Future QOF

The hamster wheel of the quality and outcomes framework (QOF)continues to turn. Although the changes for this year are only just starting to feel familiar, there are already plans for what will be new in the year 2013-14.

A NICE committee produces an annual menu of possible new indicators. These are put forward for consideration by the negotiator from the BMA’s GP Committee and NHS Employers. They are not bound to include only indicators from the menu – the quality and productivity indicators came as a complete surprise, but particular attention should be paid to these.

Last year, NICE produced an extensive range of new indicators and almost as numerous suggestions for indicators that should be withdrawn from the QOF. There was, said NICE, simply not enough evidence that these were doing any good. Particularly noticeable was a suggestion to remove all of the depression indicators and also to stop the hypothyroidism indicators.

In the end only one indicator was removed completely and most of the new indicators that were taken forward were funded by trimming of some of the points from existing indicators.

All of the previous suggestions remain and the current proposals from the government are to introduce these in 2013-14. In the meantime, the NICE committee has produced a further set of indicators although rather fewer and less radical than last year.

There is only one new disease area on the menu. Rheumatoid arthritis has a prevalence in the UK of a little less than 1% with about one in 20 being severe cases, according to Arthritis Research UK. This would represent around 50 cases in a typical practice. Only patients over 16 years old would qualify for this register – excluding juvenile arthritis.

As well as an indicator for compiling the register, there are three suggested indicators for actions on this population. All patients with rheumatoid arthritis will need an annual review. Essentially, this will be fairly simple monitoring of disease activity and assessment of the need for further treatment or referral. In general, NICE is pitching the threshold for referral pretty low, especially at the time of diagnosis. The guidance requires that this review is done face-to-face.

The other two indicators are not directly about arthritis at all but apply to patients with rheumatoid disease as a risk factor. They both apply to calculating risk. There is a distinct cardiovascular bias in QOF already so it is no surprise that one of these risk assessments is for cardiovascular disease for those patients between 30 and 84 years of age. This would be a similar assessment to that used already in the primary prevention indicators. Rheumatoid arthritis is a significant independent risk factor for coronary vascular disease and is included as part of the QRISK formula (www.qrisk.org). The final indicator is an assessment of fracture risk in patients between the ages of 50 and 90 years old. There are two recognised formulas to calculate this risk. QFracture is available freely in England (wwww.fracture.org ) and FRAX (www.shef.ac.uk/FRAX/tool.jsp?country=1) is used by the World Health Organization. In both of these formulas rheumatoid arthritis is a significant multiplier for risk of fracture.

Although not specified in the indicator, guidelines suggest patients at increased risk should then have a measure of bone mineral density. Risk can then be recalculated using the FRAX formula, which is the only one that will take a bone mineral density result into account.

Changes in other disease areas are fairly minor. Grading the symptoms of patients with COPD according to the Medical Research Council dyspnoea scale has been part of their annual review for several years. Two new indicators apply to patients who have grade three dyspnoea or above.

Firstly they will need a measurement of blood oxygen saturation, which should be relatively easy for practices to include along with the annual review. In some cases practices may need to invest in a pulse oximeter, although these are available for very little cost.

The second action required will be the offer of a pulmonary rehabilitation course. The course itself would need to be commissioned by the local clinical commissioning group (CCG) and availability and accessibility may vary. Implementation of these courses varies, and patients, by definition, have problems with mobility. There can be a poor uptake if courses are offered without good transport arrangements.

Although the indicator as currently written looks back over the previous year, one course of pulmonary rehabilitation would be required per patient. It is not clear whether invitations will have to be repeated annually until they are accepted or if the invitation will only have to be given once.

There are also a couple of changes suggested to the diabetes area. The first, probably uncontroversial change is an update to the microalbuminuria testing indicator. This has previously allowed for dipstick testing of the urine. This will be changed to come in line with NICE guidelines and the National Diabetes Audit to only look for albumin: creatinine ratio testing. This seems almost certain to be accepted.

More controversial are likely to be two indicators about erectile dysfunction (ED) in diabetic men. This is a common problem but not one that has been tackled in the QOF before. The political acceptability of financially incentivising GPs to ask about and prescribe for erectile dysfunction has yet to be tested.

The screening for ED will most likely take place at the annual review and the suggested indicators are: asking whether the patient has current symptoms and investigating contributing factors and discussion of treatments.

As many of the contributing factors such as blood pressure, obesity and smoking are already covered in other parts of the diabetes area, the focus is likely to be on treatment. In many cases PD5 inhibitors such as sildenafil (Viagra) will be appropriate although there will be a higher incidence of coronary heart disease in these patients so referral to an andrology clinic for other measures may be more appropriate.

A minor modification is suggested in the cancer area. Under the current rules, a review is required within six months of the diagnosis. The suggested change is to limit the review to within three months after the practice is informed of the diagnosis. Although this would be a fairly minor change practices would need to be aware of it right from the start of the QOF year.

NICE proposes a tightening of the targets in the hypertension area. The current blood pressure target is 150/90. This target would remain for patients aged 80 or over at the end of the QOF year but in younger patients the systolic target would drop to 140mmHg. This could be quite a challenge depending on where the thresholds are set – the setting of thresholds and points value will be crucial.
Still in the area of blood pressure, the Records 11 and 17 indicators currently pay out ten points if 65% of patients over the age of 45 have had a blood pressure reading in the previous five years with an additional five points for getting to 80%. These are simple thresholds without a sliding scale.

The menu proposes replacing these with single indicator giving points on a sliding scale in the same way as other clinical indicators. The age threshold would also be moved down to 40 meaning that blood pressure measurements in anyone over the age of 35 could pay off in the long term.

A small change in the stroke and transient ischaemic attack (TIA) area is that the cholesterol indicator now only applies to patients who have had a non hemorrhagic stroke or a TIA. Previously it had applied to all strokes including intracerebral bleeds.

Perhaps the most eagerly anticipated change has been the proposed change to the indicators relating to patients newly diagnosed with depression as discussed in the previous article. The assessment questionnaires have never been popular and have so little evidence behind them that NICE recommended their complete removal last year.

It was not considered acceptable by the negotiators to have nothing about depression in the QOF and so NICE have returned this year with an alternative.
This is described as a biopsychosocial assessment, which should be performed at the time of diagnosis. There are 16 areas that should be documented to complete the assessment, including: past mental health history, living conditions, alcohol use and discussion of a treatment plan. Piloting by NICE has suggested that this may take 20 minutes to perform.

It is not clear how the coding of this area will occur. One option – to require 16 separate codes – could be complicated for practices to enter. A single code for the whole assessment would not be terribly specific. It is possible there may be a compromise with three or four codes being required but there has been no decision announced by NICE and it may well be left to negotiations.
Only one assessment is required but there should be a review between 10 and 35 days after the diagnosis. While this is a shorter window of time than the current indicators, it should be consistent with the standard reviews of most practices. This review is likely to be simpler than the current assessment through the patient health questionnaire (PHQ) 9.

This is a relatively modest set of changes although practices will need to be ready for them at the start of the QOF year to avoid having to catch up later in the year. While most of these are evolutionary the new indicators for depression and erectile dysfunction will be a significant change in the way that practices work. Training in the new depression assessments would be a good entry to clinicians’ personal development plans over the next few months.

NICE does not specify thresholds or the point values to be set for these indicators. There are proposed points and threshold values in the government consultation for England and these are likely to be adopted across the UK. In the end it will be for practices to balance the cost of these measures against the clinical and financial benefits.