We are now about a third of the way through the QOF year and I have just come back from my holidays to find that the new version of the QOF business rules has arrived. It is a no more gripping read than it was before and fortunately the changes are fairly minor this year. Most of the obvious changes seem to be in the area of smoking - both the clinical area and Records 22. This is the area that has received most attention this year - at least in terms of the coding areas. Just a reminder of what the guidance says:

The guidance has also been updated and in particular we would draw your attention to amendment to non-smokers and ex-smokers. Non-smokers should be recorded as such up until the age of 25 while the smoking status of ex-smokers should be for 3 years and only thereafter if their smoking status changes.

Now this has been implemented almost exactly as you see it here (for the one problem see below). Arguably there is a degree of ambiguity, and a missing bracket, in the way that the rule about three years is written but I am sure that the system suppliers can be relied on to implement it sanely. There is, however, an interesting anomaly in the way that the text above specifies the criteria. If a young man were never to have smoked by the age of 24 this would still have to be coded on an annual basis. If, however he had smoked when he was 15 and then became an ex smoker this would only have to be recorded from the ages of 18 - 20 and can then be stopped. Ex-teenage smokers are thus less work than those who have never smoked.

There are not that many young people in the smoking clinical indicators - they just don't feature in the chronic diseases that much with the possible exception of asthma and for asthmatics the smoking indicator only starts at age 20 (there is another indicator for younger asthmatics at Asthma 3). However around 80% of the practice population is also covered in Records 22, including all of the 18-25 year olds. For a typical practice this represents about 4742 patients. There are only 11 points here, around £1370 equivalent to just 58 pence for each patient in the "scoring zone" from 40-90%. It is likely that annually chasing young people who don't often attend the surgery to check that they have not started smoking will simply be uneconomic. That is not to say that nobody will do it though. For 2006/7 practices achieved 82% overall.

The recording of ex smokers for three years is however rather fragile. This may cause problems in the future although the effect should be limited this year. The problem is that the rules look only at the most recent codes and this could trip practices up. If a patient had given up smoking you could record this in years one, two and three. They would then not need a record again - ever. However if you recorded in years one, two and three - missed year four and then recorded again in year five another code would be needed in year six. The rules would see the code in year five and missed the previous year and not the three codes in the years before.

Now this is not really the fault of the rules writers. The structure of the rules is not that flexible and they have done their best within these limits. The rules have a very linear structure and there is no option for looping or iteration. The designers of QOF at the DH and the BMA are getting more ambitious with much more complex targets; the smoking rules are probably the most complex in the whole of the framework so far. Many people have big plans for new QOF areas in the future and it may be time to look at an overhaul of the way the rules are set and the systems that implement them. We are likely to see an increasing number of problems of this nature unless ambitions are reigned in a bit - and personally I don't see that happening.

Labels: data entry, QOF_review

# posted by Gavin Jamie - QOF database @ 20:45 1 Comments Links to this post

A couple of weeks ago the BMA issued its guidance on the QOF changes for this year. Basically some organisational areas were cut and the points transferred to two new areas to be based on surveys of patients.

The survey questions seem likely to be very similar, if not identical, to those asked about appointment booking in the 2007 patient survey.

As we have some data to go on, for England at least, the effect of the changes can be modelled at practice level. In fact I have done this for all practices in the UK, simply the results are likely to be less reliable outside England. In particular the square rooting of the COPD prevalence is based on the English average - slightly overestimating losses outside England.

To find the data for individual practices just use the search or browse pages to find the practice and then select from the menu on the left side.

Labels: QOF_review, site news, survey

# posted by Gavin Jamie - QOF database @ 23:12 0 Comments Links to this post

The BMA has released details of the changes to QOF targets for the year 2008-9. Actually this is more a summary of where the changes are as the detailed guidance is not yet out, and it is in the detail that the interesting details are located.

The headline is probably the removal of fifty eight and a half points largely from the organisational domain but five points have also been take from the COPD spirometry measurement section. The spirometry has also been made more explicit in asking for post bronchodilator spirometry.

There are some other minor changes. They are worth knowing early because they may be difficult to catch up with later in the year. There is now a requirement to refer all patients with stroke or TIA within one month of diagnosis. Along with the spirometry changes this will apply to new diagnoses from the first of April 2008. The reference date for ECG investigation in atrial fibrillation has also been moved to the same date.

One of the changes with widest effect may be the changes to the smoking area - particularly as it affects around one in five patients. As it stands this refers only to the clinical area on smoking which refers to those with diabetes, cardiovascular and lung disease. Patients with psychotic and bipolar disease have now been added to this area (probably a drop in the ocean) and the criteria have changed. Currently if a person had never smoked then you didn't have to ask them again. If they had ever smoked they needed to be asked annually. Now all patients under 27 need to be asked annually and you can stop asking those 27 and over who have never smoked or have not smoked for over three years. My sympathies go to whoever has to write the business rules for that one.

In practical terms this is likely to mean fewer patients needing coding over the course of the year as there are few patients under 27 years old on the chronic disease registers. The BMA guidance seems to suggest that there is to be no change to the organisational smoking indicators which apply to the whole of the practice population over 15 years old. As it stands it would appear that the old rules (if they have ever smoked then you need to ask annually) still apply to RECORDS 22. This would seem to be an odd situation, but I am sure that they have spotted it already!

