Comments Proforma

Potential new indicators for QOF

Consultation dates: 9th January 2012 – 6th February 2012

General Comments

Stakeholders are welcomed to submit comments in Table 1 for all indicators based on the following set of questions:

Do you think there are any barriers to the implementation of the care described by any of these indicators?
Do you think there are potential unintended consequences to the implementation of any of these indicators?
Do you think there is potential for differential impact (in respect of age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation), if so please state whether this is adverse or positive and for which group?
If you think any of these indicators may have an adverse impact in different groups in the community, can you suggest any guidance on adaptation to the delivery of the indicator to different groups which might reduce health inequalities?

Specific Questions

There are a number of specific question we would like to ask on certain indicators. These are outlined in Table 2 of the comments proforma

How to submit your comments

If you would like to comment on any of the 20 indicators currently being consulted on please use the comments proforma and forward this to Emma Boileau at qof@nice.org.uk.

Consultee name:	Dr Gavin Jamie	Consultee organisation:	The Whalebridge Practice Swindon and QOF Database www.gpcontract.co.uk

Table 1: Stakeholder comments on all indicators

Indicator Area	Indicator	Consultee comments
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	There is a capital cost for practices with this and the points value will have to be enough to cover this even for the smaller practices
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 a referral to a pulmonary rehabilitation programme (excluding patients on the palliative care register)	Availability of suitable programmes may limit this indicator. Availability includes accessibility - these programmes may not include the same sort of transport arrangements as are available for out patient appointments. The current wording suggests that the referral would have to be repeated annually. Is this intended?
Heart Failure	The percentage of patients with heart failure (diagnosed after 1/4/2013) with a record of referral for an exercise based rehabilitation programme	Availability and accessibility are issues as above.
Secondary prevention of CHD	The percentage of patients with an MI within the preceding 15 months with a record of a referral to a cardiac rehabilitation programme	Availability and accessibility are issues as above.
Diabetes	The percentage of male patients with diabetes with a record of being asked about erectile dysfunction in the preceding 15 months	Presumably there is an financial analysis for this.
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
Depression	The percentage of patients with depression who have had a bio-psychosocial assessment by the point of diagnosis	Replaces the PHQ9 etc score
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	Replaces the second PHQ9 etc score
Diabetes: Lipid management	The percentage of patients with Type 2 diabetes aged 40 years and over with successful lipid management defined as either: last recorded cholesterol in the preceding 12 months ≤ 4.0mmol/l last recorded cholesterol in the preceding 12 months > 4.0mmol/l and commenced on a moderate dose generic statin within 90 days of cholesterol recording last recorded cholesterol in the preceding 12 months > 4.0mmol/l and generic statin dose increased within 90 days of cholesterol recording or, last recorded cholesterol in the preceding 12 months > 4.0mmol/l and cholesterol lowering therapy changed to a different drug within 90 days of cholesterol recording	Whilst the clinical criteria are generally laudable there are likely to be a couple of problems with implementation. Firstly is that there is no pathway for patients who have not reached the target and are already at the top of the treatment ladder. There is of course exception reporting (maximum therapy) as an option here but that would mean that indicator relies on exception reporting to work properly which may not be desirable. Implementation cannot succeed with the current rules and extraction systems. The implementation will depend in England on the capabilities of the GPES system and be dependant on that. Similar systems would have to be developed for Scotland, Wales and Northern Ireland. These systems would have to be able to look at drug doses to tell the difference between a base level and an increase. Complexity may occur because different doses may be constructed in different ways. Recently the 80mg dose of Simvastatin was more expensive than two capsules of 40mg. Thus to avoid excess cost an extraction system would have to know that 2x40mg is equivalent to 80mg.
Hypertension: Blood pressure management	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	This is a reduction in the systolic by 10mmHg
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
Rheumatoid arthritis	The practice can produce a register of all patients aged 16 years and over with rheumatoid arthritis
Rheumatoid arthritis	The percentage of patients with rheumatoid arthritis in whom CRP or ESR has been recorded at least once in the preceding 15 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	Effectively this mandates the use of QRISK Practices in Scotland tend to use ASSIGN for other risk scores as it is developed for Scotland specifically. ASSIGN would not be valid for this indicator and thus Scottish practices would either use two different formulae for different patients or would use the QRISK only which is less valid for their population.
Rheumatoid arthritis	The percentage of patients with rheumatoid arthritis who have had an assessment of fracture risk using a risk assessment tool adjusted for RA
Rheumatoid arthritis	The percentage of patients with rheumatoid arthritis who have had a face to face annual review in the preceding 15 months
Asthma	The percentage of patients, 5 years and over, newly diagnosed as having asthma from 1 April 2013 in whom there is a record that the diagnosis of asthma has been made supported by the current BTS-SIGN guidelines
Asthma	The percentage of children reaching the age of 5 years after or on 1 April 2013 with an existing diagnosis of asthma in whom there is a record that the diagnosis of asthma has been reviewed and confirmed (supported by the current BTS-SIGN guidelines) within 15 months of becoming 5 years	Whilst the aim may desirable this indicator is virtually impossible to implement as it currently stands. A child who turns 5 on the 1 April 2013 will have to have the review before 30th June 2014. As the QOF year ends on the 31st March 2014 then it will be impossible to fail the indicator in the first year. The conventional way this sort of thing has been dealt with in the past is to push the start date back in the business rules (although this tends not to be reflected in the guidance). The push back in this case would have to be 15 months meaning children turning 5 now (many months before the negotiators consider the indicator) would be included.
Cancer	The percentage of patients with cancer diagnosed within the preceding 18 months who have a review recorded as occurring within 3 months of the practice receiving confirmation of the diagnosis
Cancer	The percentage of patients with recurrent or distant metastatic cancer diagnosed within the preceding 18 months who have a review recorded as occurring within 3 months of the practice receiving confirmation of the diagnosis

