NICE recommends overhaul of one in seven QOF points

NICE has recommended 14 indicators worth 135 points be retired from QOF for 2013/14 and replaced with new indicators.

Professor Helen Lester: RA indicators recommended for inclusion had been well received.
Professor Helen Lester: RA indicators recommended for inclusion had been well received.

Following its June meeting, NICE’s QOF advisory committee has now published its recommendations for the 2013/14 QOF. Among the new indicators proposed for inclusion are four for rheumatoid arthritis (RA), which has not previously been covered in QOF.

The committee's recommendations will be put forward to the GPC and NHS Employers to decide which should be included in the 2013/14 framework.

NICE recommended three depression, three diabetes and two hypertension indicators, for retirement alongside six other indicators (full details below). It also recommended changes to BP targets and to the diabetes DM13 indicator.

Birmingham University Professor Helen Lester, who leads the piloting of potential QOF indicators on behalf of NICE, said the RA indicators recommended for inclusion in QOF had been well received during piloting.

Speaking to GP magazine between the committee’s meeting and the publication of its recommendations, Professor Helen Lester said ‘pilot practices thought they were great indicators’. ‘The indicators flew through the pilots,’ she said.

'Practices liked the fact that it was a new domain for QOF,’ she said. ‘A third of practices hadn't been aware of the increased CVD or fracture risk, or of how many people needed to be referred for a DEXA scan or bisphosphonates. In that sense, if you put a QOF spotlight on something like RA, things happen.’

Professor Lester said that, in several of the practices, nurses and GP registrars took the RA indicators on as a project and called patients for their reviews.

'GPs saw this as real quality improvement, rather than just fiddling at the edges,’ she said. ‘One GP said including RA in QOF reminded him of the joys of medicine.

Professor Lester said the indicators had meant that a new group of people received a focus of attention. ‘Patients liked the fact that their condition was being reviewed,’ she said. ‘They said they felt "validated" and "taken seriously".’

 

 

