QOF: new indicators

Like the apocryphal painting of the Forth Bridge, the work towards the Quality and Outcomes Framework (QOF) never ends. As many of the indicators cover 15 months, practices have actually started working towards a new year three months before the previous one has ended.

The changes to the QOF for 2012-13 have already begun and are largely evolutionary, but early preparation will reduce the changes of unpleasant surprises later in the year. At the time of writing, the full guidance has not been published. Nevertheless, there is sufficient detail to start work towards the new indicators.

The atrial fibrillation (AF) area has been changed extensively. The previous indicators for electrocardiogram (ECG) confirmation of diagnosis and the use of aspirin or warfarin have been removed. The 22 points have been spread over three new indicators, which all depend on the CHADS2 assessment: a score of the risk of a cerebrovascular event in patients with AF.

Patients with a score of one should have either antiplatelet therapy or formal anticoagulation. If the score is greater than one then only anticoagulation – with warfarin or digabatrin – will do. There are 10 points for calculating the scores in 90% of patients. Six points each are available for 90% of patients with a score of one receiving aspirin and for 70% of patients with a higher score receiving anticoagulation.

The chances of scoring less than one (see Box 1) are small and the number of patients with a score of two or more is likely to be pretty high. A score of one suggests a risk of about 2.8% and a score of two a risk of 4%. The first step to seeing what is required is to calculate the CHADS2 score for all patients in your practice with AF. Until this is known it will not be possible to see the current level of achievement. The earlier this is done during the year, the easier it will be to effect any required changes.

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While having a huge number of these patients on your register is unlikely, calculating by hand could be tedious and error prone. A useful tool for practices is the Guidance on Risk Assessment for Stroke Prevention (GRASP) queries available with the Primis CHART (Care and Health Analysis in Real Time) information service.

This will not only calculate the score but also allow you to see where your practice stands against the anticoagulation indicators before the QOF indicators are implemented in the practice systems. You will still need to add the scores for each patient onto your clinical system manually.
The CHART tool will also calculate the more modern CHA2DS2-VASc score. Currently it seems that this will not be valid for QOF. If this is used then the CHADS2 score (38DE) should also be entered at the same time.
Much of the evidence base for anticoagulation comes from the ASCOT study (see Resource). This study can also give some clues about the expected exception reporting from these indicators – the actual exception reporting is likely to be higher than that in the study, owing to less support away from a formal research programme. This was, however, a primary care study, which increases its validity.

Around 5% of patients had some contraindication to anticoagulation in ASCOT and a further 7% declined warfarin. About the same number declined to take part in the research and so their other contraindications or preferences are not known. This would suggest an exception rate of at least 15% is to be expected in this area and possibly rather higher outside of a research environment.

Peripheral arterial disease (PAD) is also an entirely new area. Although there are only nine points for the whole area it will still be important to start by looking at prevalence figures. There are only two points for compiling the register and this may be difficult. There are several Read codes for peripheral vascular disease, although they may not be widely used. There is no unique combination of drugs or laboratory findings that would suggest PAD on a search of practice systems.

The guidance for this area suggests that 20% of patients over 60 years old may have peripheral vascular disease, although only about a quarter of these have claudication. The definition used is an ankle-brachial pressure index (ABPI) of less than 0.9. The ABPI may be inaccurate in obesity or in diabetes with calcification of the vessels. In these cases diagnosis may then be made by history and palpation of the leg pulses.

The remaining indicators are all fairly familiar as they are very similar to others dealing with vascular disease in the rest of the QOF. Aspirin or an alternative should be given to at least 90% of patients in order to gain two points. As in other areas the use of over-the-counter aspirin is acceptable as long as the code is entered in the preceding 15 months.

There are another two points for hitting a blood pressure of 150/90mmHg and three points for a cholesterol of less than 5mmol/L. Both have top thresholds of 90%.

PAD has also been added to the list of diagnoses that need smoking data to be collected during the year. Despite the increase in patient numbers the number of points for this indicator has been reduced from 30 to 25. The same reduction has happened to the smoking advice indicator.

While the number of points is relatively small, many patients with PAD are likely to have other diagnoses. With so much commonality in indicators, achievement here can count across several areas. These indicators serve to increase the emphasis on vascular disease already seen in the QOF.

