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Indicating depression

Indicating depression
8 February 2013

Depression is one of the most common diagnoses made in general practice and one that makes up a large proportion of consultations in primary care. Its introduction into the quality and outcomes framework (QOF) has, however, been controversial since the start.

Other areas have clear, quantifiable actions or targets such as taking blood pressure or achieving a particular cholesterol level. Mental health does not lend itself easily to such a rigid analysis. There are very few numbers involved and fewer hard outcomes relating to mental illness.

Depression is one of the most common diagnoses made in general practice and one that makes up a large proportion of consultations in primary care. Its introduction into the quality and outcomes framework (QOF) has, however, been controversial since the start.

Other areas have clear, quantifiable actions or targets such as taking blood pressure or achieving a particular cholesterol level. Mental health does not lend itself easily to such a rigid analysis. There are very few numbers involved and fewer hard outcomes relating to mental illness.

In recent years the QOF area dealing with psychosis and bipolar disorder has become more physically based. Its indicators now concern easily quantifiable information such as alcohol consumption or tests for cholesterol and blood pressure. Actions now include cervical cytology, which does not leave a lot of room for interpretation.

Learning disabilities is similar. It had no indicators other than the register until recently and its sole indicator now is for thyroid function testing.
Depression is different. There simply are no recommended physical tests or interventions. This has made the setting of indicators rather harder. There is clearly a will that an area as important as depression remains within the framework that has created a pressure to find suitable indicators.

It seems likely that the indicators may change in detail in the next year. The basis for this change will be the latest guidance from NICE on the assessment and treatment of depression. It is also likely that there will not be, and need not be, a huge change in the way that depression is treated in general practice. As ever, it will be important to use the right words and documentation to ensure that good care is recognised under the QOF.

The first indicator is about screening for depression in patients who already have a diagnosis of either diabetes or coronary heart disease and has remained the same since the depression area was introduced. Both of these conditions are associated with a greater lifetime prevalence of depression.

Patients who are diagnosed with depression for the first time in the 15 months of the QOF year do not need this screening. In fact the screening will not count if they are subsequently diagnosed with depression after the test. Oddly patients with ongoing depression still need screening.

The specified screening is the asking of two questions: “During the past month have you often been bothered by feeling down, depressed or hopeless?” and “During the past month have you often been bothered by having little interest or pleasure in doing things?”

These questions are fairly general and should be fitted into a clinical consultation. The guidance is quite clear that these should not be posted to patients as a screening test. It is not necessary, however, that the screening be done by a doctor. If the answer to either of the questions is “yes” then the patient should be referred on to see a GP for further assessment.

A follow on question “Is this something with which you would like help?” can help to make the screen more specific – that is produce fewer false positives. In practical terms it is also very difficult to treat someone who does not want help.
Like any screening test the sensitivity and specificity are key to being a useful test. Use of the follow up question will increase the negative predictive value slightly to 98.8% – an incorrect figure as stated in the guidelines.

This is essentially a reasonably reliable test although it will certainly not identify every case of depression. One patient in 83 with a negative response will actually have depression.

There is no evidence about whether this screening test is any better than the general impression of an experienced GP but this is considered an easily measurable factor.

The screening questions need to be recorded in the 15 months before the end of March, although this may reduce to a 12 month window next year.

The other two indicators are about the assessment of the severity of depression in patients who have already been diagnosed. In the current year this has been done by formal questionnaire although this is very likely to change in the next QOF year.

There are three assessment questionnaires that are approved for use in QOF – the hospital anxiety and depression scale (HADS), the Beck depression inventory second edition (BDI-II), and the primary health questionnaire (PHQ-9) scale. All three of these are under copyright but the PHQ9 scale has been made freely available to use by Pfizer. Many also find that it is the simplest to implement with only nine questions.

As the first two questionnaires require payment for use, the PHQ9 is overwhelmingly the most commonly used.

All of these assessment tools were developed in research environments and is designed to be self- administered by the patient. As points can be lost if the patient does not fill in a questionnaire, it is often more efficient to administer it in the context of consultation and ensure that the score is coded. There is no evidence for its use in this way but can be made necessary in the way that QOF is implemented.

