The new Quality

1
The new Quality Outcomes Framework, (Q.O.F.)
as of September 2007 -
2
Aim of this talk

• Whats new in the version 10.0 Rulesets?
• Which diseases have catches to avoid?
• How can we optimise points scoring?
• Where can I get Support documentation?
• (See last slide for a Web address)

3
Ethical disclaimer

• A.) Options are suggested for avoiding
• accidental loss of points for points
• enhancements, using the QOF rules
• as they are written.
• B.) However, decisions on implementation
• of any of the suggestions rest with each
• practice / clinician!

4
The disease areas

• OLDER DISEASES
• Mental Health
• CHD
• DM
• Stroke ( T.I.A.)
• Hypertension
• Asthma
• COPD
• Cancer
• Epilepsy
• Thyroid

• NEWER DISEASES
• Heart Failure
• Atrial fibrillation
• Chronic Kidney Disease
• Dementia
• Learning difficulties
• Obesity
• Palliative care
• Smoking Management
• Depression

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Concentrate on diseases which have either

• changes since the implementation of Version 10.0
  rulesets?, or
• catches within them that are worth knowing
  about?

6
Rulesets with either Version 10.0 changes or
catches

• Version 10 changed Rulesets
• A.F.
• Cancer
• Dementia
• Depression
• HF
• Learning Disabilities
• MH

• Rulesets with catches
• Asthma
• CHD
• CKD
• COPD

7
Atrial Fibrillation

• AF1 Register includes all pts with A.F
  diagnosed ever, (including paroxysmal A.F.) but
  (Version 10.0) now excluding Atrial flutter
  (G5731)
• Episode - coding rules changed since version
  10.0, so that the earliest ever occurrence of an
  A.F code is the valid one. (Later A.F. codes in
  the record no longer require another ECG to be
  done afterwards.)
• AF2. Ensure ECG done on new pts diagnosed since
  1.4.06. Be aware that the only valid ECG code
  for A.F is 3272. only if its added from 3/12
  before diagnosis to 12/12 after .

8
Atrial Fibrillation (cont)

• Since Version 10.0, Evidence of a blood thinner
  script e.g. Aspirin, or addition of an advice
  Read code, such as Advice to take Aspirin must
  now be within 6/12 of the Ref date.
• (Changed from 15/12 months previously)

9
Cancer

• Date window slightly changed in
• Version 10.0 to include Oct 1st each year
  (previously accidentally excluded)

10
Cancer catch

• For Ca3 indicator, (Cancer review required within
  6/12 of diagnosis), the denominator for this
  indicator is All Cancers diagnosed in 18/12
  before Ref date, except those whose Ca R/V had
  already occurred between 18/12 to 12/12 before
  the Ref date. (Avoid double counting).
• (Explain this with example diagnosis date of Oct
  13th)
• Review the list of Ca pts in April each year, to
  see if there are outstanding Ca reviews still
  required from the previous QOF year.

11
Dementia disease area

• Since Version 10.0, Some of the non-specific
  codes for Dementia review have been removed and
  are therefore no longer valid to score the DEM2
  indicator. These are 6A6.., 8CM2., 8BM0.,
  8CR7., 3A
• The only valid code now to score DEM2 is 6AB..
  (Dementia Health Review)
• ? Check for use of .1461 H/O Dementia which
  is not included)

12
Dementia disease area, (cont)

• DEM2 R/V of care in last 15/12. (to include
• Face to face R/V of pts physical mental needs,
• Support needs assessment of pt carer,
• Carers need for info, impact of caring on the
  carer
• Co-ord with 2 care if applicable.
• Lower threshold of 25 recognises difficulty of
  reviewing care. (60 max necessary threshold).

13
Depression 2 change

• Dep 2 logic has changed slightly in Version 10.0
  to exclude patients from the Dep2 denominator if
  they were diagnosed on 31st March from the
  previous QoF year.

