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Making the new QOF smoking rules work for you

New QOF rules for smoking status were released last month and they are even more complex than those they replace. Dr Simon Clay takes you through the changes and how you can cut down your work and maximise the return.

New QOF rules for smoking status were released last month and they are even more complex than those they replace. Dr Simon Clay takes you through the changes and how you can cut down your work and maximise the return.

Version 12.0 of the QOF rulesets was released in December 2008, with new rules underpinning smoking - both for the "smoking" ruleset and for one section of the "records" ruleset (namely Records 23).

Smoking ruleset

Smoking looks at the smoking status of patients with one or more of eight qualifying diseases – CHD, CVA/TIA, asthma, COPD, hypertension, diabetes, & MH.

GPs are charged with recording the smoking status of all patients with any of these diseases every 15 months (within 15 months of each "reference date" - 1st April, each QOF year).

However there are a few exceptions:

1. "Never smokers" where the "never smoked" code is added at any time from their 26th birthday and either on the same day as or after the date of the first qualifying diagnosis code. Such patients never need smoking status adding again, presumably due to the assumption that someone who confirms "never smoker" status after they're 26 is unlikely to start.

2. "Never smokers" aged less than 25 on the reference date must have had their never smoking status confirmed within 15 months of the reference date.

3. For ex-smokers, one or other of 2 criteria must be fulfilled:

either
a.) Last smoking status is "ex-smoker" and was added in last 15 months before reference date.

or
b.) i) Last smoking code is "ex-smoker". ("Ex-Smok"), AND

ii) A further "ex-smoker" code was recorded ("Ex-Smok1") between a year & a day and 2 yrs before the date of "Ex-Smok", AND

iii) A further "ex-smoker" code ("Ex-Smok2") was recorded between 2 yrs and a day & 3 yrs before the date of "Ex-Smok".

In the case of b.), if these three criteria are fulfilled, the authors of the rulesets have presumably decided that this person is probably a long term "ex-smoker" and so they permit that this patient will be permanently exempted further requirements to be asked about their smoking status.

You can see that the dates for the three ex-smoker codes all hinge on the most recent ex-smoker code and then look at two further previous time windows, each of which is in relation to this last ex-smoker code.

The date of the last Ex-Smoker code therefore becomes critical.

For example, say the patient was documented as being an ex-smoker on 25th September 2006 ("Ex-Smok"), also on 24th September 2005 ("Ex-Smok1") , and also on 24th September 2004 ("Ex-Smok2").

The patient has not been asked about Smoking status this QOF year, but because he fulfils b.) above, he not only "scores" for this QOF year, but as long as there are no further smoking or ex-smoker codes added, he's permanently exempted.

A keen clinician now sees the patient on 30th November 2008 & decides to ask him his smoking status again. He records this as ex-smoker and the patient "scores" for the 2008-09 QOF year, (although he was actually scoring already.) But now, the last ex-smoker code date is 30/11/08 ("Ex-Smok") and the previous one ("Ex-Smok1") is more than 2 years previously (26th Sept 2006) so the following QOF year (2009-10) the patient will have to be asked again, or will fail the test.

So the moral is, if the patient is already scoring Smok3 due to b.) above, it's best never to ask again!

What happens if a patient has had several "Ex-Smoker" codes added within the 3 year time window back from "Ex-Smok" date?

That's fine. As long as there ARE 3 ex-smoker codes within the required time windows, further ex-smoker codes added BEFORE the critical most recent ex-smoker code don't harm things at all. Neither do "never smoked" codes which seem to creep in occasionally! Neither do codes implying "current non-smoker" such as .137L.

For the purposes of QOF, 137L "current non-smoker" is an "ex-smoker" code. However, if anyone is also documented as any sort of smoker during the dates between "Ex-Smok" code & "Ex-Smok2" code, then this mucks everything up and the patient can't "count".

The Records 23 rules

Records 23 charges GPs with recording the smoking status of everyone from the QOF year during which they become 15 onwards, every 27 months. However, again, there are variations and exceptions:

1. "Never smokers" continue their exemption from further recording provided that the last "smoking status" is "never smoked" AND the patents was more 26 years old when recorded as a "never smoker".

2. Patients aged 15-25 who are "never smokers" need to have that status re-confirmed & recorded every 15 months (not even every 27 months) in order to "score" under records 23.

3. As in the smoking rulesets above, patients aged 15+, whose last recorded smoking status at any age is "ex-smoker", are exempted further documentation, provided that:

either
a.) Last smoking status is "Ex-smoker" and was added in last 15 months before reference date.

or
b.) i) Last Smoking code is "ex-smoker". ("Ex-Smok"), AND

ii) A further "ex-smoker" code was recorded ("Ex-Smok1") between a year and a day & 2 yrs before the date of "Ex-Smok", AND

iii) A further "ex-smoker" code ("Ex-Smok2") was recorded between 2 yrs and a day & 3 yrs before the date of "Ex-Smok".

Two potentially useful "tricks"

For both the smoking ruleset and the records 23 ruleset, there are two "tricks" I would commend to you:

1. Let's suppose you ask a patient if they smoke and they say "Oh no, I gave up in 1980" (as some patients do).

There's therefore nothing to stop you adding 3 "ex-smoker" codes consecutively.

- Leave one dated today.

- Change the date of the second to a year and a day before today.

- Change the date of the 3rd to 2 yrs and a day before today.

For example, today is 24th Oct 08. Add 3 codes dated 24th Oct 2008, 23rd Oct 07. 23rd Oct 06.

These 3 records are all an honest account of what the situation was at each date, but you have just permanently exempted the patient from any further recording of their smoking status and permanently scored that patient for you in your QOF scores (as long as some keen clinician doesn't add any more smoking data!)

2. You may have patients with an "ex-smoker" code as their last smoking status code, who gave up several years ago and a keen clinician has added some free text documenting that fact – e.g."quit in 1982", but perhaps this "ex-smoker" code was added more than a year ago.

If so, then these patients will probably not be "counting" for the smoking or records 23 indicator at present.

At my practice, we ran a report looking for patients aged 15 plus with "ex-smoker" as their last smoking status code, added before 1.4.08, which had any free text added to the entry which might indicate a quit date some time before.

Codes to search for are: 1377 to 137B plus 137F, plus 137K and 137L, plus 137N and 137O and finally 137S and 137T. Most of these patients will not be "counting" for us this QOF year, as they won't have had 3 "ex-smoker" codes added with the correct time frames.

We then printed these out & looked at each one. We found more than 200.

Many of these had free text which allowed the addition of two additional ex-smoker codes, back dated as described above, so that the patient was made to count for us THIS year & also in every subsequent year.

For the more organised or obsessive practices, this may be an idea worth looking at!.

These are the depths to which we have now sunk in our efforts to satisfy the absurdities of the QOF 2008.

Dr Simon Clay is a GP in Birmingham

Making the new QOF smoking rules work for you

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