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.

The 5% rule

The square root formula for adjusting prevalences finished a year ago but we are still left with the 5% cut off for the year just gone. This was less well known than the square root formula but its effects could be rather larger. It seems to have become more of an issue for many practices recently - perhaps we are all looking at our budgets just that little bit more closely.

The basic rule is this. You find the practice with the highest prevalence for any given condition and then calculate 5% of that prevalence. Any practices below that 5% value have their prevalence moved up to that level. Simple? No, not really.

The problem is that there are a small number of practices out there that are quite exceptional in their prevalence. You can see the spread of prevalences in the boxplot below (2008-9 data). For those unfamiliar with a boxplot the middle 50% of practices are within the box. The whiskers spread out from this upto 1.5 times the size of the box. The really outlying practices are plotted separately.

As you can see there are high outliers in every area, some more than others. The 5% rule really starts to kick in when the highest outlier is more than 20 times the mean. When this happens more than half of the practices will be bunched together at the 5% level. Prevalence adjustsment can simply stop. Last year, for instance, only three practices in England had a dementia prevalence more than 5% of the maximum. This meaned every other practice received the same prevalence factor.

To illustrate this effect the results for one of these extreme practices below. I am not giving their name as who they are is not really the point. They provide services to a group of patients with significant needs and there is no reason at all to doubt their figures.

Under the current rules this one practice can significantly change the QOF payments to thousands of others. But how many are affected? Well we can use the database to see.

As you can see it is not only in dementia that the 5% rule affects the vast majority of the 8229 practices in England. Learning disabilities, stroke and mental health area all hugely affected and over half of practices are affected in the area of CKD. As a side note you may notice that learning disabilities, heart failure and epilepsy all have the same maximum. This is all down to a single, and highly unusual practice, although this time down to very small numbers of patients. The same practice is also responsible for the highest stroke prevalence. Another "special" practice has the highest rate of mental health problems, although fewer than 100 patient overall.

There is no blame to attach to these practices. They are providing services to often very difficult populations and there is no doubt that they are recording accurately. The problem is with the operation of the rule, now thankfully in its final year. Expect big changes in these areas next year.

Removing Indicators

There have been a couple of new pieces of research in the last week or so relating to the QOF. I am trying to track down a copy of the this month's BJGP but fortunately there is free access to research in the BMJ and the paper The impact of removing financial incentives from clinical quality indicators. Lester et al.

The paper looks at the removal of incentive payments in California and, at the risk of spoiling the end for you, finds that there is a decrease in achievement when the incentives are withdrawn. In fact this decline is continuous over the years so things get worse. Comparisons are drawn with the UK and QOF although there are differences. In the US the payments rarely affect the clinicians directly but rather their employer. There were other programmes associated with the incentive payments that could have made a difference. Things not mentioned in the paper are that the incentives tend to be higher in the UK as a proportion of funding. Additionally most of the targets incentivised were fairly uncontroversial (cervical screening, diabetes control) whilst there is much more scepticism amongst clinicians about some of the QOF targets.

In general though the paper is a pretty easy read everyone except possibly for the NICE QOF advisory committee. Of course we won't really know what happens in the UK until it actually happens and has a chance to work through the system. As the earliest indicators will be removed is the 2011/12 year we won't really know until after the Olympics. Until then this is our best clue.

NICE New Indicators Consultation

NICE has a current consultation about possible new QOF indicators. It is open until the 11th of April (a week after Easter) and is certainly worth a look.

I won't go through the whole thing here, if you are interested you can read my submission. I will admit I am a little disappointed in the general scope of the indicators. Some of the current indicators are joined together and some are split apart. There is little feeling of an overall strategy or direction and even less of how indicators fit into the whole QOF. There is not really enough information to give a proper response. They are knee to know about potential unintended consequences but these tend to appear at the business rule level and there are not even draft versions of these. The document reads more as a list of intentions than indicators ready to be used. They don't even included suggestions of point scores which should be part of the economic evaluations.

I suppose this may get sorted at the negotiation level but we probably won't know that for another nine months. We will also find out how much the DH and GPC think of the QOF Advisory committee's work.

Prevalence Predictions

I am grateful for an email pointing me to some work done to try to predict the prevalence of QOF related diseases. The prediction is based on the age, sex, ethnicity, deprivation and smoking status of a practice's population. Readers with long memories may remember something similar being done by the North East Health Observatory a few years ago. This new work, however, covers more disease areas and is rather easier to use as the predictions are now featured on NHS Comparators (that link only works on NHS computers, sorry)

The methodology is interesting as the "expected" prevalence is based on various household surveys rather than GP data. The national prevalences are all rather lower than the "expected" prevalences except for cancer. The high relative prevalence of cancer in the QOF data is likely due to the predictions being based on one year and QOF registers being based on several years.

It is possible to argue with the methods of determining prevalence. It is not entirely clear that it is desirable that medically recorded prevalence should be the same as some of these surveys. Data about pratice populations is generally limited to age and sex and so various assumptions and approximations have been used in the model with data from other sources. Whilst there is some validity in these objections they do not justify writing off this work. For the first time at an accessible national level there is an attempt to produce corrected prevalence figures for practices. Comparison of one practice with another is still not simple but it is a little simpler. It is only thing that has made me log on to NHS Comparators recently.

QOF upper thresholds

The Marmot report on health inequalities, published a couple of weeks ago, had a few things to say on the subject of the QOF. Somewhat unsurprisingly it suggested that the QOF is used to reduce inequalities. One of the ideas mentioned, although not an official suggestion, was removing the upper threshold on QOF targets. I have to admit some sympathy to this idea in principle although it would certainly add to my work as a GP and the benefits are not entirely clear cut.

There are, however, a number of practical problems which could make implementation hard.

The biggest problem is one of funding. Currently practices receive a certain amount for each patient that meets the criteria between the lower threshold (currently mostly 40%) and the upper threshold (anywhere from 50-90%). If we want to expand that top threshold up to 100% there are a couple of ways of doing this. First we can keep the number of points the same. This means that the incentive per patient falls but the total potential cost to the government remains the same. Where thresholds are at 90% the difference will be 15% - enough to make some unhappiness but probably not earth shattering.

For DM 23 (diabetics with HbA1c less than 7) each patient will be worth a sixth of what they were before.

The other option is to keep the payment per patient the same. This is a lot more costly for the government. DM23 would need 102 points allocated to it (it has 17 at the moment) to keep up the incentive.

None of this takes account of exception reporting. As thresholds have not risen in this way before. It seems very likely that exception reporting would rise, but by how much? Would it incentivise exception reporting more than achievement? Might it simply lead to more organised exception reporting systems to send out the three letters? Most practices already get quite well over thresholds without the incentive of extra points.

And would it really reduce inequality? Could it make it worse? In the first years of the new contract practices in deprived areas did rather worse than those in less deprived areas, however they later caught up. Two years ago when moving the thresholds was mooted before extended hours came in I did some of the maths. It seems effects on practices are likely to be marginal only, but we won't know until it is implemented.

So not an absolutely awful idea but a lot of work would be needed before implementation.

There is more reaction reported at GP magazine.

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