An assessment currently needs to be made within four weeks after the diagnosis is made. When this has taken place patients qualify for a second assessment between two and 12 weeks after the first. If the first assessment does not take place then any later assessment will not be counted.

The calculation of these makes for some oddities in the business rules which set out how the achievement for each practice is defined. The rules do not behave as you might expect and the reasons have only recently been made explicit.
Assessment will count as positive achievement in the QOF year in which they occur. Where the assessment is not carried out this is counted as a failure in the QOF year in which the timescale expires.

To give an example, consider a patient who was diagnosed with depression on Christmas Eve 2011. The clock starts ticking and the first assessment takes place on the 14th of January. This will count in that QOF year.

If the second assessment were to take place in March then that would also count for the QOF year ending 31 March 2012. The second assessment could equally take place in the first couple of days of April then this would count as achievement in the year ending March 2013.

If no second assessment took place at all then the failure would be recorded in March 2013 despite the diagnosis being made more than 15 months before.
There is some logic to this as otherwise some patients would be lost during the year change and the logic is the same in other QOF indicators. The longer timescales available for this indicator make it more apparent and a common cause of confusion for practices.

There is very little evidence that these paper assessments on their own have a significant effect on the outcome of depression. In summer 2011, NICE suggested that the indicators be withdrawn – both for screening and further assessment. This was not accepted by the negotiators so proposals for next year are for other forms of assessment.

These would work in a very similar way to the current indicators. The first assessment should be made before the diagnosis is made with a review between ten and 35 days after the diagnosis. The timings are tighter but should be easier to understand. There will effectively be a small gap at the time of transition to the benefit of practices where a diagnosis of depression is made in January and February.

The new process is described as a biopsychosocial assessment and, despite the unfamiliar jargon, is much closer to what most GPs would describe as routine history taking and mental state examination.

This should involve assessing the environment, both physical and social – where the patient lives and works – as well as looking at the biological and psychiatric symptoms. Social support and past mental health history will also be included. There will be a set of 16 questions to be asked although the answers are likely to be free text rather than a score or multiple choice.

Questionnaires such as the PHQ-9 may well be a part of this assessment although they will certainly not be compulsory. The whole assessment may take 20 minutes depending on the patient and may have to be split over more than one appointment.

The later review will repeat some of the questions, especially those around suicidal ideation although it is not expected that the full assessment will be repeated. In general, this will be a review of progress in symptoms, social support and possibly external referrals – for instance to a psychologist.

While the initial assessment should be face-to-face the review could be conducted by telephone although it is still expected that the majority will be in person. Although a review must be made in the 10 to 35 day window this does not, of course, preclude an earlier review if it is thought appropriate.

One indicator that is not in the depression area is concerned with producing a register of patients with depression. As the value of points depends on disease prevalence then there has to be a register somewhere even if it is not explicitly stated in its own indicator. In fact, there are two registers for the depression area; one for the screening indicator and another for the two assessment indicators.
The first register is simply all of those patients who are eligible for screening – those patients with diabetes or ischaemic heart disease. The register is normally a bit smaller than you would expect from simply adding together the diabetes and CHD registers as some patients will appear on both.

The second register is more interesting. Until this year the register was made up of any patient who had ever been diagnosed as having depression. This tended to favour practices with good notes summarisation as a diagnosis even 20 or 30 years ago could increase the value of points.

From April this year the new measure of prevalence is based on the number of patients who have a recorded diagnosis of depression since April 2006. This was the first date that depression was included in QOF. Practices are encouraged to use a code of  “depression resolved” where appropriate although doing so will cut your income without removing any requirements.

It is also important to ensure the correct codes are used for diagnosis. Although the business rules used for extraction do not set out to be difficult they can be confusing. The general rule is that “depression” is a diagnosis while “depressed” and “low mood” are descriptions of symptoms are will not be included on the register.

With big changes likely it will certainly pay to keep your eye on the depression indicators over the new QOF year.

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