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Breathe Easy

Breathe Easy

Dr Gavin Jamie takes a closer look at asthma and COPD in the QOF
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Asthma and chronic obstructive airways disease (COPD) have been part of the Quality and Outcomes Framework (QOF) since the very beginning. The QOF has always tended to be dominated by cardiovascular indicators and the respiratory indicators can to point to a different population. Asthma  in particular includes brings a much younger population into the QOF than any other area.

The actual indicators within these areas have changed quite considerably over the years. As is generally the case throughout the QOF these newer indicators have tended to be more complex to achieve.

 

The first thing, as always, is getting the diagnosis made and the patient being put onto the register. This has been a controversial area in the past - particular debate being about whether a patient could be on both registers. The eventual conclusion has generally been that they can although this is not expected to be particularly common. In that case both of the diagnostic criteria would have to be met.

 

Diagnosis of COPD is by spirometry. The ratio of the forced expiratory volume in one second (FEV1) to the forced vital capacity (FVC) should be less than seventy percent. This can be fairly simply measured with a handheld spirometer. The spirometry should be performed after bronchodilation reversible obstruction is more characteristic of asthma. Not using a bronchodilator first is likely to lead to overdiagnosis.

 

If the FVC is also below 80%  of the predicted value, based on the patient's age and sex, then the diagnosis can be confirmed. Even if the FVC is not reduced to this degree NICE is happy for the diagnosis to be made where the patient has characteristic symptoms. Population studies suggest that there is quite a lot of undiagnosed COPD in the population although this is likely to be at the milder end of the scale.

 

Asthma is defined as a reversible airflow obstruction. 

The diagnosis can be made using either spirometry or more commonly a measurement of peak flow. There should be a difference 15% (and 60 l/min) between the peak flow before and after bronchodilation. There is no necessity for the two measurements to happen on the same day. 

 

Commonly, where asthma is suspected clinically, a salbutamol inhaler may be prescribed and a follow up appointment made to measure peak flow after bronchodilation as well as checking on the effects of the inhaler on symptoms.

 

If spirometry is used, perhaps where a patient has COPD also, there should be a 20% variability in FEV1 and this change should also be at least 200ml. 

 

There is a second criteria before patients will appear on the register. Asthma is one of two clinical areas (the other being epilepsy) where a record of medication in the previous 12 months is needed before patients qualify for the register. This is useful where asthma has been diagnosed in young children who then grow out of it. It can sometime cause difficulty in patients with very mild asthma who request a repeat inhaler prescription towards the end of the QOF year. They will appear on the register often without it being obvious, but they will still need their annual review.

If a patient no longer has asthma but an inhaler is needed for another reason, such as COPD, the asthma should be coded as resolved. The code 212G will do this.

 

You can see from the above criteria how a patient may appear on both registers. If there is both fixed and significant reversible components then the patient will have both diagnoses and appear on both registers. It is, however, felt that this should not be a terribly common combination - the guidelines suggest that these patients should account for no more than around fifteen percent of the COPD register.

As older indicators there are points for compiling the registers - three for COPD and four for the asthma register.

 

The actual diagnostic codes are a little difficult. When Read codes were first devised in the 1980s there was a different concept of obstructive airways disease with a trinity of emphysema, chronic bronchitis and asthma. COPD now covers the whole of the H3 codes with the exception of H33 which covers asthma. This is a common pitfall when searching for patients with COPD - it is easy to include all of the patients with asthma also.

 

For both asthma and COPD there is an indicator about how the diagnosis was made. In the case of COPD there should be a record of post bronchodilator spirometry for all patients with a new diagnosis since April 2011.

 

This date is fixed. The code for spirometry should appear within 12 months of the diagnosis code, although it can also be three months before. This can cause problems where patients come to the practice from another surgery. It is important that any spirometry is transferred from the old notes. Where spirometry has not already been recorded practices may find they have no possible way to achieve this indicator in these patients.

 

The diagnostic spirometry will earn five points in the COPD area. In the case of asthma the diagnostic test code can be entered any time from three months before the diagnosis. This is just as well as all patients over eight years old diagnosed since April 2006 need to have peak flow coded. If a patient has been diagnosed with asthma from an early age they can have the check at any point although it will not actually be recognised until they turn eight (although it won’t be penalised before this age either).

There are 15 points for this with a relatively small number of patients so each patient is quite valuable.

 

The core of the indicators for both clinical areas is the annual review. As with most things in the QOF that are described as annual the actual timescale for these is within 15 months of the end of March. Reviews conducted between January and March each year will count towards two consecutive QOF years. 

 

Asthma reviews were previously pretty simple from a coding point of view. They have become more complicated for the 2012 QOF year. The review should now include a three question symptoms assessment. These are referred to as the RCP three questions as they were initially recommended by a committee of the Royal College of Physicians.

 

These are a fairly simple subjective assessment of symptoms during the day, at night and whether the patient feels that activities have been curtailed by their asthma. While there is a Read code which states that this assessment has been used this is not sufficient for by the current business rules. 

 

There should be a coded answer to each of the three questions before a patient will be considered to have passed this indicator. This is best done with a template although close inspection of your QOF figures during the year should spot if patients are not having all three codes entered.

 

The guidelines also recommend a measurement of peak flow and inhaler technique although neither of these is specifically looked for under the business rules. These obviously should be face to face although the assessment of symptoms could be conducted over the telephone. There are 20 points for 70% of patients having an annual review.

 

The COPD annual review follows a similar pattern with multiple codes being required. The symptoms score used here is the MRC grading of dyspnoea. This is again a fairly practical score of everyday activities.

 

The appropriate code should be entered but there should also be a code of the annual review taking place (66YM, 66YB0 or 66YB1). Both of these are required in order for a patient to pass the indicator.

 

An additional indicator, which is probably also part of the annual review, is the measurement of FEV1. While there are plenty of sophisticated spirometers around I find it invaluable to have a handheld machine in the consulting room to ensure that this measurement is recorded.

 

There are nine points for 90% of patients having a review with a further seven points if 75% have a measurement of FEV1.

 

Patients with COPD clearly have an increased risk from respiratory infections. There is an indicator with six points 85% of patients having an influenza vaccination after the first of September. This top threshold is a little lower than for some of the other flu indicators.

There has been no flu indicator for patients with asthma for several years. Patients who use inhaled steroids will be included in the Directed Enhanced Service for influenza vaccination along with all patients on the COPD register.

 

Patients on either the asthma or COPD registers also qualify for the chronic disease smoking indicators - Smoking 5 and 6. Smokers will need a code every year with smoking cessation advice or treatment given annually also.

 

These indicators apply to all COPD patients over 17 years old at the end of the QOF year, which will most probably be all of them. In patients with asthma the age limit is 20. The reason for this is a separate indicator for patients between 14 and 19 years old. The structure for this indicator, which carries six points, is nicely simple. Each teenager should have a record of their current smoking status entered annually.

 

There is little in either of these areas that is medically terribly new or innovative. The guidelines for asthma and COPD have evolved over the years and are fairly well known. The coding has become more complex over the past few years and it is relatively easy to miss points for technical coding problems rather than tasks not being carried out.

Clear guidelines for conducting annual reviews and well designed templates should leave your practice well placed to score highly for respiratory disease management.

 

MRC dyspnoea score:

 

1. Not troubled by breathlessness except on strenuous exercise

      2. Short of breath when hurrying or walking up a slight hill

3. Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace

4. Stops for breath after walking about 100m or after a few minutes on level ground

5. Too breathless to leave the house, or breathless when dressing or undressing 

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