14
Dep2 Dual depression / psychosis coding catch
resolved

• Previously, many depression codes were from the
  Psychotic depression chapter so triggered a
  psychosis diagnosis too.
• Now since version 9.0, only a small list of 7
  codes trigger inclusion in both Depression AND MH
  disease groups
• E1124 Single episode maj depress with
  psychosis,E1134 Recurrent maj depress with
  psychosis,E130 Psychotic Reactive
  Depression,Eu204 X Post-Schizophrenic
  depression,Eu251 X Schizophrenic psychotic
  depression,Eu323 X Single episode of psychotic
  depression.Eu333 X Recurrent psychotic
  depression.

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Depression PHQ-9s Making them count!

• DEP2 All newly depressed pts aged 18 from
  1.4.06 (except Post-Natal D.) should complete a
  specified questionnaire. Coding of result of
  questionnaire (e.g. PHQ-9) needs adding between
  day of diagnosis to one month after diagnosis, to
  determine severity.
• Since Version 9.0 - Questionnaire results added
  before the Depression diagnosis is added do not
  count!
• Since Version 9.0 - As long as first PHQ-9 is
  added within a month of Depression code, later
  PHQ-9s may now be added without prejudice to
  points.
• Indicator looks only at pts diagnosed in
  previous 12/12.

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Depression disease area,Episode codes their
relevance

• Officially, all Depression diagnoses should be
  episode coded. E.g. First or New.
• Where a diagnosis is not episode - coded, if
  there is more than one occurrence of a diagnosis
  code, ever, QOF software will focus on the first
  ever occurrence of the diagnosis.

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Depression, Episode codes gaining or losing
points

• So if a depression code is added to a pts
  record without an episode code of first or
  new a PHQ-9 is completed in time, this will
  be ignored by the software if they have had a
  previous diagnosis of depression.

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Some of our newly Depressed pts this year didnt
hand in a Depression severity questionnaire
(DEP2)

• Patients whose depression resolves who have the
  Read code 212S added (Depression resolved), are
  removed from the Depression register, whether or
  not they completed a depression severity
  questionnaire at the time.
• Practices might wish to review patients in March
  each year with diagnoses of depression over
  previous year, adding the resolved code if
  appropriate.)

19
Heart Failure change

• Since Version 10.0, The old incorrect global
  expiring LVD exception codes have been removed.
  This is the Read code chapter 9h1.. They
  include the 9h1 stem itself and also 9h11.
  (Excepted from LVD Patient unsuitable) and
  9h12. (Excepted from LVD Informed dissent.)
• If any of these have been added since 1.4.07, I
  suggest changing to codes from .9hH chapter.
  (Heart failure global exception codes)

20
Heart Failure catch

• Differing populations for HF2 HF3
• HF2 (Echo needed in new HF since 1.4.06) is for
  all HF pts (.G58)
• HF3 (Pts with HF should be on an ACE / A2RB)
  only looks at Pts with HF due to LVD. This does
  not include .G58 (Cardiac failure) or .G580
  (CCF) but only includes pts with .G581 (LVF)

21
Heart Failure catch (cont)

• 2 consequences of this clinical financial
• 1. Clinical Pts with only CCF or HF codes (not
  valid LVD codes) will NOT be prompted for ACEI Rx
  risk of missing out on life-prolonging Rx.
• 2. Financial Pts with CCF or HF codes who are on
  ACEIs wont be counting for you unless they have
  an LVD code too.
• Moral If you want pts with CCF or HF to be
  included in your HF3 denominator ( be prompted
  for ACEs), add G581 to their records, provided
  you think they DO have LVD.

22
Learning disabilities

• Since Version 10.0, The cluster Eu81 of Read
  codes on 5-byte systems, ("X Specific
  developmental disorders of scholastic skills"),
  all of which were previously valid to include a
  patient in the LD register, has been replaced
  with the single code Eu81z. "X Developmental
  disorder of scholastic skills, unspecified (Eu81
  Eu81y now non-valid codes)
• Must come from one of 4 specific Read code
  chapters E3, Eu7, Eu81z, or 918e (On
  learning disability register).
• (N.B. Downs syndrome is not, in itself, a
  trigger for inclusion in the register)
• Must be aged 18

23
MH7 rules (follow up of pts DNAing their MH
review)

• To score this indicator, at least one patient
  has to have 2 codes entered
• 9N4t. This patient DNAd an appt for a MH R/V
• 6A60 (six ay six zero) A Mental Health R/V
  follow up was conducted.
• (Previously, 8HB8. Mental Health Medication
  review, was
• also allowed. This Read code option has been
  removed in
• version 10.0. )
• In addition
• The 6A60 follow up code must be added on the
  same day or within 2 weeks after the 9N4t. (DNA)
  code date.

