The QOF 2013-14: What’s new, What’s tricky, What else can help?

1. The QOF 2013-14:What’s new, What’s tricky, What else can help? Dr Simon Clay MB ChB FRCGP DPD Poplars Surgery, Erdington, Birmingham This full presentation, a Word doc copy and a suite of other QOF resources are available for purchase in one package here: www.tinyurl.com/qofdisc

2. Two sections to talk: • Cover some areas from Q.O.F. 2013 which are complex / confusing. • Some general areas of Q.O.F. management that can help points acquisition.

3. Generic new rules that apply across QOF 2013-14: • Indicators previously having a 15/12 “time window” now only have a 12/12 one. (44 different indicators) (Hence almost no clinical entry ever “counts twice” for us over 2 consecutive QOF yrs) • Most Expiring Exception codes now expire every 1st April. (Hence no Expiring Exception code ever exempts a patient from the relevant indicator over 2 consecutive QOF years. (bar CS002) • But variations across U.K. countries

4. All new changes highlighted in Green. • This PowerPoint only covers additional QOF changes that go beyond the “timeframe changes” noted in previous slide. • It also relates to the Business Rules as released for England but is not necessarily correct in all respects for other areas of U.K.

5. Diseases where there are not only “time window” changes, but also “point threshold” changes: (2) • AF • Smoking

6. CHD HF Hypertension Stroke / TIA Diabetes COPD Depression Mental Health Cancer CKD Epilepsy CVD-PP Osteoporosis Disease areas where there are significant changes: (13)

7. New Disease areas / Rulesets: • Rheumatoid Arthritis (new Disease area) • BP (new Ruleset)

8. The 2 “Point Threshold” diseases • AF • Smoking

9. A.F. • CHADS2 remains – (No CHA2DS2VASc yet) • AF2 (was AF5) (“DO CHADS2 on patients every 12/12”) Was 15/12. • AF3 (was AF6) If CHADS2 is 1, Pt issued Anti-platelet OR Anticoag’ in 6/12 before Ref Date. Now 57-97% Was 50-90.

10. Smoking • Smoking indicators 5-8 re-numbered 1-2 & 4-5. • Smok 3 added (was Info 5) (“Practice has literature & Rx available for Smokers”) • Smok5 (Smokers with any of: HYP / CHD / PAD / CVA / ASTHMA / COPD / CKD / MH / DM offered support or Rx in L12M. Now 56-96% (was 50-90)

11. CHD HF Hypertension Stroke / TIA Diabetes COPD Depression Mental Health Cancer CKD Epilepsy CVD-PP Osteoporosis Disease areas where there are significant changes: (13)

12. CHD6 Indicator: (“M.I. patients need 4 drugs”) • Previous requirement that patients on an ARB only “counted” if they also had an exception code to ACE’s has been quietly dropped. • Threshold increased Now 60-100% Was 45-80. • CHD10 is retired. (“All CHD Pts to be Rx’d with Beta Blocker”)

13. Heart Failure: • HF3 Pts with HF due to LVSD treated with ACE or ARB. • Threshold now 60-100% Was 45-80.

14. HF & HF due to LVSD:( = Left Ventricular Systolic Dysfunction) • Important concept of HF vs. HF due to LVSD. • Why does it matter? • Because… • Only patients with LVSD are in denominator for HF3 (“Put Pt on an ACE/ARB”) & HF4 (“Put Pt on a B Blocker if they’re already on an ACE/ARB”) • 19 points available for HF3 (10) & HF4 (9)

15. LVSD cont’ • New QOF definition of HF due to Left Ventric’ Systolic Dysfunction. • Previously: Defined by Read code used for the HF: • E.g. G581 LVF (as opposed to G58 Cardiac Failure or G580 CCF) • Now No HF code is “HF due to LVSD” unless accompanied by an additional official LVSD code:

16. Valid codes to define LVSD: • G5yy9 Left ventricular systolic dysfunction • 585f. Echocardiogram shows left ventricular systolic dysfunction • One of these codes needs to be added to all new Pt’s with HF due to LVSD to add them to denominator of HF3 & HF4 indicators. • One of these also needs to be added retrospectively to all Pts with Read codes of LVF, or they’ll STOP counting as HF due to LVSD

17. Hypertension • BP4 retired (Check Hypertensives’ BP annually) • HYP2 (was BP5) Patient’s BP to be ≤ 150/90. Points dropped to 10. Was 55. • Threshold for HYP2 now 44-84% Was 40-80. • HYP3 (new) Patients aged <80 whose last BP in 9/12 before Ref date is ≤ 140/90. Threshold 40-80% 50 points available!

