Epilepsy can be complicated to treat and the fairly complicated rules in the Quality and Outcomes Framework (QOF) do not make it any easier. It has also become more complex this year with an additional indicator.
Epilepsy can be complicated to treat and the fairly complicated rules in the Quality and Outcomes Framework (QOF) do not make it any easier. It has also become more complex this year with an additional indicator.
Epilepsy can be complicated to treat and the fairly complicated rules in the Quality and Outcomes Framework (QOF) do not make it any easier. It has also become more complex this year with an additional indicator.
Epilepsy can be complicated to treat and the fairly complicated rules in the Quality and Outcomes Framework (QOF) do not make it any easier. It has also become more complex this year with an additional indicator.
In most practices there are a reasonably small number of patients affected. The national prevalence is around 6 per thousand and only patients 18 or older are included on the register. For a typical practice, it would be a little over thirty patients but there are 14 points to be gained for these patients. To turn this around each patient carries with them about fifty pounds of potential income.
The key to ensuring that you receive full recognition for work done is to produce a good register of patients who have epilepsy. Under the current prevalence arrangements this is at least as important as the number of points attained. The register is constructed in a similar way to the asthma register: there needs to be both a diagnostic code and a record of prescription of anti-epileptic drugs. The prescription must be issued during the final six months of the QOF year i.e. from October onwards.
Epilepsy can be a difficult diagnosis and should be subject to ongoing review. It is not uncommon for a diagnosis to be revised. In some cases it may be appropriate to delete the original diagnostic code although there should be a corresponding entry describing the removal and the reasons for it.
It is possible to code patients as having recovered from epilepsy although normally this would be accompanied by a cessation of treatment also. For completeness, and in cases where anti-epileptics may be used for other indications such as neurological pain or bipolar disorder, the code 212J or 21260 may be used to record formally that epilepsy has been resolved.
Each patient on the register is worth around fifty pounds if all points are obtained. Searching your practice system annually for patients taking anti-epilepsy medications and comparing this with your register is likely to take less than twenty minutes. This will ensure all patients are appropriately monitored and that you achieve maximum income. Evidence of this annual audit of the register will also assist in any QOF inspection.
There are two indicators based around the control of seizures. Until last year a third indicator required an annual review of medication, but this has now been removed although periodic review of medication remains best practice. It does not, however, need to be specifically coded.
The first of the current indicators is simply a record of the frequency of seizures. This is entered in a single code and is intended to be entered as part of a more general annual review of epilepsy. Other parts of the review should include any adverse effects from the medication and plans for the future. In well-controlled patients this could include plans to stop medication entirely with all of the implications for driving that this could involve. Current guidance from the DVLA is that patients should not drive while reducing medication and for six months afterwards, and this advice, if given, should be recorded in the notes.
The second indicator is an outcome indicator. Achievement here is based on there being a record that the patient has been free of seizures for twelve months. The code looked for is a record of the patient being fit-free rather than an absence of codes indicating seizures. For this reason a single occurrence of the code will count as achievement for QOF. As this looks back for fifteen months there needs only to be a single twelve-month period of being fit-free in this time.
In practical terms it is best to ask at each appointment whether the patient has been fit-free for twelve months. If this can be recorded then any subsequent fits during the QOF year are ignored for the purposes of this indicator.
This indicator can be quite challenging for practices although the upper threshold is only set at 70%. Nationally, the average achievement is around 75% but around a quarter of practices failed to achieve the 70% threshold in 2009/10. Exception reporting, however, is fairly high at nearly sixteen percent, which is high even when compared against other outcome indicators. There can be a number of reasons for this: Epilepsy is one of the areas where patients can make a particularly well informed choice about increases in medication that may give increased control but with a greater severity of adverse effects. Patients with irregular or non-intrusive seizures may well decline further medication and should be coded as on maximum tolerated anticonvulsant therapy (8BL3). Similarly, patients may have highly resistant epilepsy and be on the maximum possible and should be coded the same way.
There is a small anomaly for new diagnoses. There would normally be a nine-month grace period as an outcome measure but the current rules only allow three months. For a new diagnosis, which generally follows a seizure, there is simply not time for twelve fit-free months to pass and so patients will fail this indicator automatically. There is no exception code or reason that is entirely appropriate in this case.
The new indicator this year, Epilepsy 9, relates to contraception, conception and pregnancy advice to women age 55 and younger. Along with the rest of the epilepsy area this applies only from age 18 which may seem a little old in some populations. Patients who have had a hysterectomy or sterilisation will be excluded automatically from these requirements if they have been coded appropriately.
All three areas of advice need to be coded through the 15 months of the QOF year although not necessarily at the same time. The advice needs to be repeated annually. The codes are split into three areas; contraception (6110), conception (67IJ0) and pregnancy (67AF).
Of course there may be other reasons that this advice is not appropriate. Menopause would render all of the areas irrelevant and patients attempting to conceive would not find contraceptive advice useful. Exception report codes are available where advice is not indicated or declined.
The business rules, which prescribe the way this data is extracted from the system, have a few oddities in this area. If advice is coded in all three areas then the indicator is marked as achieved. Predictably if advice is not given in one or more areas and no exception report is entered then the indicator is regarded as failed. However in the third case where one or more areas have exception reports and other areas of advice are given then the patient is not eligible for the indicator. This leads to the slightly odd situation where giving advice to a patient with an exception report could move the patient from failure to non-eligibility for an indicator.
While this is not an area with a huge number of points they are not especially hard to attain in the small number of patients that a typical practice would have. The incentive for ensuring that all patients are correctly on the register is also high. A little time spent on these smaller areas can prove fruitful.
Dr Gavin Jamie
Swindon GP
Webmaster of the
QOF Database
Swindon GP
Webmaster of the
QOF Database