Finally prevalence day is being moved to March 31st from next year which makes a lot more sense. It takes seconds to do the calculation on a computer and allowing six weeks turned out to be overkill.

Update 1st April

A Department of Health letter landed on my desk today confirming that the smoking rules apply to both the clinical and organisational sections.

Labels: QOF_review

# posted by Gavin Jamie - QOF database @ 21:08 1 Comments Links to this post

Perhaps an old fashioned phrase to describe a significant event but there have been questions in Parliament about the QOF. At health questions this week the Alan Johnson defended of putting cash into extended hours rather than clinical areas. He accused the BMA of propaganda in suggesting the reverse. That suggestion seems to have produced a sharp intake of breath from the Honorouable Members. Ultimately though, like most parliamentary answers, there is more heat than light here.

Labels: extended hours, QOF_review

# posted by Gavin Jamie - QOF database @ 12:32 0 Comments Links to this post

As many of you are probably aware the site has had information about the potential loss of cash to practices under the government's proposed imposed changes to the QOF in England. If you have not seen this you can click on the link on the left of each of the practice pages. There is also table of the changes effects at PCT level.

Of course now that we have these statistics we can look at the breakdown a little. As I have said before the threshold changes will mostly affect those who have had most problems in meeting the targets. The practices that have tended to have lower score have tended to be those in more deprived areas. A reasonable hypothesis would be that more deprived practices tend to loose out more.

We can go onto test this. Helpfully the deprivation index for most practices was published as part of last year's GP patient survey. We can put all of this together in a spreadsheet and work out the loss per patient for the threshold changes and overall for whole set of changes. Not difficult as we have practice list size from the QOF data as well.

As it turns out there is a correlation between the deprivation and the cash lost through threshold changes at practice level. For the mathematically minded the correlation is 0.13 - not particularly strong but it is there. In practical terms the thousand least deprived practices are to loose 62 pence per patient whilst the thousand most deprived practice will loose 84 pence per patient - a difference of 12 pence. For a "typical" practice of 5891 patient this works out at £1,287 per year between the most and least deprived practices.

This all looks pretty bleak but there is another factor that works against this effect. The removed points take more from practices that have gained all of these points in the past. Statistically these tended to be practices in the least deprived areas. If we bring in the removed points then the effect almost disappears. The correlation drops to 0.03 which is small enough to be ignored.

So balance is restored - whether by luck or judgement! It does however give some idea of the less obvious effects of changes to QOF.

Labels: analysis, QOF_review

# posted by Gavin Jamie - QOF database @ 18:09 1 Comments Links to this post

It has been a busy few weeks. Just as I was starting to digest a report suggesting the development of the QOF then the negotiations for changes to next year's GMS came crashing to a halt. The report is still worth reading, if only for the summary of research done with QOF data thus far.

There is a pretty good summary of the situation in a letter from Laurence Buckman - chair of the GPC which I would recommend reading. In summary, for the impatient, the government (only in England for now) is imposing changes to the contract to move cash from QOF and Choose & Book and put it towards increased hours of availability. This, we are told, its only priority for primary care this year. Arguably this is a move from quality to quantity

As far as QOF is concerned several indicators are to be removed taking with them a total of sixty points.

• Holistic points (20 of them) - points for consistency - all gone
• Records 3 (1 point) - communication with out of hours service
• Education 4 (3 points) - induction training for new staff
• Management 2 (1 point) - computer back up
• Management 4 (1 point) - instrument sterilisation to national standards
• Management 6 (2 points) - job description for all new posts
• Management 10 (2 points) - employee procedure manual (absence, bulling etc)
• Medicines 4 (3 points) - repeat prescriptions in 72 hours - 48 hour target remains
• Medicines 11 (7 points) - medication review for patients on four or more medications (review for all patients remains)
• CS 5 (2 points) - there is a system for inform women of smear results
• CHD 12 (7 points), Stroke 10 (2 points), DM 18 (3 points) and COPD 8 (six points) - flu jabs in high risk groups

As there are 1000 points in the QOF a rather obvious bit of maths shows a 6% drop already. There is more, however. Initially the scoring area for each of the indicators started at 25%. This was increased two years ago to 40% and this new imposition will increase it to 50%. The top thresholds for payment will also be increased to something around the mean of current achievement. This second part is likely to be more significant for most practices. Pretty much by definition half of practice would be expected not to hit this higher threshold.

The effect of all this remains to be seen. We already know that exception reporting tends to be reactive - i.e. there is more exception reporting when below the threshold than above it. This is largely because practices stop reporting when they get over the threshold. It would not be unreasonable to expect a bit of an explosion in exception reporting with these changes. Of course there will almost certainly some increase in achievement but the extent is uncertain.

We can use the data we already have to try to model the effect of these changes - and apply them to last 2006/7 data although with the caveat above. This should be online in the next day or so.

Labels: QOF_review, site news

# posted by Gavin Jamie - QOF database @ 13:00 0 Comments Links to this post

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.

Labels: QOF_review

# posted by Gavin Jamie - QOF database @ 22:04 0 Comments Links to this post