18. Hypertension (cont’) • HYP4(New): Those Hypertensives aged 16-74 to have annual assessment of physical activity using GPPAQ. • General Practice Physical Activity Questionnaire • 5 pts available. 40-90%

19. GPPAQ (developed in 2006) • 7 questions: • 1. How much work their Job requires: • 2. How many hours of Sport per week? • 3. How many hours of Cycling per week? • Questions 4-7: How many hours of Walking, Housework, Gardening is done. What is the usual “Walking speed”? • Answers to 4-7 ignored in the calculation (“not validated” (!) • http://www.patient.co.uk/doctor/General-Practice-Physical-Activity-Questionnaire-(GPPAQ).htm

20. GPPAQ result options: * • Patients are categorised as: • 1. Inactive – sedentary job and no physical exercise or cycling • 2. Moderately inactive – sedentary job and some but less than one hour of physical exercise and/or cycling per week or standing job and no physical exercise or cycling • 3. Moderately active – sedentary job and one to 2.9 hours of physical exercise and/or cycling per week or standing job and some but less than one hour of physical exercise and/or cycling per week or physical job and no physical exercise or cycling • 4. * Active – sedentary job and three hours or more of physical exercise and/or cycling per week or standing job and one to 2.9 hours of physical exercise and/or cycling per week or physical job and some but less than one hour of physical exercise and/or cycling per week or heavy manual job.

21. GPPAQ Read code options: • Inactive: 138X. • Moderately Inactive: 138Y. • Moderately Active: 138a. • Active: 138b.

22. Hypertension (cont’) • HP5(New) Those patients (aged 16-74 only) who score less than “Active” on GPPAQ have received “Brief Intervention” in L12M. • 6 pts available. 40-90% • Brief interventions examples: “opportunistic advice, discussion, negotiation or encouragement”. • Read code 9Oq3. “Brief intervention for physical activity completed” • Exception code: 8IAv. “Brief intervention for physical activity declined”

23. Stroke / TIA: • STIA5 (was STROKE8) “Patients whose last CVA was Non-haemorrhagic or Hx of TIA should have last Tot’ Cholest’ of ≤ 5.0mmol/L in L12M”. • (Was previously ALL patients with a CVA / TIA) • G61 Intracerebral Haemorrhage excluded. • Most G66 “Stroke & CVA unspecified” codes also excluded • i.e. basically includes Cerebral Infarctions & TIA’s

24. Stroke / TIA, (cont’) • STIA6 (was STROKE10) Flu vacc uptake. Thresholds increased to 55-95%. Was 45-85. • STIA7 (was STROKE12) Patients with Hx of TIA or Non-haemorrhagic Stroke to be issued with Asp’/Dipyrid’/Clopid’/Anticoag’ in L12M. Thresholds increased to 57-97% Was 50-90.

25. Diabetes: • DM2 (was DM30) Patient’s last BP (in L12M) is ≤ 150/90. (53-93%) Was 45-71 ! • DM003 (was DM31) Patient’s last BP (in L12M) is ≤ 140/80. (38-78%) Was 40-65.

26. Diabetes:(DM5) • DM5 (was DM13) Patient has had a Urine Alb/Creat Ratio (ACR) done in L12M. • Note that ACR of ≥ 2.5 mg/mmol in men & ≥ 3.5 mg/mmol in women defines “Microalbuminuria” (NICE) • Now, even Pts with previous “Proteinuria” diagnosed (defined as ACR ≥ 30mg/mmol), need testing. • New Exception code: (Ver 26.0!) • 9RX..– “Declines to give urine specimen”.

27. Diabetes (cont’) • DM6 (was DM15) Pts with Nephropathy (= Proteinuria) or Microalbuminuria are Rx’d with an ACE / ARB. 57-97% (was 45-80) • DM7 (was DM26) (Number of diabetics with HbA1c of ≤ 59mmol/mol) 35-75% (40-50!) • DM8 (was DM27) (Number of diabetics with HbA1c of ≤ 64mmol/mol) 43-83% (45-70) • DM9 (was DM28) (Number of diabetics with HbA1c of ≤ 75mmol/mol) 52-92% (50-90)

28. Diabetes (cont’) • DM10 (was DM18) Diabetics had Flu vaccination: 55-95% (was 45-85) • DM13 NEW: Percentage of ALL the Practice’s Diabetics receiving an annual dietary review with a “suitably qualified professional”. • 3 whole points!!! 40-90% • Read code options: • 66At. Diabetes Dietary R/V • 66At0 Type I Diabetic Dietary review • 66At1 Type II Diabetic Dietary review