QOF indicators proposed by NICE for retirement from 2013/14 QOF

  • Cancer 3 (‘The percentage of patients with cancer, diagnosed within the preceding 18 months, who have a patient review recorded as occurring within 6 months of the practice receiving confirmation of the diagnosis’). NICE’s QOF committee recommended that the Cancer 3 indicator be retired if the proposed indicator for patient review after cancer diagnosis is introduced (‘The percentage of patients with cancer diagnosed within the preceding 15 months who have a review recorded as occurring within 3 months of the practice receiving confirmation of the diagnosis’).
  • CHD10 (‘The percentage of patients with coronary heart disease who are currently treated with a beta-blocker’). NICE’s QOF committee recommended that the CHD10 indicator should be retired. The committee said that the evidence of effectiveness for this recommendation was for patients who have had an acute myocardial infarction and that this is covered by the QOF indicator CHD14. The committee noted that beta-blockers may be beneficial for the symptomatic relief of angina but that there was no strong evidence for the secondary prevention of coronary heart disease.
  • CKD2 (‘The percentage of patients on the CKD register whose notes have a record of blood pressure in the preceding 15 months’). The committee repeated its recommendation that this indicator be retired.
  • DEP01 (‘The percentage of patients on the diabetes register and/or the CHD register for whom case finding for depression has been undertaken on one occasion during the preceding 15 months using two standard screening questions’). The committee repeated its recommendation that this indicator be retired.
  • DEP6 (‘In those patients with a new diagnosis of depression, recorded between the preceding 1 April to 31 March, the percentage of patients who have had an assessment of severity at the time of diagnosis using an assessment tool validated for use in primary care’). The NICE QOF committee has previously recommended the indicator DEP6 be retired. It has now recommended that it be retired  if the proposed new indicator for bio-psychosocial assessment in depression was included in QOF (the wording for the proposed new indicator is: ‘The percentage of patients with a new diagnosis of depression in the preceding 1 April to 31 March who have had a bio-psychosocial assessment by the point of diagnosis’).
  • DEP7: (‘In those patients with a new diagnosis of depression and assessment of severity recorded between the preceding 1 April to 31 March, the percentage of patients who have had a further assessment of severity 2 - 12 weeks (inclusive) after the initial recording of the assessment of severity. Both assessments should be completed using an assessment tool validated for use in primary care’). The NICE QOF committee has previously recommended that DEP7 be retired. It has now  recommended that DEP7 be retired if the proposed new indicator for review after cancer diagnosis was included in the 2013/14 QOF (the wording for the proposed new indicator is: ‘The percentage of patients with a new diagnosis of depression in the preceding 1 April to 31 March who have been reviewed within 10-35 days of the date of diagnosis’).
  • DM02 (‘The percentage of patients with diabetes whose notes record BMI in the preceding 15 months’). The NICE QOF committee recommended that the DM02 indicator be retired. It has previously made this recommendation.
  • DM10 (‘The percentage of patients with diabetes with a record of neuropathy testing in the preceding 15 months’). The NICE QOF committee recommended that the DM10 indicator should be retired as it overlaps with DM 29 on foot risk classification
  • DM22 (‘The percentage of patients with diabetes who have a record of estimated glomerular filtration rate or serum creatinine testing in the preceding 15 months’). The NICE QOF committee recommended that the DM22 indicator be retired. It has previously made this recommendation.
  • EPILEPSY06 (‘The percentage of patients aged 18 years and over on drug treatment for epilepsy who have a record of seizure frequency in the preceding 15 months’). The NICE QOF committee recommended that the EPILEPSY06 indicator be retired. It has previously made this recommendation.
  • BP04 (‘The percentage of patients with hypertension in whom there is a record of the blood pressure in the preceding nine months’). The NICE QOF committee recommended that the BP04 indicator be retired. It has previously made this recommendation.
  • BP05 (‘The percentage of patients with hypertension in whom the last blood pressure [measured in the preceding 9 months] is 150/90 or less’). The NICE QOF committee recommended that the BP05 indicator be retired if two proposed indicators defining differential BP targets for those over and under 80 years old are introduced (the wording of these two indicators is: ‘The percentage of patients under 80 years old with hypertension in whom the last recorded blood pressure [measured in the preceding 9 months] is 140/90 or less’ and ‘The percentage of patients aged 80 years and over with hypertension in whom the last recorded blood pressure [measured in the preceding 9 months] is 150/90 or less’).
  • Records 11 and Records 17 (‘The blood pressure of patients aged 45 years and over is recorded in the preceding 5 years for at least 65% of patients’ and ‘The blood pressure of patients aged 45 years and over is recorded in the preceding 5 years for at least 80% of patients’). The NICE QOF committee recommended that the Records 11 be retired if a proposed new indicator for blood pressure recording was included in the 2013/14 QOF. The wording of this new proposed indicator is: ‘The percentage of patients aged 40 years and over with a blood pressure measurement recorded in the preceding 5 years’.


