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Dr Dave Jeffery Primary Care Data Quality Manager and QOF Management Lead NHS Herefordshire

QOF Update. Dr Dave Jeffery Primary Care Data Quality Manager and QOF Management Lead NHS Herefordshire EMIS NUG Conference Warwick 6th Sep 2012. QOF 2012-13 QOF 2013-14 CQRS. Leeds 7 th March 2012. Where is Hereford?. Clinical points 2011 from http://www.ic.nhs.uk/qof. QOF 2012-13.

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Dr Dave Jeffery Primary Care Data Quality Manager and QOF Management Lead NHS Herefordshire

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  1. QOF Update Dr Dave Jeffery Primary Care Data Quality Manager and QOF Management Lead NHS Herefordshire EMIS NUG Conference Warwick 6th Sep 2012

  2. QOF 2012-13 • QOF 2013-14 • CQRS Leeds 7th March 2012

  3. Where is Hereford?

  4. Clinical points 2011from http://www.ic.nhs.uk/qof

  5. QOF 2012-13 reminders for last year = 2011-12 then this year = 2012-13 indicators retired: CHD13, AF4, QP1-5 indicators changed new indicators inc Osteoporosis & PAD changes to thresholds

  6. and also… pounds per point increased £130.51→ £133.76 (2.5%) no square root adjustment to PF no 5% cut-off “maintain accurate register” exemption exclusion persisting exception expiring

  7. www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/QOF/Pages/ChangestoQOF2013.aspxwww.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/QOF/Pages/ChangestoQOF2013.aspx

  8. Read codes & Business Rules v23www.pcc.nhs.uk/business-rules-v23.0

  9. Read codes & Business Rules v23www.pcc.nhs.uk/qof-read-codes-v23.0

  10. Changes to thresholds Those that were 40-90% - all lower thresholds raised to50-90% Those that had upper threshold between 70-85% - all lower thresholdsraised to 45% and changes to CHD6, CHD10, PP1, PP2, HF4, STROKE6, STROKE8, DM17, DM31, COPD10, BP5, MH10 and DEM2

  11. Diabetes DM 19 →DM 32: register of patients aged 17 years and over with Diabetes Mellitus, which specifies the type of diabetes where a diagnosis has been confirmed Diagnosed by: Fasting plasma glucose ≥ 7.0mmol/l or 2 hour plasma glucose ≥ 11.1mol/l or IFCC HbA1c ≥ 48mmol/l (≡ 6.5%) If too early to diagnose the specific type of diabetes, or if the specific diagnosis is uncertain code diabetes using the parent term C10Diabetes mellitus update records when their type of diabetes confirmed

  12. Diabetes – new codes Diabetes mellitus Type 1 (C10E%) or Type 2 (C10F%) (excluding C10F8 Reaven's Syndrome = Metabolic Syndrome X) C10 Diabetes mellitus C109J Insulin treated Type 2 diabetes mellitus C109K Hyperosmolar non-ketotic state in type 2 DM C10C Diabetes mellitus autosomal dominant C10D Diabetes mellitus autosomal dominant type 2 C10G% Secondary pancreatic diabetes mellitus C10H% Diabetes mellitus induced by non-steroid drugs C10M% Lipoatrophic diabetes mellitus C10N% Secondary diabetes mellitus

  13. HbA1c DM 26, 27 & 28: now IFCC only e.g. DM 26: The percentage of patients with diabetes in whom the last IFCC-HbA1c is 59 mmol/mol or less in the previous 15 months

  14. Epilepsy EP 9: % of women with epilepsy under the age of 55 who are taking antiepileptic drugs who have a record of information and counselling about contraception, conception and pregnancy in the previous 15 months Risk of congenital malformations 1.5%  6% Register starts at 18 years so 18-55 Need to advise on all 3 Exception codes eg pregnancy

  15. Mental Health 10-16 last year →MH 10-13, 16, 19 & 20 this year MH 10: % of patients on the register who have a comprehensive care plan documented in the records agreed between individuals, their family and/or careers as appropriate new mental health remission exception codes, min 5 yrs Recode for relapse

  16. Asthma ASTHMA 3→ASTHMA 10: The percentage of patients with asthma between the ages of 14 and 19 years in whom there is a record of smoking status in the previous 15 months. New exception: 137kRefusal to give smoking status ASTHMA 6 → ASTHMA 9: The percentage of patients with asthma who have had an asthma review in the last 15 months that includes an assessment of asthma control usingthe 3 RCP questions

  17. Asthma 9 questions – In the last month: have you had difficulty sleeping because of your asthma symptoms (including cough)? have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? has your asthma interfered with your usual activities e.g. housework, work/school etc?

