QOF 2012-13 Hints, tips (and Excel occasionally!)

1. QOF 2012-13Hints, tips (and Excel occasionally!) Dr ArunAggarwal

2. QoF overview • Compromise • Evaluation and testing • Helen Lester • From process to soft outcomes to hard outcomes • Reward for effort and workload, or for healthgain?

3. REMEMBER • 25% pay • 15% primary care budget • Other countries, watching, copying, improving • Debate about proof it achieves…BMJ July ‘12 • Movement towards public health informed- for better or worse • QP- contribution to QIPP challenge of 4% savings (the Nicholson challenge!) • QoF- “ a marathon, not a sprint”

4. Changes from 2011-12 • Hopefully already aware- nearly half year on.. • DES into QOF- osteoporosis • Out of QoF- lots • Process points removed • Lower and upper target levels changed- harder! • Some clinically sensible changes • Duplication removed • Some lumping, AND some splitting of indicators

5. CHD • CHD2 angina- treadmill test gone previous year, referral code instead- and why- anyway, now totally gone!! • CHD 14- new MI polypharmacy required-all 4 classes rx or exception code (ACEI or ARB, aspirin, statin, BB)- lumped not split.

6. AF • CHADS2 scoring- anytime up to April 13- not too late if rx ok! Annual coding. Score 0 or 1= aspirin etc. 2 or more = warfarin etc • Not automated- but could be!! • Clinically sensible • Probs of paroxymal AF pts • - but are most pts with score at ≥2 on warfarin (40-70%) • Score 0= no need rx, though clinically =aspirin!

10. PERIPHERAL ARTERIAL DISEASE • Late release of template and codes • No different to stroke or heart patients clinically- BP target 150/90, chol≤5 • Rx aspirin, clopidogrel or warfarin (not dipyrid alone) • OTC aspirin- code or rx on script- pros+cons • Can have essential hypertension also…!

11. DIABETES • DM 29 Foot check risk factor- combination of pulse, neuropathy and inspection- retrospective too (((check re DM10 neuropathy testing))) • DM30 and 31- BP targets more sensible clinically- still high!(150/90- 8 pts- 71% upper target and 140/80 -10 pts- 65% target) – please do NOT exception code- • (( global grouping of all diabetes indicators!!))

12. COPD • Spirometry codes allowed reduced++ • 8HRC ( referral code) • 745D4 ( reversibility spirometry testing) • Disallowed 33H/I/J* (salbut rev testing etc!!!) and 66Ya/b (resp disease monitoring codes) • NOTE – up to 15% pts will have COPD AND asthma

13. ASTHMA • RCP questions on • exercise induced wheeze, (663e*) • cough or wheeze disturbing sleep (663N*) • Affecting daily activity

14. DEMENTIA • Lumped, not split. • Have to pass all blood test indicators ( and a pain to fix…. ) • A real pain for pts moving in from elsewhere, not GP2GP, or with incomplete tests from elsewhere or hospital. • (rule set improved re allowed codes for LFT and folate RBC)

15. DEMENTIA BLOODS- sequenced logic • Hb • Calcium (nb some mismatches here) • Gluc or Hba1c (IFFC) • Creatinine • ALT (nb some mismatches here)- older matches still running • TSH • B12 • Folate • CHECK PT OPTION VALUABLE

16. DEPRESSION • DEP5 PHQ rpt at 2-12 w, instead 5-12w, fits with clinical care and prescribing better ( esp if you start with half tabs for a few days, and/or review pts before first box runs out, or see again at approx 2wks to see how much impact first counselling/chatting/unloading helped even if not prescribing)

17. LEARNING DISABILITIES • Down’s pts to have had TFT in last 15m • Make sure all Down’s patients are on LD register • If you have no Down’s adults over 18, you get 0/3 points!!! TOUGH

18. EPILEPSY • EP9 women under 55 -awareness re foetal issues- • A few specific codes for positive entries- see template • EASY to say not indicated (template option)- eg severe LD, single, hysterectomy- worth adding in consultation