29. Who’s a “suitably qualified professional”? The NICE quality standard defines an appropriately trained healthcare professional as one with specific expertise and competencies in nutrition. This may include, but is not limited to, a registereddietician who delivers nutritional advice on an individual basis or as part of a structured educational programme. The Diabetes UK competency framework for dieticians sets out level one competencies that are the minimum standard for any staff involved in the healthcare of people with diabetes. Therefore, if non-dieticians are employed to deliver dietary advice, they should conform to the level one competencies described in the Diabetes UK framework as a minimum. http://tinyurl.com/cn2krhz

30. Diabetes (cont’) • DM14 NEW: Newly diagnosed Diabetics to be referred to a structured education programme within 9/12 of diagnosis. 11 pts. 40-90%. • New valid codes: • 8Hj0. Referral to Diabetes structured education programme • 8Hj3. Referral to DAFNE DM Educ programme • 8Hj4. Referral to DESMOND Educ’ programme • 8Hj5. Referral to XPERT Educ’ programme. • New Exception code(s): • 9OLM. “Diabetes Structured Educ’ programme declined • 8IEa. – Referral to DAFNE diabetes structured educn prog declined (Ver 26.0)

31. The 5 NICE Criteria for the “New Diabetic” Educational Programme: • Evidence-based and suit the needs of the individual. Specific aims and learning objectives. Support the learner & family & carers to develop knowledge and skills to self-manage diabetes. • Structured curriculum, theory-driven, evid’-based and resource-effective, have supporting materials and be written down. • Delivered by trained educators with understanding of educational theory appropriate to the age and needs of the learners & trained and competent to deliver the principles and content of the programme. • Quality assured & reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency. • Outcomes from the programme should be regularly audited.

32. Who is allowed to provide the “New Diabetic” education? • “Some practices may be able to deliver Structured Education programmes in-house. These programmes would need to meet the requirements outlined above.” • (Blue book, p83)

33. Two New Erectile Dysfunction Indicators. • DM15 NEW: Male Diabetics to be asked about any problems with erections annually. 4 pts 40-90% • Pts need one of these 2 codes adding annually: • 1D1B. C/O Erectile Dysfunction • 1ABJ. Does not complain of Erectile Dysfunction. • Note that many E.D codes ignored (e.g. E2273 “Erectile Dysfunction”) • No maximum age limit on this indicator, so even if he’s 99 & in a Nursing home… • No specific exception code to except from this indicator alone. Only global DM Exception code

34. Further E.D. Indicator: • DM016 NEW: “Diabetics with Erectile Dysfunction have an annual record of Advice & assessment of contrib’ factors & Rx options”. • In fact, only those Diabetic men documented as Complaining of E.D in the relevant QOF year & having 1D1B. “C/O E.D.” added, need “Advice & assessment.” • (so if it’s not actually bothering them, could you add 1ABJ. “Does not complain of E.D” & ignore it! • Read code: 66Av. : “Diabetic assessment of E.D.” • Ver 26.0! 66Au.– Diabetic erectile dysfunction review • 6 pts. 40-90% • No specific Exception code to this indicator either.

35. Retired Diabetic Indicators: • DM2 (Measure BMI annually) ?? • DM10 (Neuropathy testing) ?? • DM22 (eGFR or Serum Creatinine) ??

36. COPD • COPD5 NEW: Pts MRC Dyspnoea score of ≥ 3 to have O2 saturation coded annually. • Read code 44YA0: “Oxygen saturation at periphery” • 44YA1 “Peripheral blood oxygen saturation on room air at rest (Ver 26.0) • 44YA3“Peripheral blood oxygen saturation supplmentl oxygen at rest” (Ver 26.0) • Must also insert the result into a numeric field to “score” the indicator • 5 pts 40-90% • NICE clinical guideline CG101 recommends that patients with oxygen saturations of 92% or lower when breathing air, be referred for consideration for oxygen therapy.

