generally so small as to be unreliable and thirdly they are so small they are suppressed for confidentiality reasons in many cases by the departments of health.

There are about half a dozen English practices without names or addresses. There was not a comprehensive look up table included with the English data this time so I have used several different sources. I will try to correct these in time.

Finally we are still awaiting the Welsh data. I have heard nothing official but will keep asking!

Resources for Primary Care Research

I have had a few emails over the last few months about using QOF data for research and trying to break down some of the data. Unfortunately QOF is quite limited in what can be divined about individual patient treatment. There is a little more potential for breaking down populations with some of the composite registers this year but things are still pretty limited.

For those looking at used primary care data there is an excellent report on all of the sources of primary care data available. A user’s guide to data collected in primary care in England is a summary of all of the data sources, including QOF, with details of their uses and limitations. It is published by the Eastern Region Public Health Laboratory - one of the rather unsung chain of public health laboratories.

This has to be essential reading for anyone conducting or even contemplating doing research or analysis on primary care data. I can't actually see that a printed version is available or I would get a copy for my bookshelf - but get it on your computer now!

UK Prevalence Data

Although we don't have full practice level data for Wales and England yet there is some national level data. We can work out prevalence in all four of the countries and for the UK as a whole. They are listed below. Smoking is not in the table as it is not listed at the national level but should be available when the practice level data comes through.

On the subject of practice level data there is some more information on the information centre website. They are planning to send out CDs so I will apply for one. Unfortunately there is a postal strike over the next week which may affect delivery somewhat. There should certainly be some demand. The 2006 full data database has been downloaded from this site over eight hundred times.

No news from Wales as yet.

	England	Scotland	N Ireland	Wales	UK
Asthma	5.78%	5.48%	5.75%	6.53%	5.79%
Atrial fibrillation	1.29%	1.27%	1.25%	1.61%	1.30%
Cancer	0.91%	0.92%	0.79%	0.93%	0.91%
Chronic kidney disease	2.39%	1.82%	2.44%	2.28%	2.34%
COPD	1.43%	1.86%	1.53%	1.94%	1.49%
Coronary heart disease	3.54%	4.55%	4.18%	4.28%	3.67%
Dementia	0.40%	0.55%	0.52%	0.42%	0.41%
Depression Screening		7.24%	7.50%	7.56%	7.39%
Depression Ever		6.25%	6.13%	7.27%	6.55%
Diabetes mellitus	3.66%	3.52%	3.17%	4.21%	3.66%
Epilepsy	0.60%	0.72%	0.74%	0.73%	0.62%
Heart failure	0.78%	0.88%	0.81%	0.51%	0.78%
Hypertension	12.51%	12.61%	11.68%	14.26%	12.58%
Hypothyroid	2.55%	3.14%	2.90%	3.13%	2.63%
Learning disabilities	0.26%	0.41%	0.32%	0.30%	0.28%
Mental health	0.71%	0.79%	0.75%	0.72%	0.72%
Obesity	7.42%	7.01%	8.38%	9.64%	7.53%
Palliative care	0.09%	0.10%		0.10%	0.10%
Stroke and TIA	1.61%	1.97%	1.62%	1.97%	1.66%

Scottish and Irish data ... and that's it.

The data for Scotland and Northern Ireland was released last Monday and is now on the site. It has been a little more awkward uploading the data this year due to the changes in the areas and the appearance of areas without prevalences (palliative care) and depression having two different prevalences. I hope this makes some sense when viewing the data but nothing is set in stone and bright ideas welcome!

Wales also released some data this week but this did not go down to practice level and is therefore not particularly useful for many purposes. The statistical release was described as release one so there may be more although the site also suggests that there will not be an update for a further year. I am enquiring about further data.

Even more oddly is the English data. The Information Centre has spreadsheets of data at national, SHA and PCT level but not practice level. Practice level data is available but only one practice at a time through their own web interface. I have emailed them asking about spreadsheets but have not year heard back. In fairness they were probably quite busy on Friday.

I will keep you informed about their replies.

New Business Rules (v10)

There is presumably some schedule behind the production of new business rules for QOF. These are the rules that govern the data extraction from practice systems and are negotiated across all four countries. For this reason they tend to be a bit of a camel.They pop up every six months or so, and the version numbers seem to increase by 0.5 each time. Counter intuitively it is the ones ending in .5 that are the big ones but with version ten of the business rules being recently released what is new?

Well not a lot. This has its downsides. Mental health is still a bit of a mess with its Hotel California register (once you are on it you can never leave). For the most part this will be something of a relief to practices who don't fancy changing all of their codes again.

There are a few changes worth noting. Firstly smoking exception codes have disappeared, but only for Records 22. The exception codes (for informed dissent and unsuitability) are still there for high risk groups counted in the smoking indicators.

Also in relation to smoking patients under 20 with asthma are no longer in the high risk group. I don't know why, especially as patients of that age with diabetes, heart disease or strokes are still in there, but there you go.

More important changes have been made to dementia assessment. There is now a specific code for annual review ( 6AB ) and the old, vaguer, codes no longer count.

In a similar vein the old LVD exception codes no longer apply (those starting 9h1 ) and have been superseded with 9hH codes.

My suggested action plan for practices would be

• Check the review codes for dementia (especially on templates) since April and make sure they are 6AB
• Check the exception codes for heart failure (templates again) and make sure you are using 9hH codes

Happy coding!

Osteoporosis and Crystal Balls

Waiting, waiting. We are waiting for this years data but just around the corner is also the report from the review group as to what they would like to see in next year's QOF.

Well a rather heavy hint has arrived in the form of Evaluation of standards of care for osteoporosis and falls in primary care commissioned by the Information Centre from the Kings Fund. (it was published co-incidentally with the National Library for Health's Osteoporosis & Fragility Fractures National Knowledge Week which I seem to have missed).

The King's Fund document is a very thorough review of current information in practice systems about osteoporosis (basically not a lot) and the possibilities of generating some useful QOF targets. It seems to be possible. It is however a relentlessly practical document - for which its authors deserve a lot of credit. It is acknowledged that it is very difficult to work out differences in coding from differences in practice. New codes and a proper definition of treatment are required. The huge (and probably undefinable) strain on investigative resources in secondary care are also highlighted. One final conclusion stands out as understanding the problems with QOF.

A preferred set of codes would need to be agreed and disseminated to GPs at least three months before implementation.

You would not normally think that you needed to point out that design needs to come before implementation, but in the wake of last year's mental health mess apparently you do.

Only one problem remains - what goes out for this to come in? No word yet and very little time if it is to be implemented properly next year.