20. MENTAL HEALTH • Lumpers and splitters • Old MH9 was lumping- all or none • New MH 11-16 in serious mental illness is splitting • Easier to be approp rewarded. • ( alcohol, BMI, BP , gluc+ lipid ratio if over 40, smear) • Lithium MH17 creat + TFT time window reduced to 9m from 15m, and lithium level ok within 4m, not 6m. Effectively means @3m for Lithiums and @6m for TFTs

21. SMOKING • Lumped, not split • Not paid triple for same pt with multiple CHD+DM+COPD!!! • Can stop asking ex-smokers after 3 consecutive years of coding as ex ( very clever search in Popman) • Advice given can now be 8CAL as before, or NRT script, or long list of codes • NRT declined code useful 8IEM

22. OSTEOPOROSIS • Need to code all appropriate fractures as fragility fractures to get on register • (N331* as well as frac hip/spine/wrist) • - easily missed-Search for all fracs minus already coded… • DXA scanning 58E* text based, ((or T value based worse than -2.5- but none are value properties in READ classification yet- you can change to a value, but not a negative value in LV) • Drugs bit easy- tolerance and concordance harder • Consider drug dose dictionary issues- are they explicit and safe? Full glass, vertical (DT, A, C, E, B) • A few drugs not allowed (infusions, denosuMAB)

23. QP6-8- OUT-PT REFERRALS • Your CCG rules… • Benefits of coding all referrals out with associated features (yugh…..see example) • - or manually compiling Excel file ( great….)- • Examples

25. QP9-11- EMERGENCY ADMISSIONS • Depends on your CCG • Examples include reducing • inapprop admissions from nursing homes • Inapprop admissions in palliative care pts • Inapprop admissions in vulnerable adults • Huge variability within a CCG/LCG, can be altered, DNAR, PPC, community matrons, intermediate care, respite beds etc

26. PREVALENCE • No square root, no 5% • Probably cost effective to increase prevalence • Missed diagnoses- • Hypertension ( raised BP codes etc) ( Bp>160 not coded) • CKD ( 3 eGFR<60- use CKD finder) • Depression ( coded stress, anxiety etc etc) • COPD (within asthma cohort, over 50+ smoker or ex-smoker) • Obesity- height missing!!!

27. PREVALENCE 2 • Missed diagnoses • Dementia- ( coded memory disturbance, memory symptoms etc) • HOW TO FIX • searches

29. EXCEPTION CODING • Do minimum necessary • Ask if could stand up to scrutiny and newspapers (Daily mail test!!) • And peer group scrutiny • High variation within a LCG or CCG • Do it late in year- jan-march 2013- valid for both years. • Easier for external scrutiny now

30. EXCEPTION CODING 2 • Lots of codes allowed • Does not mean you have to use them. • Remember upper targets for payment- no point exception coding more if already getting full payment ( but some practices still do++). • No justification for exception coding in BP, HbA1c targets, as upper levels are realistically set.

31. Exception coding 3 • Exception coding removes pt from numerator as well as denominator if criterion not met ( 37/50 (74%) becomes 37/49(75.5%) if pt unfixable, or 38/50 (76%) if fixable. • Can increase your % score • But lowers your prevalence, hence lowers your pay if already above top threshold

32. FUTURE LIKELY • Statins in new essential hypertension • Diet review and structured education for diabetes • Pre- diabetes ( IGT, GDM, IFG) and annual tests • BTS levels in asthma control • Enquiries about psychosocial dimensions in depression (money, housing, sex!) • Health checks for carers • Rheumatoid registers- with CHD and osteoporosis risk/screening • Screening adult AE attenders for alcohol issues

33. TIGHTLY LINKED MEASURES • TLMs • The art of being a GP • Veterans hospital, USA • E.g., BP 150/90 or on 3+ drugs, or acted on within 90 days, or one drug added or BP lowered when next checked • Can software cope?

34. TAKE HOME MESSAGES • Olympic message- a marathon, not a sprint • Paralympic message- we all bring various handicaps to the race- team, pts, geography, education, affluence- mental approach makes more difference. • Play the game fairly, gets better with practice • KNOW THE RULES, USE THE TOOLS YOU CAN.