37. COPD Cont: • COPD8 Vaccinate COPD patients against Flu: 57-97% (45-85)

38. Depression • DEP1 retired. (Depression Screening questions for patients with CHD / Diabetes.) • DEP1 (was DEP6) New Depression patients aged 18+ to have “Bio-Psychosocial Assessment” at time of diagnosis.(Assessment on same day as the diagnosis recorded.) (instead of “within 28d after diagnosis”). 21 pts 50-90% • Valid Read code: 38G5. “Bio-Psychosocial Assessment” • Valid Exception codes: • 8IET. Bio-psychosocial assessment declined • 9NSA. Unsuitable for bio-psychosocial assessment

39. “Bio-Psychosocial assessment” (BPA): should assess the following: • Current symptoms including duration and severity • Hx of depression • Family history of mental illness • Quality of interpersonal relationships with, for example, partner, children and/or parents • Living conditions • Social support • Employment and/or financial worries • Current or previous alcohol and substance use • Suicidal ideation • Discussion of treatment options

40. Depression (cont’) • DEP2 (was DEP7) R/V Newly diagnosed Depr’ Pts, 10 – 35 days after diagnosis. • 8 pts 45-80% • R/V “could” (not must!) consist of: • Symptom R/V • Social support R/V. • Other Rx options if req’. • Progress of external referrals • Enquiry about suicidal ideation • Valid Read codes: • 9H91. Depression medication review • 9H92. Depression interim review

41. The Depression R/V (DEP2) & some helpful bits from the Blue book: • Face to face R/V “usual”, but telephone R/V by Dr or Nurse Practitioner ok if: • Pt starting Antidepressants or • Depression is mild with no suicidal ideation. • Dr phoning should know patient well • Dr should be confident of their ability to R/V by phone • Pt should have said they want telephone f/u or • Pt has failed to attend a face to face R/V

42. What if secondary care diagnose the Depression? • If CMHT diagnose & do the BPA or if you “don’t know whether the BPA has been completed”, it’s permissible to add global Depression Exception code. • If ongoing care being provided by CMHT, “patient should be Excepted from DEP2.” (except you can’t except from that alone! So)… • 9hC0. Depression: Pt. unsuitable.

43. Big practical problem here with DEP2, (the R/V) (8 points to lose here) • Lots of patients won’t come back, or not within the 10-35d time window. (That’s General Practice!) • By then, if we’ve added Depression & whether we did the BPA or not, they’re still in the denominator for DEP2, but we’ve lost the points & it’s too late to chase them. • We can’t write to every depressed Pt 3x in a month reminding them to come to their R/V!

44. Suggestion 1: • Don’t code new Depressed Pts as “Depressed” until they return for R/V. (Code it “Low mood?”) Do BPA. • If they return for R/V, retrospectively change Low Mood to “Depression”. Ensure BPA code has same date. Add the Dep R/V code as well. Ensure Episode code of Dep’ is “New” Now Dep1 AND 2 are scored. • This will enhance points acquisition, as those that don’t return won’t get coded as Depression & then pull your DEP2 scores down. • It doesn’t solve problem of when they DO return, but outwith the 10-35d window.

45. Suggestion 2: • Add Depression code with Episode code of “New” on those you think are depressed when first seeing them. • Add BPA code on same day & add whatever details you feel you can. • Ensure you’ve got their correct mobile No. on the clinical system. • Ask them to book a pre-booked appointment with you in 2 weeks & get the receptionists to do it on way out. • Have a system in place to spot if they don’t come. You now have 3 weeks to get a GP to do the phone R/V within the 35 day window.)

46. Mental Health • MH2 (was MH10) “Psychotic patients” have a CARE PLAN documented in the record in L12M. Threshold changed to 40-90% (was 30-55 !!!). 6 pts. • Note that previously, a “Care plan” documented once ever after the Psychosis was added sufficed. Now code needs to be re-added annually (& to 90% of Pts.)

47. MH (cont): • Valid Read codes for MH2 (Care Plan done): • 8CY.. Mental Health Care Programme Approach • 8CG6. Care Programme Approach review ====== Ver 26.0! ===================== • 8CS7. Agreeing on mental health care plan • 8CG62 Discharge Care Programme Approach review • 8CG60 Initial Care Programme Approach review • 8CG61 On-going Care Programme Approach review • 8CMG1 Review of mental health care plan • Note: Old Read codes for MH Care plan now NON-Valid! • 8CM2. Psychiatry care plan NOT VALID. • 8CR7. Mental health personal health plan NOT VALID.

48. Cancer • CAN2 (was CANCER3) Patients with a Cancer added in the last 15 months to have a Cancer R/V added within 3/12 of date of diagnosis. • R/V should cover both “individual health and support needs“ & “coordination of care between sectors” • 6 pts. 50-90% • Ca R/V should be face to face but CAN be done by telephone.

49. CKD • CKD2 RETIRED: (“Check BP of CKD patients every 15/12”) • CKD2 (was CKD3) Last BP documented as ≤ 140/85 mm Hg in L12M. • 11 pts 41-81% (45-70) • CKD4 additional Exception code: • 9RX.. – Declines to give urine specimen

50. Epilepsy • EPIL6 RETIRED: (“Document the patient’s Seizure frequency every 15/12”)