  18. Asthma 9 questions – In the last month: have you had difficulty sleeping because of your asthma symptoms (including cough)? have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? has your asthma interfered with your usual activities e.g. housework, work/school etc?

  19. Asthma 9 – Read codes Asthma annual review 66YJ 66YK 66YQ 66YR 8B3j 9OJA 90J2 Refuses asthma monitoring (as before) And the same day – answers to all 3 questions So if repeat review?

  20. Asthma 9 – Read codes 1) In the last month, have you had difficulty sleeping because of your asthma symptoms (including cough)? eg Asthma disturbing sleep663N Asthma not disturbing sleep 663O etc 2) Asthma symptoms by day eg Asthma daytime symptoms 663q etc 3) Interference with activities eg Asthma not limiting activities 663Q etc

  21. Asthma 8 • ASTHMA 8: % patients aged eight and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility • If diagnosed < 8 yrs then come on to register? • Either carry out spirometry or PEFR within 3 months • Or use 8I2j Spirometry contraindicated (expiring)

  22. Dementia: DEM 3 → DEM 4: The percentage of patients with a new diagnosis of dementia recorded between the preceding 1 April to 31 March with a record of FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded 6 months before or after entering on to the register i.e. not cumulative Remember all tests within (before or after) 6/12 of diagnosis, one code from each group

  23. Depression DEP4 → DEP 6: 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 Change to prevalence calculation – now cumulative from April 2006 *within 28 days of the entry of the diagnosis which means up to 28 days after not before

  24. Depression DEP 5 → DEP 7: 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 Was 4-12 weeks

  25. Atrial Fibrillation AF 4: % with AF diagnosed after 1 April 2008 with ECG or specialist confirmed diagnosis AF 3: The percentage of patients with atrial fibrillation who are currently treated with anti-coagulant drug therapy or an anti-platelet therapy • AF 5: The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHADS2 risk stratification scoring system in the preceding 15 months (excluding those whose previous CHADS2 score is greater than 1)

  26. Atrial Fibrillation AF 6: In those patients with atrial fibrillation in whom there is a record of a CHADS2 score of 1, the percentage of patients who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy AF 7: In those patients with atrial fibrillation whose latest record of a CHADS2 score is greater than 1, the percentage of patients who are currently treated with anti-coagulation drug therapy

  27. Atrial Fibrillation AF 6: In those patients with atrial fibrillation in whom there is a record of a CHADS2score of 1, the percentage of patients who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy AF 7: In those patients with atrial fibrillation whose latest record of a CHADS2 score is greater than 1, the percentage of patients who are currently treated with anti-coagulation drug therapy

  28. What? CHADS2 = clinical prediction rule for estimating the risk of stroke in patients with AF GRASP-AF = Guidance on Risk Assessment and Stroke Prevention in Atrial Fibrillation PRIMIS+ = Primary Care Information Services www.primis.nhs.uk CHART = Care and Health Analysis in Real Time MIQUEST = Morbidity Information Query and Export Syntax

  29. Atrial Fibrillation 5, 6 & 7

  30. AF 5, 6 & 7 - choice of intervention

  31. Atrial Fibrillation AF 6: In those patients with Atrial Fibrillation in whom there is a record of a CHADS2score of 1, the percentage of patients who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy AF 7: In those patients with Atrial Fibrillation in whom there is a record of a CHADS2 score of greater than 1, the percentage of patients who are currently treated with anti-coagulation drug therapy

  32. Atrial Fibrillation – codes 38DECHADS2 score + value does include dabigatrin - guidance confusing otherwise same as eg CHD 9 re anticoagulants and antiplatelets: Aspirin prophylaxis contraindicated8I24 Warfarin contraindicated8I25 Clopidogrel contraindicated8I2K Dipyridamole contraindicated 8I2b

