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QOF: Minor indicators

QOF: Minor indicators

Insight: QOF
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While the major areas of the Quality and Outcomes Framework (QOF) such as diabetes and heart disease are well known and have been present since the introduction of the framework, smaller areas should not be ignored. These sections tend to have fewer patients and provide only a few points individually but together they make up a sizable proportion of the points available. Many of these areas first arrived in a flurry of changes about four years ago and can still feel quite new and different. 
While the major areas of the Quality and Outcomes Framework (QOF) such as diabetes and heart disease are well known and have been present since the introduction of the framework, smaller areas should not be ignored. These sections tend to have fewer patients and provide only a few points individually but together they make up a sizable proportion of the points available. Many of these areas first arrived in a flurry of changes about four years ago and can still feel quite new and different. 
 
Some of the areas do not have any actual indicators and exist only as a register. Others have a small number of indicators and are still weighted towards prevalence rather than activity. Investment in building up a register in these areas can eventually pay off year-after-year. Additionally, the prospects of these areas continuing in the future are good: no disease area has ever been removed from QOF.
 
Obesity
The obesity register is a good example. There are no activity indicators at all in this area and payment is based entirely on the number of patients on the register. The register itself is made up of all patients over the age of 16 who have a BMI recorded over 30kg/m2 over the previous fifteen months. The payment per patient is not huge – between two and three pounds per year –  but the process is quick to enter and payment is repeated the following year. There is no payment for measuring a BMI that is less than 30 but screening by eye is likely to suggest the patients who would qualify.
 
Learning disabilities
Learning disabilities has worked in a similar way over the past two years. Creating a register in this area is particularly worthwhile as adding an extra patient can be worth around £25, largely for work that you may be doing anyway. Only patients 18 years and older are counted on the register. The QOF guidance is fairly clear about the difference between a learning difficultly and a disability. The former could include things like mild to moderate dyslexia while the latter has a significant effect on a patient’s life with loss of function. In practice, things may not be so clear-cut.
 
There is still a directed enhanced service (DES) providing annual health checks to patients with learning disabilities. The criteria for this are, annoyingly, slightly different. The population for the DES should be agreed with the local authority social services department who maintain their own register. The comparison of this register with the practice's QOF register, however, is likely to be useful and may show up patients who previously were not recognised formally by the practice.
 
Down’s syndrome
This year, a single indicator has been attached to the learning disabilities area. It requires patients with Down's syndrome over the age of 18 to have an annual measurement of TSH to screen for thyroid disease. While this is simple in theory there are a couple of small complications in practice. The first is ensuring that you have an identified patient with Down's syndrome in the right age group. Smaller practices, in particular, may find that they simply do not have a patient who qualified and so miss out on the points.
 
If a patient is identified as having thyroid disease they are then excluded from this indicator. If they were your only patient this would mean missing out on the points in the following year, although you would get the small advantage of the increase in thyroid prevalence.
 
Dementia
Dementia is another clinical area where there are quite a large number of points for a relatively small number of patients. This makes identifying patients for the register quite a valuable exercise. Of course to get the full value you need to achieve the indicators. 
 
There is one indicator for patients already on the register to have an annual review. In many cases these patients are seen quite regularly anyway so it is simply a case of ensuring that the required actions are carried out. 
 
The guidelines indicate four areas, which the review should cover: the physical and mental health of the patient; the information needs of the patient and their carer; the effects of the disease on the carer and; the communication between primary and secondary care. There are fifteen points here and a typical practice will have around twenty-five patients on the register.
 
New this year is an indicator requiring blood tests within six months of the diagnosis being entered - the blood tests can be either before or after the diagnosis. Timing is important here. One practical problem in my practice has been the time between pre-referral blood tests and a formal diagnosis can exceed the six-month limit. Sometimes the tests may need to be repeated.
 
There are six points for this indicator and the number of new diagnoses during the year may be small. It is again essential that you have at least one patient to whom this indicator applies in order to get the points.
 
Small numbers are a problem in several of these indicators. In the palliative care area there is no adjustment for prevalence. It is vital that a practice has a patient on the register on the 31st of March to get the points in this area. For obvious reasons this register has quite a high rate of turnover through the year. The only indicator in this area concerns the holding of multidisciplinary meetings. Even if meetings are held throughout the year payment remains dependant on at least one current patient being coded as requiring palliative care at the end of the year.
 
Smoking
One area where small numbers is not a problem at all is smoking. There are currently two indicators in the smoking section that deal with patients who also have a chronic disease. Patients on virtually every other register count towards these indicators. There is also one smoking indicator in the records section that deals with all patients over the age of 15. This will move to the main smoking area next year and the rules are identical for these areas.
 
The smoking history for patients must be recorded for patients on the chronic disease registers in the fifteen months before the end of the QOF year. For all other patients the recording must be in the previous 27 months.
 
The rules for coding are complicated. There are three possible statuses that can be recorded to count as achievements for the indicator. Firstly a patient may be recorded as a smoker. The form (cigarettes, rolling own tobacco, etc) and quantity of smoking should be recorded. If this is done in the fifteen months (27 months for Records 23) before the end of the QOF year then the patient is counted as passing the indicator.
 
Secondly the patient may be recorded as having never smoked tobacco (code 1371). If the patient is less than age 25 at the year end then the code must be entered in the same time limit as above. If the patient is 26 or over then the code need only be entered once, but crucially must be after they turn 26. For patients with birthdays in March there may only be a couple of weeks in which the code can be entered.
 
Thirdly the patient might be recorded as being an ex-smoker. This should be recorded within time limits above. However if a patient is recorded as an ex-smoker for three consecutive years then they do not need to be recorded again. There is no age requirement for age to be taken into account for this indicator. 
 
There is a pitfall to be aware of. The rules look back at the last ex-smoker code and the two years before that. If a patient has three codes already then adding a new one may break that chain and you will have to start again to build up three consecutive years.
 
Where patients smoke they should be given smoking cessation advice or referred to a local smoking cessation clinic - again within the timescales mentioned above. There is little in the guidance about what form this should take but NICE did publish guidance (PH10) in 2010. 
 
There is no requirement to give smoking advice to patients who do not have a chronic disease in the current QOF year but this will become a requirement next year. As this will look back over 27 months any advice given this year will contribute to achievement in March 2013. It is never too early to start as many of these patients may attend rarely and so it could be very difficult to achieve this fully in a single year.
 
Like all of the QOF a bit of organisation goes a long way. The small size of these indicators can make that plan quite simple, but one that could be financially beneficial to the practice.
 
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