24
MH7 rules (2)

• What constitutes following a patient up?
• The QOF guidance notes say
• This indicator requires proactive intervention
  from the practice to contact the patient and
  enquire about their health status. This may be
  through telephone contact or visit where
  appropriate. If the person is in contact with
  secondary care, it will be appropriate to contact
  their key worker to discuss any concerns.
  Evidence will be required as to how this contact
  has been made
• Since Version 9.0 Obligation to actually do an
  MH R/V to score MH7 is now removed.
• MH R/V DNA follow up done between Jan March
  2008 score in 2009 too.

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Diseases with prevailing catches
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Asthma disease area

• PEF required once for all new Asthmatics aged 8
  after 1.4.06, but old PEF Read code (3395) no
  longer allowed.
• QOF guidance 2006 The practice should report
  the
• percentage of patients aged eight or over
  diagnosed
• as having asthma after 1 April 2006 with
  measures of
• variability or reversibility.
• Must demonstrate reversibility by the use of
  such codes as 339A (PEF before Bronchodilation)
  and 339B (PEF after Bronchodilation)
• But either code will score the PEF
  reversibility requirement!
• Flu vaccination requirement removed.

27
CHD catches

• Prevailing catches -
• Exception codes needed for Aspirin AND Warfarin
  AND Clopidogrel before they count
• BP needs checking annually, even if on Maximal BP
  Rx. ( ditto DM, CVA, CKD )
• Lipids need checking annually, even though
  exception coded for Statins or on Maximal Lipid
  Rx. ( ditto DM, CVA )
• CHD is otherwise unchanged, including look back
  window for Aspirin scripts remaining at 15/12
  unlike the change to 6/12 in A.F.

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C.K.D. catch -

• CKD4 Only CKD patients who also have a
  Hypertension diagnosis too, need to be treated
  with an Ace or A2RB, or exception reported to
  both drug families.
• Any patients with CKD raised BP, taking an ACE,
  where Hypertension has not been added to the
  record, will not count for you under CKD4.
• Any patient with CKD where you are keen to avoid
  adding an ACE (e.g. little old lady with low BP)
  doesnt need one if not also Hypertensive.

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C.K.D. points optimisation -

• CKD3 All BPs need treating to achieve target
  level of 140/85.
• (The stringent BP target age group of many pts
  may require consideration of On maximum BP Rx
  exception code to achieve full BP scores.)
• (70 coverage needed)

30
COPD catches

• Annual FEV1 still required on all pts. (but note
  that adding repeat complete spirometry code is
  not valid, as a demonstration of FEV1 being
  done.)
• Specific Exception codes exist for those unable
  to perform Spirometry, but no specific exception
  codes exist for FEV1 recording.

31
COPD catches (cont)

• Adding a global exception code to a demented COPD
  patient who cant do an FEV1 will potentially
  take them out of the Flu vaccination catchment
  group the following Autumn if Exception code is
  added after 31st December, so backdate any such
  global exception codes to previous year end.

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Learning points for clerical summarising staff

• If A.F diagnosed gt 1.4.06, ensure ECG result
  added too if done. (.3272 ! )
• Adding CHD diagnosis gt 1.4.03 ? Exercise test
  or ref to Cardiol recorded.
• CVA gt 1.4.06 ? Scan done or referred.
• eGFR lt 60 ml/min Add appropriate .1Z1 code
• COPD Use correct codes to note Spirom FEV1
• Ensure Ethnic status recorded for all new
  registrations (Min score100 for 1 point !
  Worth it? )