The osteoporosis will be familiar to many practices as they are very similar to those previously part of a directed enhanced service (DES). The biggest change is that, while the DES only applied to women, the QOF indicators apply equally to men and women. As osteoporotic fractures are much less common in men the overall increase in numbers is likely to be around 20%. The payment system for QOF is very different to that of the DES, but it seems probable that there will be a modest increase in income.

Two groups of patients qualify for this area. The first are patients aged 50-74. Following a fragility fracture they should have a DEXA scan. If the scan shows osteoporosis they are eligible for the indicators in this area.

Patients aged 75 and simply need to have a fragility fracture. These will need to be coded explicitly. There is no particular type of fracture that is automatically considered a fragility fracture – the circumstances of the fracture are as important as the fracture itself. In general, these are fractures that occur as low energies, mostly as the result of a simple fall. The relevant codes are 'N331N' or 'N331M', the latter simply being a fragility fracture secondary to osteoporosis. The code should be used in addition to a specific code for the type of fracture – eg, hip fracture or Colles fracture.

This area is only about secondary prevention. Patients with a diagnosis of osteoporosis without suffering a fracture after April 2012 will not be included in these indicators. The current business rules are rather peculiar with relation to the patient's age. The age counted is that at the end of the QOF year. This has the odd effect that a patient may have a fracture aged 49 but still require a scan if they turn 50 before the end of March. For similar reasons, a patient aged 74 may have a fracture and a negative DEXA but still be required to have a bone-sparing agent.

The two groups are combined to form a single register, worth three points. The other two indicators are for the use of bone-sparing agents in each of these groups, with three points for each indicator. These drugs are often poorly tolerated and the thresholds reflect this with the upper at 60% and the lower at 30%. If the rules remain as they are then this issue will become greater each year.

In small practices there may be small numbers of fractures. It will be essential that a fragility fracture is recorded after 1 April in each of the two age groups in order to be able to score the points. Interestingly, the date of 1 April 2012 is a fixed one, suggesting that success and failure this year will also count in future years. This sort of ongoing indicator has been removed in other areas and it is a little surprising to see a new one being introduced.

Exception reporting can be complicated. The simple codes are '9hP' – indicating the patient has informed dissent or is unsuitable for treatment. If allergy codes or other specific drug codes are used then four codes are required – one each for bisphosphonates, raloxifene, teriparatide and strontium ranelate. Teriparatide is recombinant parathyroid hormone and should normally only be initiated in secondary care.

Since the start of the QOF there has been an indicator in the records section requiring all patients over 15 at the end of the year to have a record of their smoking status. This has always operated in the same way as an indicator in the clinical domain with a sliding scale of achievement. From this year this has been tidied into the clinical smoking indicators.

It is worth briefly reiterating the smoking data requirements. Patients must be coded as either current, ex or 'never' smokers. A code of 'current non-smoker' is not valid. If a patient has a never smoked code after their 25th birthday or has ex-smoker codes in three consecutive years (and no more since) then no future codes are needed.

New this year is a requirement for smoking-cessation advice in all patients who are found to be current smokers. This will work in the same way as the current cessation advice indicator for patients with chronic disease and many patients will fall into both indicators. There are 12 points for this, which will, to an extent, subsidise the data collection indicator which always carried very few points for the effort involved.

Lots of thresholds have changed this year. In general, upper thresholds below 75% have increased by 5%. One exception is the blood-pressure target of 150/90mmHg in the hypertension area, which goes from 70% to 80%. It also loses two points but the total is still a pretty hefty 55 points.

Lower thresholds have also increased, although this is likely to have rather less impact on practices. There are relatively few practices around these bottom centiles, and the impact with higher achievement is quite small. Where the top threshold is 90%, the lower threshold generally will move to 50%. Where the top threshold is 70% or over, the bottom threshold will be 45%.

Other minor changes are a more formal annual asthma review that incorporates the three RCP (Royal College of Physicians) questions. The second depression assessment questionnaire is also more flexible. It can now be used from two weeks of the first assessment up to the full 12 weeks.

Despite two new areas in this year's QOF, little is radically different. I would urge practices to compile their PAD registers and calculate CHADS2 scores as soon as possible – it will make achievement during the year that much easier. This is likely to be a very busy year and early preparation will make things much simpler later in the year.

Resource

ASCOT study
www.ascotstudy.org

Box 1.
The CHADS2 score