By Lilian Anekwe
NICE advisors have caved into significant GP concern and recommended retiring depression screening indicators from the QOF, after widespread complaints about the poor diagnostic ability of commonly-used primary care tools.
At a meeting this week, the NICE advisory committee reviewed the QOF indicators that reward practices for screening patients for depression – prompted by a deluge of complaints from GPs.
The Primary Care QOF Indicator Advisory Committee, the independent group that makes recommendations on QOF indicators on behalf of NICE, reviewed two QOF indicators – Depression 4 and 5. The indicators offer 17 and 8 points respectively, for the percentage of patients with depression who have an assessment of severity at the time of diagnosis, and then again four to 12 weeks afterwards, using an assessment tool validated for use in primary care.
Three tools are validated for use in primary care – the PHQ-9, the Hospital Anxiety and Depression Scale and the Beck Depression Inventory-II. But GPs have long complained the questionnaires are blunt tools that over-diagnose patients and could potentially increase the number of patients inappropriately prescribed antidepressants.
A study published in the BMJ in April 2009 by Professor Tony Kendrick – a GP and member of the QOF advisory committee - found the depression severity scores used by GPs perform ‘inconsistently in practice'. The PHQ-9 tool diagnosed 50% more patients as moderately or severely depressed than the hospital anxiety and depression scale.
The study also found older patients were less likely to be referred than younger ones, and patients with diabetes, CHD or other chronic illnesses were treated and referred less often than those without a chronic illness.
Other studies have found the tools over-diagnose people as moderately or severely depressed, and appropriate for antidepressants.
Despite debate within the committee – with some members arguing the indicator should be retained – the decision was made to recommend the indicators are scrapped due to the lack of evidence for their use.
The recommendation will be forwarded to GPC negotiators and NHS Employers, who will begin their negotiations on the QOF in August.
At the meeting in London yesterday, Dr Colin Hunter, the committee's chair and a GP in Aberdeen, said: ‘These indicators came into us because of the level of post we had from GPs about the lack of belief in the evidence base. It's my feeling that we should continue to look for indicators that do work in depression because mental health in general practice is very important. There are indicators coming up on the horizon that might do a better job. We don't believe the evidence base is strong enough to continue with this indicator.'
And Dr Hunter, who was involved in the negotiations for the 2004 QOF, admitted the decision to include the depression screening indicators came after ‘pressure' from ministers.
‘There was a strong driver from the Department of Health to come up with indicators around mental health, and having been around the process the first time there was a lot of pressure from the DH to put in indicators for which there was very little evidence. We resisted some of the pressure on QOF the first time around but I know that for QOF2 there would have been even more pressure.'Many GPs have complained about the evidence-base for the QOF indicators on depression screening Many GPs have complained about the evidence-base for the QOF indicators on depression screening QOF indicators recommended for retirement
• CKD2: The percentage of patients on the CKD register whose notes have a record of blood pressure in the preceding 15 months
• BP4: The percentage of patients with hypertension in whom there is a record of the blood pressure in the preceding nine months
• EPILEPSY 6: The percentage aged 18 years and over on drug treatment for epilepsy who have a record of seizure frequency in the preceding 15 months
• DM22: The percentage of patients with diabetes who have a record of eGFR or serum creatinine in the preceding 15 months
• THYROID2: The percentage of patients with hypothyroidism with thyroid function tests recorded in the preceding 15 months
• AF2/4: The percentage of patients with atrial fibrillation with ECG or specialist confirmed diagnosis