33
Learning points for Drs Nurses

• Depression diagnosis - Consider giving out PHQ-9
  form to each newly diagnosed depressed pt, or Use
  a Non-depression triggering code for weepy pts
  until PHQ-9 returned, e.g. Low mood (1BT..)
• CKD Aggressive attention to BP in CKD pts needed
  to achieve stringent BP control.
• Use Maximal BP Rx code once you give up on
  achieving optimal BP control in any hypertensive
  pt!
• Records 22 Collect Smoking Hx in all patients
  15 (huge numbers to collect data on, needs
  doing every 27 months)
• (11 points, 90 coverage needed)

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Episode codes Do you need them?(Below is a
quote from an author of a software package which
has gone through conformance testing for
submission to QMAS )

• The earliest ever incident of a code "cluster"
  is taken
• to be the "first", UNLESS it is explicitly
  marked as
• "ongoing".
• All successive incidents of a code "cluster" are
• assumed to be ongoing, UNLESS they are
  explicitly
• marked as "first" or "new".
• So episode coding is optional and you really
  only
• need to add it to make the meaning of a
  specific entry
• explicit where the implicit rules as described
  above
• would not describe the semantics of the
  patient
• history.

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Episode codes Do you need them?

• Rulesets with Diseases NEEDING an Episode code,
• according to the Rulesets.
• (These will affect your QMAS analysis.)
• Cancer (Looks only at the latest added Read code
  that has been episode-coded as First or New
• (2nd Cancer its Ca R/V ignored if another
  gt1.4.03
• CKD (Looks only at the latest added Read code
  that has been episode-coded as First or New
• (Improvement in CKD addition of new 1Z Read
  code e.g. 1Z11 (CKD2) ignored)

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Episode codes Do you need them? (cont)

• CHD M.I. codes. Looks only at the latest added
  Read code that has been episode-coded as First
  or New.
• (Episode code possibly only relevant if new M.I
  occurs Jan to March where 3/12 grace period for
  ACEs etc only applies if this M.I is a new
  one.)
• Depression Looks only at the latest added Read
  code that has been episode-coded as First or
  New.
• (New episodes of depression ignored if occurred
  previously)
• Stroke codes Looks only at the latest added Read
• code that has been episode-coded as First or
  New.
• (New CVA ignored if another occurred at any time
  previously.)

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Support documentation

• The following documents are available online at
  the web page shown shortly
• Two Summary spreadsheets of the diseases
• A Summary sheet of all valid Exception codes for
  Version 10.0 in 2007
• Word document with all Version 10.0 changes
  listed
• A document with Web links to useful QOF
  documentation.
• The text of this presentation.
• Various other Word docs on aspects of the QOF.

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The EndQuestions please?

• Website address for full text of talk, plus
  Summary / Exception code spreadsheets etc
• www.Poplarssurgery.co.uk/upload/
• Dr Simon Clay
• Poplars surgery Birmingham
• Simon.clay_at_Gmail.com

40
Psychosis coding catch

• Psychosis codes have no earliest time limit.
• Some patients may have examples of these codes
  lodged within their records perhaps added
  several years ago, but which now define them as
  actively psychotic under QOF.

41
Solution to Psychosis coding catch (1)

• Probably worth cross - checking old list of
  Psychotics from QOF 2005 with new list of
  Psychotics from QOF 2006. (Use the presence of
  9H6 or 9H8 to derive the former list)
• Many patients not appearing in old list may have
  a resolved Psychoses e.g. E110 Single episode of
  Mania. Eu30. Manic episode or Eu30z Manic
  episode unspecified.

42
Solution to Psychosis coding catch, (2)

• a.) Temporary fix
• Add .9h91 to these records to exception code
  them temporarily from all indicators.
• (N.B. Expiring code pt is left in M.H register
  - increasing your prevalence payment)
• b.) Permanent fix
• Change the old no-longer active Psychosis code
  to a History of code from the .146 chapter,
  e.g. 1464 H/O Schizophrenia, 146D H/O Manic
  depression 146H H/O Psychosis.
• (N.B. One-off fix, Pt is removed from M.H.
• register. (but H/O codes are deprecated by
• several agencies, including PRIMIS)

43
STROKE ( TIA) disease area

• Amaurosis fugax is a TIA since Sept 05
• (so is Vertebro-basilar insufficiency (G65)
• CVA11 replaces CVA2 Now only looks at CVAs
  since 1.4.06. Required to demonstrate scan, or
  ref for scan, or ref to CVA clinic.
• (Again, we lose all credit for CVA pts
  diagnosed before 1.4.06 who did have imaging.)
• CVA12 added (Blood thinners). Now need to have pt
  on either Aspirin, Warfarin, Clopidogrel or
  Dipyridamole, or exception codes needed for all 4
  classes.

