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ACR testing: the QOF indicator that won't die

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At a conference last May, Jeremy Hunt declared that the reduction of QOF targets in this year’s GP contract did not go far enough, stating that he would remove the lot of them if he could. I wonder if anyone had told him yet that as fast as he is trying to reduce the tick-box culture in the GP contract, our chief inspector Prof Steve Field is putting it back again?

Whatever you think of Mr Hunt’s desire that GPs should be freed up to spend more time with our patients, the reduction in QOF targets last April was to be welcomed. Bizarrely, we now find one of the now defunct indicators has risen, zombie-like, from the dust under the disguise of the CQC’s oddly-named intelligence monitoring.

The target in question is the old QOF requirement to measure the albumin-creatinine ratio (ACR) in the urine of all patients with diabetes. The constant monitoring of this surrogate marker has long been of questionable value, with results rarely seeming to have a meaningful impact on patient care. Few were sorry to see its retirement last April, and so it was somewhat startling to see it resurrected by the CQC last week.

How has this happened? Is it simple incompetence that has allowed this indicator to be included as one of the 38 most important pieces of data on what defines good patient care? Did the CQC fail to notice that it no longer features in QOF? Or is Prof Field acting in deliberate contradiction to the health secretary and the BMA General Practitioners’ Committee who negotiated last year’s contract? Why does he think he knows better?

The inclusion also raises practical issues. Since it is not part of QOF, GPs will no longer have QOF reminders to prompt them to measure ACR in diabetic patients. Nor will the CQC be able to use the QOF database to assess practice performance in this measure for the coming year, since it won’t be included. Does this mean this indicator will be retired from the CQC intelligence monitoring dataset next year? If so, should practices be trying to achieve high levels of ACR measurement for 2014-15, or is that a waste of effort? What will replace it? Are we to be subjected to a merry-go-round of ever-changing CQC requirements each April in the same way as we have to adapt to the constant revamping of QOF targets?

For those practices that have been deemed to be at risk due to insufficient ACR measurements, how are they meant to respond to their current predicament? They can’t afford to wait for inspectors to come and then argue that this measurement is no longer required, for fear that their protests will fall on deaf ears and the dreaded ‘requires improvement’ label becomes a reality. They shall have to slave over this target and conduct an internal audit to prove to the inspectors that they are responding to criticism, regardless of whether or not they think it will benefit their patients, or be a good use of their time.

I’m sure Jeremy Hunt never reads this blog - much as I might like to hope otherwise - but this is one post that I hope somehow might find its way onto his desk. I’m sure he has no idea that his decision last April has been reversed and I like think there might be an uncomfortable phone call to the chief inspector asking him to explain himself.

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68. 

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Readers' comments (5)

  • Phil Yates

    I'm all for retiring QOF indicators that have no clinical value but ACR is not one of them. It's a good discriminator of the amount of damage to the endothelium and basement membrane in the kidney and associated with vascular damage elsewhere (like the eye). It therefore gives a much earlier warning of incipient diabetic nephropathy than eGFR alone (which starts to fall much later) and focus the mind on interventions that relieve the strain on the kidney (like tight BP control). QOF used as a political tool does harm - but used well clinically has been a good support in identifying who really needs our concentrated input. ACR is a useful marker that shouldn't be abandoned.

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  • Ivan Benett

    I agree with Phil Yates, of all the QoF indicators this is one of the most important. It signals renal endothelial damage and is associated with vascular damage throughout the body. There is moderate evidence that ACEI slow down deterioration and that statins prevent cardiovascular events.
    I do sometimes despair at some of the headline grabbing columnists that appear in this magazine

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  • I have to disagree with you both. The point of this post is that ACR has been retired after negotiation between the Department of Health and the GPC, and so it is bizarre that the CQC should unilaterally bring it back to life. It raises real logistical problems for practices who now have to tick this box again, and it is not at all clear how the CQC will monitor it since it is no longer part of QOF.

    However, since the comments have shifted to the merits of ACR measurement, let me comment on this. We should never forget that this is a surrogate marker and far removed from meaningful clinical endpoints. In fact, it is a surrogate marker for renal damage, which in itself is only a surrogate marker for anything clniically relevant to the patient (like morbidity or mortality).

    Measuring ACR in a young type 1 diabetic may be of useful value, but most of the patients caught up in QOF are older type 2 who will never have significant nephropathy in their lifetime, but will easily be overtreated with more and more medications to achieve tight blood pressure control, and may suffer harm as a consequence.

    The only reason why measuring ACR does not cause more overtreatment than it might is that we already have targets for BP in patients with diabetes, and will use an ACE in preference whether they have albuminuria or not. - hence the ACR measurement very rarely makes any real difference to a patient's treatment: it has largely been an expensive waste of NHS resources.

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  • Have to totally agree with Martin. Think the point of the article was not to debate the merit of ACR but to point out that it had ALREADY been retired by the DoH and GPC, but now used by the CQC. think the blinkered commentors have 1. not read or fully understood your article, 2. missed the point entirely. Please re-read paragraph 4 and 5 again, Phil and Ivan.

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  • Is there any point in doing ACR measurement in patients already on ACE or sartans? Almost all of my type 2 diabetics are already on those drugs, so even if the ACR is positive there is no further action to take is there?

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