Quality markers for epilepsy, hypothyroidism and cancer
These three clinical areas appear to have little in common, but they are linked by the fact that
each has been allocated a handful of quality points in the new contract. Altogether they are worth a total of 36 points, and some of these can be earned with relatively little effort by a
Preferred Read codes
Seizure frequency recorded 6675
Epilepsy medication review 667
Acquired hypothyroidism CO4%
Congenital hypothyroidism CO3%
Thyroid function tests 442%
Cancer diagnosis discussed 8CL0
A full list of preferred codes for individual cancers is included on pages 53-54 of the new contract document
This condition is included because it is relatively common, with a prevalence of 0.5-1 per cent and appropriate clinical management can reduce the risk of complications.
lCompile a register of patients aged over 16 who are taking medication for epilepsy
(two points). It is not necessary to include patients who have never taken drug treatment or who have been treated in the past but have been seizure-free off medication for many years. Children are excluded because their management is generally a secondary care responsibility.
A computer prescribing search should be sufficient to generate a list of patients, although it is important to recognise that some patients without epilepsy may be taking carbamazepine, sodium valproate or gabapentin for their mood-stabilising or pain-modifying properties: these patients should be excluded from the register.
lRecord seizure frequency (four points for 90 per cent coverage) and perform a medication review (four points for 90 per cent coverage) annually. This may involve reviewing patients in surgery whose epilepsy has previously been managed entirely in secondary care.
Record the patient's drug treatment and any adverse events.
lAim to optimise control of seizures (six points for 70 per cent of patients seizure-free over the previous 12 months). Remember to use the exception-reporting system for patients whose compliance with treatment is poor, in whom treatment is contraindicated for other reasons, or whose epilepsy is uncontrolled despite maximal doses of medication.
The new contract document does not include a preferred code for 'seizure-free' so this will have to be agreed within the practice.
Hypothyroidism is included because it is fairly common, with a prevalence of 1.4 per cent in women aged between 75 and 80, and because it is managed almost exclusively in primary care.
lCompile a register of patients with hypothyroidism (two points). A search on repeat prescribing of thyroxine should be sufficient, provided there are no maverick doctors in your practice prescribing thyroid supplements to euthyroid patients for inappropriate indications such as weight control or fibromyalgia.
lCheck and record every patient's thyroid function at least once a year (six points for 90 per cent coverage).
Pathology links will make recording this information virtually effortless. It is also acknowledged as good practice to check TSH and/or T4 annually in patients who have had radio-iodine or surgery to treat hyperthyroidism.
Given the relative ease of treating to target in hypothyroidism, it is rather a pity that there are no points available for bringing patients' TSH and/or T4 within the normal range.
Cancer is a clinical priority in all areas of the UK and it is recognised that most of the active management which influences measurable outcomes takes place in secondary care, with the GP's roles being to recognise symptoms and signs which could indicate cancer, to
refer promptly and appropriately, to provide ongoing support for patients and families and to co-ordinate the various agencies involved in their care.
This indicator set is not evidence-based but reflects intuitive good practice.
lProduce a register of all cancer patients diagnosed after April 2003 (six points). It is unnecessary to include non-melanoma skin cancers. The new contract document includes a detailed list of preferred codes for each cancer site, but practices may choose to use different codes provided these are standardised within the practice. The information in these registers may prove a vital tool in future for the development of locally-sensitive measures of the prevalence of different cancers.
lReview all patients with cancer within six months of diagnosis (six points for 90 per cent coverage). The remit of this review is to assess support needs and ensure you and the patient have a clear picture of the follow-up arrangements planned by secondary and/or tertiary care services.