There are five main changes to diabetes for this year’s QOF.
Firstly, some indicators’ thresholds are being raised, making them harder to score.
Secondly, some indicators have been altered.
Thirdly, there are four new indicators to absorb and act on.
Fourthly, three indicators have been retired.
Finally, all indicators now have to be scored within the new 12-month window – at least in England & Scotland. (In Wales & Northern Ireland, I believe the 15-month window will remain).
In fact, many of the changes noted below are not relevant for the other three countries in the UK and readers who are not practising in England are advised to consult the more detailed guidance referenced at the end of this article, which has fuller information.
There are seven indicators where the only change is a rise in the thresholds:
1 DM002 (was DM30) Patient’s last BP (in L12M) is ≤ 150/90. New threshold 53-93%, (was 45-71%).
2 DM003 (was DM31) Patient’s last BP (in L12M) is ≤ 140/80. New threshold 38-78%, (was 40-65%).
3 DM006 (was DM15) Patients with Diabetic Nephropathy (= Proteinuria) or with Microalbuminuria, documented and Readcoded at any time in the past, are treated with an ACE/ARB. New threshold 57-97%, (was 45-80%).
4 DM007 (was DM26) Number of diabetics with HbA1c of ≤ 59mmol/mol. New threshold 35-75%, (was 40-50%).
5 DM008 (was DM27) Number of diabetics with HbA1c of ≤ 64mmol/mol. New threshold 43-83%, (was 45-70%).
6 DM009 (was DM28) Number of diabetics with HbA1c of ≤ 75mmol/mol. New threshold 52-92%, (was 50-90%).
7 DM010 (was DM18) Number of diabetics receiving the Flu vaccination. New threshold 55-95%, (was 45-85%).
Secondly, one indicator has changed slightly in the denominator inclusion criteria:
DM005 (was DM13) Patient has had a Urinary Albumin/Creatinine ratio (ACR) done in the last 12 months.
This has changed, in that until this year, patients who had previously been found to be proteinuric and had this Read-coded were exempted from further testing. This exemption is now rescinded, so every diabetic, however severe their diabetic nephropathy, has to be re-tested annually. Quite what the justification for this is, I do not know – neither does the guidance book give any explanation.
Note that ACR of ≥ 2.5 mg/mmol in men and ≥ 3.5 mg/mmol in women defines ‘microalbuminuria’ (NICE). Now, as noted above, even patients with proteinuria coded at any time in the past (defined as ACR ≥ 30 mg/mmol), also need testing.
There are four new indicators for diabetes this year:
DM013: Percentage of ALL the practice’s diabetics receiving an annual dietary review with a ‘suitably qualified professional’.
The reward for achieving this on 90% of your diabetics – a well-nigh impossible task I imagine, even if local facilities exist, is a rather paltry 3 points.
Payment thresholds are 40-90%.
These are the Read code options to score this indicator:
- 66At. Diabetes Dietary R/V
- 66At0 Type I Diabetic Dietary review
- 66At1 Type II Diabetic Dietary review
Who is a ‘suitably qualified professional’ to give dietary advice to diabetics?
The NICE quality standard defines an appropriately trained healthcare professional as one with specific expertise and competencies in nutrition. This may include, but is not limited to, a registered dietician who delivers nutritional advice on an individual basis or as part of a structured educational programme. The Diabetes UK competency framework for dieticians sets out level one competencies that are the minimum standard for any staff involved in the healthcare of people with diabetes. Therefore, if non-dieticians are employed to deliver dietary advice, they should conform to the level one competencies described in the Diabetes UK framework as a minimum.
DM014: Newly diagnosed diabetics are to be referred to a structured education programme within 9/12 of diagnosis. 11 points. Payment thresholds 40-90%.
This new indicator seems far more sensible – clearly helpful both clinically and educationally, likely to be logistically feasible and reasonably well remunerated for the practice.
These are the valid Read codes to score this indicator:
- 8Hj0. Referral to Diabetes structured education programme
- 8Hj3. Referral to DAFNE DM Educ programme
- 8Hj4. Referral to DESMOND Educ’ programme
- 8Hj5. Referral to XPERT Educ’ programme.
There is also a specific Exception code if required:
- 9OLM. Diabetes Structured Education programme declined
What does NICE say are the criteria for the ‘new Diabetic’ educational programme?
- It should be evidence-based and should suit the needs of the individual. Should have specific aims and learning objectives. Should support the learner and family and carers to develop knowledge and skills to self-manage diabetes.
- There should be a structured curriculum which is theory-driven, evidence-based and resource-effective, have supporting materials and be written down.
- It should be delivered by trained educators with understanding of educational theory appropriate to the age and needs of the learners and trained and competent to deliver the principles and content of the programme.
- It should be quality-assured and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency.
Outcomes from the programme should be regularly audited.
Who is allowed to provide the ‘new diabetic’ education? The Blue book guidance booklet says (rather optimistically I feel) ‘some practices may be able to deliver structured education programmes in-house. These programmes would need to meet the requirements outlined above.’ I suspect most practices will actually want to delegate this requirement rather than pay to do it themselves.
Two new indicators deal with Erectile Dysfunction in diabetics:
- DM015: Male Diabetics to be asked about any problems with erections annually. This apparently laudable indicator aims to reveal unspoken problems with ED in the diabetic male patients. It offers 4 points, with payment thresholds of 40-90%. To score, male diabetics need one of these 2 codes adding annually:
- 1D1B. C/O Erectile Dysfunction
- 1ABJ. Does not complain of Erectile Dysfunction.
Note that many commonly used erectile dysfunction codes are not valid to score this, e.g. E2273 “Erectile Dysfunction”.
Also rather disappointingly, there is no maximum age limit on this indicator, so even if he’s 99 and in a Nursing home… I’m sure GP’s will use their common sense.
No specific exception code is available to except from this indicator, so one of the global diabetic exception codes would be required, if felt appropriate.
- DM016: “Diabetics with Erectile Dysfunction have an annual record of Advice and assessment of contributory factors and treatment options”.
This new indicator requires us to demonstrate that we’ve assessed the factors causing the condition and offered help and treatment. This does seem reasonable in year one, though I imagine the sufferers will get somewhat irritated by us asking all over again by year 4. Still perhaps the indicator will have been altered by then.
Six points are available, with payment thresholds of 40-90%
This is the only valid Read code to score this indicator:
- 66Av. : “Diabetic assessment of E.D.”
Again, no specific exception code is available for this indicator.
Fourthly, three previous indicators are retired:
DM2 Measure BMI annually
DM10 Neuropathy testing
DM22 Check eGFR or serum creatinine annually
Finally, all these new changes to the diabetes business rules need to be acted upon within the new more stringent 12-month window now in force in England and Scotland. Of the new indicators, some are relatively easy, most are pretty challenging & one is frankly impossible in my opinion - and not financially worth attempting either. We’ll see how well
the nation’s GP’s really do with DM013. Good luck.
For information on Dr Clay’s QOF Resource Disc go to www.tinyurl.com/qofdisc
Dr Simon Clay is a GP in Erdington, Birmingham.