44
Hypertension

• No major changes.
• except Smoking status needs to be re-added
  within 15/12 of each reference date (1st April)
  annually unless Never smoked is the last
  Smoking code added.
• Smoking cessation advice should be added annually
  to all smokers (within 15/12 of reference date)
• (Always add Smoking status again as you make any
  of the QOF diagnoses assoc with Smoking!!)

45
COPD disease area

• Spirometry requirement for initial diagnosis now
  coalesced from 2 separate rules into one new one
  COPD9, ( Spirometry done from 3/12 before
  diagnosis to ever.)
• Annual FEV1 still required on all pts. (but note
  that adding repeat complete spirometry code is
  not valid, as a demonstration of FEV1 being
  done.)
• Frail elderly may be specifically exempted
  obligation to perform Spirometry if Spirometry is
  declined or not indicated. (e.g. too frail
  etc). (Indicator 9).
• But it is not possible to selectively exception
  report pts unable to do the annual required FEV1
  however (Indicator 10).

46
Cancer

• As before, ALL Cancers since 1.4.03 need to be in
  the Cancer register -with the same previous
  exclusions for non-melanoma Skin Ca.
• (i.e. denominator group for Ca1 remains the
  same)
• For Ca3 indicator, (Cancer R/Vs done within 6/12
  of diagnosis), Denominator for this indicator is
  All Cancers diagnosed in 18/12 before Ref date,
  except those whose Ca R/V occurred between 18/12
  to 12/12 before the Ref date.

47
Epilepsy disease area

• Few changes
• Age criterion relaxed. Pt must be gt/ 18yrs at
  Ref date (c.f. gt/ 16yrs in prev rules.)
• Annual medication R/V is now supposed to include
  patient or carer.
• Version 9.0 Range of codes defining Epilepsy
  slightly broadened . See rulesets for details.

48
Thyroid

• NO changes Lets move on!

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50
Conclusions

• Its going to be a lot harder to score highly.
• There are 9 new diseases to address a new set
  of potential catches.
• Those that dont make themselves aware of the
  catches are potentially going to throw money
  away.
• Education sessions with all practice personnel
  who add Read - coded data may well be a good time
  investment.
• Software support can be very helpful
  cost-effective. (e.g. Contract Plus (most GP
  systems supported) or Easy-monitor (Isoft Premier
  only).

51
Reference date signs - What do they mean?

• The Reference date (REF_DAT in the Rulesets) is
  referred to regularly in the rulesets in
  discussions on QOF timetables.
• It is defined as the 1st of April at the end of
  each QOF year.
• A read code range of G58.. means
• G58 itself and all subordinate codes to G58z.

52
The Rulesets- What are they?

• Rulesets are documents Two for each disease,
  They define
• a.) exactly which Read codes are needed to
  trigger scoring the points
• b.) which code will be look at by the software
  if there is more than one example of the code
  noted on the record.
• They also define the rules by which those Read
  codes are then analysed in order to determine how
  much practices have earned for each indicator
  each disease.
• In the Rulesets folder, each disease 2 rulesets
  documents one using 4 byte Read codes
  another, using 5 byte codes.
• Choose the correct one if looking something up!

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54

• Smoking 1 The percentage of patients with any or
  any combination of the following conditions
  coronary heart disease, stroke or TIA,
  hypertension, diabetes, COPD or asthma whose
  notes record smoking status in the 15 months
  (except those who have never smoked where smoking
  status need only be recorded once since
  diagnosis).
• Denominator ruleset

• Numerator ruleset To be applied to the above
  denominator population

55
Apologies for that!

• Rulesets arcane tedious,
• But
• they contain the only definitive guidance on what
  Read codes are are not permitted under QOF
  rules.