Table 2: Stakeholder specific comments on certain indicators

Indicator Area	Indicator	Consultee comments
COPD	Indicator 2: 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 a referral to a pulmonary rehabilitation programme (excluding patients on the palliative care register) For the purpose of the pilot, people on the QOF palliative care register have been excluded from this indicator: Do stakeholders consider it appropriate to exclude people on the palliative care register from this indicator?	Yes this is appropriate although is comfortably dealt with within the current exception reporting framework.
CHD & Heart Failure	Indicators 3and 4: The percentage of patients with heart failure (diagnosed after 1/4/2013) with a record of referral for an exercise based rehabilitation programme AND The percentage of patients with an MI within the preceding 15 months with a record of a referral to a cardiac rehabilitation programme If someone with an MI that has been referred for cardiac rehabilitation subsequently develops heart failure, should they: Still be referred to an exercise based rehabilitation programme? Be excluded from the indicator and not referred to an exercise based rehabilitation programme	Option b
Depression	Indicator 8: 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 A time frame of 10-35 days has been chosen for piloting based on the NICE recommendations for review and to allow flexibility around the setting of appointments. Do stakeholders consider the timeframe outlined in the indicator appropriate? If the timeframe stipulated is not considered to be appropriate could you suggest and alternative timeframe?	The time frame seems appropriate.
Rheumatoid arthritis	Indicator 12: The practice can produce a register of all patients aged 16 years and over with rheumatoid arthritis For the purpose of the pilot, an age range of 16 has been chosen for the RA register because at this age a person is unlikely to have a juvenile RA: Is this the appropriate age range to include in this indicator set? If no, is there an alternative age range that should be applied to the indicator?	Yes
Rheumatoid arthritis	Indicator 14: 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 The timeframe of ‘15 months’, has been included in this indicator for the purposes of piloting: 14. What timeframe should be included in the indicator for an assessment of CVD risk?	Appropriate if an annual risk assessment is intended
Rheumatoid arthritis	Indicator 15: The percentage of patients with rheumatoid arthritis who have had an assessment of fracture risk using a risk assessment tool adjusted for RA The timeframe for this indicator is under review: 15. What timeframe (if any) should be included in the indicator for an assessment of fracture risk?	15 months is appropriate

NICE consultation on potential new QOF indicators of