This site is intended for health professionals only

At the heart of general practice since 1960

Fine-tune your exception reporting

With no national guidance on exception reporting, it can be hard to gauge what constitutes an acceptable level ­ Dr John Guy shares the findings of an audit of 159 practices and advises on what is appropriate

With no national guidance on exception reporting, it can be hard to gauge what constitutes an acceptable level ­ Dr John Guy shares the findings of an audit of 159 practices and advises on what is appropriate

Exception reporting has generally not been widely used by GPs to achieve targets in the QOF. Many of the targets have been set at realistic levels and if the maximum percentage has been achieved there is little incentive to improve scores by excluding patients.It is possible that this may change if targets become more challenging in forthcoming years.

EQUIP (see end of article) has been working across seven PCTs in Essex and has had the opportunity to view QMAS scores and compare findings from 159 practices. Some of our findings are summarised here and suggest what may be reasonable and when further inquiry might be necessary as part of QOF visits.

Coronary heart disease

CHD 8 Last measured cholesterol 5mmol or less

This criterion is important but may be irrelevant in older frail patients, especially those in residential or nursing homes or who are terminally ill. Exclusion rates vary quite widely between practices. But among PCTs the average was 9.6 per cent with a tight range of 8-11 per cent. Practices excluding 15 per cent or more should have evidence to support this.

CHD 9Percentage of patients on aspirin or anticoagulant

Exclusion rates for this marker were generally very small. Before the contract it was thought that about 6 per cent of patients might reasonably be excluded, usually due to previous gastrointestinal bleed. Anyone excluding more than 10 per cent of patients should be able to justify their actions.

CHD 10CHD patients currently treated with a beta-blocker

Here the situation is quite different. The upper maximum target is set at only 50 per cent but despite this the number of exclusions is high. The average across Essex PCTs was 17.3 per cent but there was quite a range of behaviour. Up to 30 per cent looks reasonable but the practices excluding more than 50 per cent should be able to explain the clinical rationale. Co-existent asthma is probably the main reason for excluding beta-blockers and some patients who have been using beta-blockers long-term for hypertension may develop wheeze. Poor peripheral circulation would be another reason for exclusion.StrokeStroke 9 Stroke TIA patients on aspirin or antiplateletsIt is important to exclude patients who have had previous haemorrhagic strokes. These patients are generally thought to be less than 20 per cent of the total. More than twice this number (43 per cent), however, were excluded across PCTs and the rate was consistent. The graph shows the percentage of patients with stroke/TIA in one PCT who are actually receiving an antiplatelet. This is an area worthy of some clinical discussion if we are to maximise the secondary prevention of stroke. We suspect this group of patients has a number of co-morbidities and rates are higher in the PCTs with larger numbers of older patients.Stroke 10Influenza immunisation uptakeExclusions here averaged 12 per cent with a range of 9-15 per cent and most of these would be patient dissent. More than 20 per cent would need justification.Chronic obstructive pulmonary diseaseCOPD 6 Patients with a record of FEV1 in the last 27 monthsOn average 7 per cent of patients were excluded. Clinically these may include those with end-stage disease who do not have enough puff to use the spirometer. It is surprising how long these patients survive!For some of our smaller practices the absence of a spirometer presents a challenge but is not a valid reason for exclusion. A rate over 20 per cent would need justification.COPD 8Influenza immunisation uptakeThis is an important preventive measure and this is reflected in the smaller number of exclusions which was consistently 10 per cent across Essex. Exclusion rates were lowest in the PCT with the oldest patients.EpilepsyEpilepsy 4 Patients who are seizure-free for the last 12 monthsA significant number of patients cannot be controlled on treatment despite the best endeavours of GPs and consultants, and these should be excluded. Some practices that have a disproportionate number of patients discharged from long-stay learning disability institutions may have high numbers of exclusions. The Essex average was 12 per cent but PCT averages varied between 7 and 22 per cent. Higher exclusion rates tended to be from practices with small numbers of patients ­ those with rates of 30 per cent or more should be able to explain them.CancerCancer 2 Patients with a review within six months of diagnosisThis criterion looks at patients who have been diagnosed since April 2003. Some may move into the practice more than six months after the diagnosis has been made and these could be excluded, as could a small number of patients where treatment precludes a review in primary care. Most patients appreciate contact from the practice at what is often a frightening time.The average exclusion rate across Essex was 9 per cent. The negative figure is as a consequence of new diagnoses added between National Prevalence Day 14 February 2005 and 31 March 2005 when performance was measured. It is important to record an accurate date of diagnosis rather than the date the computer entry was made. Practices that exclude more than 25 per cent of their patients should have a good reason to do so.AsthmaAsthma 7 Influenza immunisation in the last six monthsHigh rates of exclusion were found here. We suggest patients be given the opportunity to decline the immunisation on the invitation letter from the practice to attend. The letter could be returned to the practice and the patient dissent logged. Many younger patients prefer not to have the jab and those who have predominantly seasonal symptoms may well not need it. Average exclusion rates are about 33 per cent and it can be seen that all who achieved the target 70 per cent in this PCT excluded at least 25 per cent. Anyone excluding 50 per cent or more would need to explain this.Lessons to be learnedThe advent of the Apollo software will give a fresh perspective on exclusions but the topics here are the main areas of relevance to all practices. For most other clinical areas exclusion rates are less than 10 per cent. GPs who have excluded half of some groups in order to achieve targets will need to be careful. In general the smaller the numbers of patients on the disease register the bigger the discrepancies that can arise.

John Guy is clinical lead for EQUIP, an organisation that evolved from the Essex Medical Audit Advisory Group and GP Education in Essex ­ he is a GP in Hatfield Peverel. Competing interests None declared

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say