  33. Smoking: Denominator for 5 & 6 now includes Peripheral Arterial Disease SMOK 3 → SMOK 5: patients with specific diseases have smoking status last 15/12 SMOK 4 → SMOK 6: patients with specific diseases who are smokers advised to stop RECORDS 23 → SMOK 7: all pts > 15 years have smoking status recorded last 27/12 (new) SMOK 8: the percentage of patients aged 15 years and over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27/12 diseases all pts

  34. Smoking 6 and 8: advice or scriptfrom v23 – no need to record both • SMOKE 6: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychosis who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months. • SMOK 8: the percentage of patients aged 15 years and over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27/12 • 8IEMNRT declined

  35. Peripheral arterial disease (1) PAD 1: The practice can produce a register of people with peripheral arterial disease codes same as CVD – PP1: G73 G73z% (except G73z1) Gyu74 Patient unsuitable 9hS0 Informed dissent 9hS1

  36. Peripheral arterial disease (2) PAD 2: The percentage of patients with peripheral arterial disease with a record in the preceding 15 months that aspirin or an alternative anti-platelet is being taken codes same as CHD 9: Aspirin prophylaxis contraindicated8I24 Clopidogrel contraindicated8I2K Excluded if warfarin prescribed or Anticoagulant prescribed by third party 8B2K

  37. Peripheral arterial disease (3) PAD 3: The percentage of patients with peripheral arterial disease in whom the last blood pressure reading (measured in the preceding 15 months) is 150/90 or less For PAD 3 and PAD 4 only, newly registered & newly diagnosed is last 9 months of QOF year not 3 months (PAD 2 is 3 months) O/E – BP reading 246% BP procedure refused 8I3Y Max tol antihypertensive Rx 8BL0

  38. Peripheral arterial disease (4) PAD 4: The percentage of patients with peripheral arterial disease in whom the last measured total cholesterol (measured in preceding 15 months) is 5.0 mmol/l or less codes same as CHD 8 eg Max tolerated lipid-lowering Rx 8BL1 Adverse reaction to statinU60CA etc

  39. Osteoporosis (1) DES discontinued but… OST 1: The practice can produce a register of patients: 1) aged 50-74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan, and 2) aged 75 and over with a record of a fragility fracture after 1 April 2012 Includes men DES was 65-74 yrs

  40. Osteoporosis (2) OST 2: The percentage of patients aged between 50 and 74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, who are currently treated with an appropriate bone-sparing agent < 75 years need scan to confirm

  41. Osteoporosis (3) OST 3: The percentage of patients aged 75 and over with a fragility fracture, who are currently treated with a bone-sparing agent > 75 years no need to scan

  42. Osteoporosis (4) – OST 2Read codes Fragility # N331N or N331M Earliestpositive DXA scan with either: Specific mention of osteoporosis eg 58E4 Forearm DXA scan result osteoporotic Or non-specific code + value of T-score < -2.5 eg 58E2 Forearm DXA scan T score + value < -2.5 Osteoporosis N330 Plus appropriate script

  43. Osteoporosis (5) – OST 3 Read codes Fragility # N331N or N331M Plus appropriate script only – no need for osteoporosis code or scan in patients over 75 years

  44. ORGANISATIONAL DOMAIN • Records 23 →Smoking 7 • Education1 →Education11: There is a record of all practice-employed clinical staff and clinical partners having attended training / updating in basic life support skills in the preceding 18 months

  45. Quality and productivity (1) Prescribing Referrals Emergency admissions Internal review, external review Using care pathways

  46. Quality and productivity (2) • Q: QP pathways, do these have to be new ones? See FAQ 4 in the QP supplementary guidance: • A:The short answer is no. Practices will be required to undertake an internal and external review. In doing this practices will need to consider the data afresh to determine whether improvements that need to be made can be delivered through following the existing pathways more closely, whether the existing pathways developed in 2011/12 require amending or whether alternative pathways should be developed.

  47. Quality and productivity (3) QP1-5 retired but…

  48. Quality and productivity (4) Indicators QP 6–8 REFERRALS (21 points) Indicators QP 9–11 EMERGENCY ADMISSIONS (27.5 points) Indicators QP 12-14 A&E ATTENDANCES (28 points)

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