Indicators proposed by NICE for inclusion in 2013/14 QOF

  • Cancer: The percentage of patients with cancer diagnosed within the preceding 15 months who have a review recorded as occurring within 3 months of the practice receiving confirmation of the diagnosis
  • COPD: The percentage of patients with COPD and Medical Research Council (MRC) Dyspnoea Scale ≥3 at any time in the preceding 15 months, with a record of oxygen saturation value within the preceding 15 months
  • COPD: The percentage of patients with COPD and Medical Research Council (MRC) Dyspnoea Scale ≥3 at any time in the preceding 15 months, with a subsequent record of an offer of referral to a pulmonary rehabilitation programme
  • Depression: The percentage of patients with a new diagnosis of depression in the preceding 1 April to 31 March who have had a bio-psychosocial assessment by the point of diagnosis
  • Depression: The percentage of patients with a new diagnosis of depression in the preceding 1 April to 31 March who have been reviewed within 10-35 days of the date of diagnosis
  • Diabetes: The percentage of male patients with diabetes who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 15 months
  • Diabetes: The percentage of male patients with diabetes with a record of being asked about erectile dysfunction in the preceding 15 months
  • Heart Failure: The percentage of patients with heart failure diagnosed within the preceding 15 months with a record of an offer of referral for an exercise based rehabilitation programme
  • Hypertension: The percentage of patients aged 80 years and over with hypertension in whom the last recorded blood pressure (measured in the preceding 9 months) is 150/90 or less
  • Hypertension: The percentage of patients under 80 years old with hypertension in whom the last recorded blood pressure (measured in the preceding 9 months) is 140/90 or less
  • Rheumatoid arthritis: The percentage of patients aged 50-90 years with rheumatoid arthritis who have had an assessment of fracture risk using a risk assessment tool adjusted for RA in the preceding 27 months
  • Rheumatoid arthritis: The percentage of patients with rheumatoid arthritis aged 30-84 years who have had a cardiovascular risk assessment using a CVD risk assessment tool adjusted for RA in the preceding 15 months
  • Rheumatoid arthritis: The percentage of patients with rheumatoid arthritis who have had a face to face annual review in the preceding 15 months
  • Rheumatoid arthritis: The practice can produce a register of all patients aged 16 years and over with rheumatoid arthritis


Changes to indicator wording proposed by NICE committee for 2013/14 QOF

  • DM13 (‘The percentage of patients with diabetes who have a record of micro-albuminuria testing in the preceding 15 months (exception reporting for proteinuria)’). The proposed revised wording is: ‘The percentage of patients with diabetes who have a record of an albumin:creatinine ratio (ACR) test in the preceding 15 months’.
  • Stroke 8 (‘The percentage of patients with stroke or TIA whose last measured total cholesterol [measured in the preceding 15 months] is 5mmol/l or less’). The proposed revised wording is: ‘The percentage of patients with a stroke shown to be non- haemorrhagic, or a history of TIA whose last measured total cholesterol (measured in the preceding 15 months) is 5mmol/l or less.’
  • DM15 (‘The percentage of patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with ACE inhibitors [r A2 antagonists]’). The proposed new wording is: ‘The percentage of patients with diabetes with a diagnosis of diabetic nephropathy (clinical proteiunuria) or micro-albuminuria who are treated with ACE inhibitors (or A2 antagonists)’.

 

Other indicators that GPC and NHS Employers may consider for inclusion in 2013/14 QOF (these have been previously recommended by NICE but not yet been included in QOF)

  • Diabetes: The percentage of patients newly diagnosed with diabetes in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months of entry on to the diabetes register
  • Diabetes: The percentage of patients with diabetes who have a record of a dietary review by a suitably competent professional in the preceding 15 months
  • Diabetes: The percentage of patients with diabetes with a record of testing of foot sensation using a 10 g monofilament or vibration (using biothesiometer or calibrated tuning fork), within the preceding 15 months
  • Hypertension: In those patients with a new diagnosis of hypertension aged 30-74 years, recorded between the preceding 1 April to 31 March (excluding those with pre-existing CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an agreed risk assessment tool) of>20% in the preceding 15 months: the percentage who are currently treated with statins (unless there is a contraindication)
  • Hypertension: The percentage of patients with hypertension aged 16 to 74 years in whom there is an annual assessment of physical activity, using GPPAQ, in the preceding 15 months
  • Hypertension: The percentage of patients with hypertension aged 16 to 74 years who score 'less than active' on GPPAQ in the preceding 15 months, who also have a record of a brief intervention in the preceding 15 months
  • Records: The blood pressure of patients aged 40 and over is recorded in the preceding 5 years for at least 65% of patients
  • Records: The blood pressure of patients aged 40 and over is recorded in the preceding 5 years for at least 80% of patients

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