Piloting of QOF indicators began in October 2009 and we've now tested over 50 different indicators in 150 practices across the UK. The practices' hard work will bear fruit in April when the new peripheral arterial disease, atrial fibrillation, osteoporosis and smoking indicators go live.
This article will give you a feel of the issues that the cohorts of practices came across, which I hope will help you prepare for the new indicators in your own practice. It also demonstrates the value of piloting by describing the indicators that might have found their way into your consulting room, were it not for the time and effort your colleagues spent in testing them out and telling us which indicators did and didn't work in frontline practice.
Atrial fibrillation
AF was introduced into the QOF in 2006 and included AF3, ‘the percentage of patients with AF who are currently treated with anticoagulation drug therapy or an antiplatelet therapy'. However, there is now even better evidence that many patients with AF who would benefit from anticoagulants are not being prescribed them#.1 Practices in cohort 3 helped to decide whether using the CHADS2 stroke risk stratification score and emphasising the need to prescribe anticoagulants where risks were higher were acceptable to the profession as part of the QOF.
Almost all the practices thought these were excellent evidence-based additions to the domain and about 50% said they had routinely used CHADS2 before the pilot (far more than were, for example, using CHADS-VASC). The risk score was useful as objective evidence to help explain the need to start warfarin in some patients had been lacking. Many practice managers calculated the CHADS2 score from notes in an initial catch-up exercise. The lower upper threshold (70%) reflects, in part, the only concern from the pilots that some older patients might not want to start warfarin despite the evidence base. In your practice, you might want to think about who will calculate CHADS2 and if there are any educational needs for staff in terms of using the calculator and discussing the need for warfarin with patients.
Peripheral arterial disease
PAD has been talked about as a missing element of the QOF for some years, so it was great to be given the opportunity to pilot six potential PAD indicators with our cohort 2 practices. Overall, practices were a little more ambivalent about these indicators than the AF ones, largely because some GPs felt that many patients with PAD were being seen and treated as part of other QOF domains. There was also a perceived tension between including a condition that puts an individual at high risk, but is relatively rare in practice (with an annual incidence of 0.2%). On balance, however, they were seen as being of value for patients not on other registers who might otherwise slip through the net.
You might be interested to know that the one indicator in the pilot that did not go forward as part of the NICE menu of recommendations to negotiators was ‘the percentage of patients with PAD who have had the diagnosis confirmed by a record of resting ankle brachial pressure index measurement (ABPI) or referral for specialist assessment'.
Most pilot practices did not routinely use the ABPI and some GPs preferred to rely on their own clinical judgment. There were also concerns about overwhelming local vascular outpatient clinics if this had been recommended for live QOF. The new nine-point PAD domain focuses on creating a register of patients with symptomatic PAD using clinical judgment, evidence-based intermediate outcome indicators of blood pressure and cholesterol control, and antiplatelet prescribing. The QOF 2012/13 guidance does, however, go into some detail about the place and value of ABPI.
Smoking
At first glance there seem to be quite a few changes in the smoking domain in 2012, but in reality the changes are simply an addition of PAD into the long-term conditions, an offer of support and treatment instead of smoking cessation advice or referral to a specialist service, a move of records 23 from the organisational to the clinical smoking domain and a new indicator, ‘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 months'.
Cohort 2 practices piloted a heroic eight different combinations of smoking indicators to help decide the most appropriate age to start asking about smoking and the level of the intervention.
Practices felt that 15 was the youngest acceptable age (we piloted asking 14-year-olds as well) based largely on their experience of records 23. As part of the pilot, a small number of practices sent a questionnaire to their 14- and 15-year-old patients asking about smoking habits, but got uniformly low response rates (0% in one practice) – so this may not be the way to go. Do remember though that the lower age range is still 14 for young people with asthma.
In the context of the 2012 QOF, ‘an offer of support and treatment' means offering referral or self-referral to a local NHS stop smoking service adviser, who might be a member of the practice team, plus pharmacotherapy. Where the patient doesn't want this sort of support, follow-up appointments with a GP or practice nurse trained in smoking cessation are fine.
Osteoporosis
Cohort 3 practices also piloted four osteoporosis indicators, based on the current osteoporosis DES. A few changes were made for the pilot, notably to include both men and women and reduce the age to 50 and above, rather than just over 65. Practices were also asked to pilot an indicator on calcium and vitamin D supplementation for people taking bone-sparing agents. This new domain is really focused on fragility fractures, defined as fractures that result from low-level trauma – for instance, force equivalent to a fall from a standing height or less. However, do remember that a patient needs both a diagnosis of osteoporosis (at any time) and a fragility fracture after 1 April 2012 in order to become part of the register.
Almost every pilot practice was very enthusiastic about these indicators. All had access to DXA scanning, and the only recurring concern was around the tolerability of bone-sparing agents, later reflected in the lower thresholds for this set. Prescribing calcium and vitamin D was seen as a routine part of practice already and was therefore included as part of the 2012/13 QOF guidance rather than as a separate indicator. In your practice, you might want to think about the processes you need in place to ensure that, for instance, A&E letters are reviewed, potential fragility fractures are identified and any educational needs relating to this task are met.
I hope you can see that the new indicators are evidence-based, should improve patient care and are not too onerous in terms of workload. Your frontline colleagues in the pilot practices have helped refine each set to ensure they work in practice and would, I'm sure, commend them to you.
Professor Helen Lester is professor of primary care at the University of Manchester and a GP in Birmingham. She is leading the QOF development programme for NICE
References
1 Ogilvie IM, Newton N, Welner S et al. Under-use of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med 2010;123:638-45
