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Quick QOF tips, 2013-4: Rheumatoid arthritis (RA)

This year, the main addition to QOF is the rheumatoid arthritis disease area.

This consists of four separate indicators, worth a total of 18 QOF points:

- RA1: Have a register of patients with Rheumatoid Arthritis aged 16+

- RA2: Do an annual review on these patients, face to face

- RA3: Add a validated CVD Risk assessment  Read code to the record of  these patients aged 30-84, annually

- RA4: Patients aged 50-90 should have had an Osteoporosis risk score calculated & coded every 2 years.

This article will introduce the new codes, and provide advice on achieving them.

RA1: Establish a register of those patients aged 16+ with any rheumatoid arthritis (1 point)

Most of the expected codes are ‘valid’ for this indicator, including the following:

  • N040% Rheumatoid arthritis and sub-types, including N040P (sero-negative RA)
  • N041.   Felty’s syndrome
  • N042% Other Rheumatic Arthropathy with visceral or systemic involvement
  • N047.   Sero-positive RA
  • Nyu11   [X] Other Seropositive Rheumatoid Arthritis
  • Nyu12   [X] Other Specified Rheumatoid Arthritis

Below are listed examples of some non-valid Read codes for RA1:

  • N043. Juvenile rheumatoid arthritis - Still’s disease
  • N04y1 Sero-negative arthritis

Basically, any code that implies children’s disease, and anything that doesn’t implicitly or explicitly describe the arthritis as being rheumatoid in nature is excluded.

RA2:  Annual review

Patients need an annual review, which must be face to face. The only valid Read code for this is 66HB0: (‘rheumatoid arthritis annual review’). It’s worth five points with a threshold of 40-90%.

During an RA2 review you should:

- Assess disease activity (e.g. ESR, CRP)

- Discuss DMARDS if relevant

- Discuss a need to refer for surgery

- Ask how much the disease is affecting their life (e.g. employment, education)

- Ask if any cross-referral to other members of the MDT would be relevant?

These five items are noted in the blue book to be things that a visiting team would want to see addressed at the review, ‘as a minimum’.

RA3: Add a CVD risk score

All RA patients aged 30-84 should have an annual CVD risk calculation added. This is worth seven points with thresholds of 40-90%. Patients with pre-existing CHD, CVA, TIA or Familial Hypercholesterolaemia are automatically excluded. The only valid Read code is 38DP. (the ‘QRISK2 CVD ten-year risk score’) - worth seven points (40-90). Note that other CVD risk scores such as QRISK (38DF) and Framingham CVD risk score (38DR) are all not valid.

There are some exception codes that may be applied for this indicator:

  • 8IEV. QRISK2 cardiovascular disease risk assessment declined
  • 9NSB. Unsuitable for QRISK2 CVD risk assessment.              

Providing you’re using the QRisk2 (2012 version), the calculator works right up to age 84, so all patients can have a calculation done. Other calculators may only work up to age 74. In addition, only the QRisk2 calculator takes RA into proper account when calculating the risk score.

RA4 : Calculate and add a Fracture Risk score in the patients aged 50-90, every two years

There are five points available for this indicator with thresholds of 40-90%. The three valid codes are:

  • 38GR. QFracture risk calculator (though this only ‘works’ up to age 84)
  • 38DB. WHO FRAX 10-year hip fracture probability score
  • 38DC. WHO FRAX 10-year osteoporotic fracture probability score

The FRAX score can be calculated using a free FRAX calculator and, like QFracture, also works for patients right up to age 90.

Three patient groups are excluded from the denominator for RA4:

- Any patient with pre-existing osteoporosis which was added > 2 years before this year’s Reference date are excluded. The Read codes defining osteoporosis are the same as in the osteoporosis ruleset (group 1).

- Those who have a DEXA scan ‘proving’ osteoporosis are also excluded, but only if coded > 24 months before the Reference date, (so, > 1.4.12 this year). The DEXA codes for this are identical to those used in the osteoporosis Business Rules for 2013 (group 2).

- Patients on valid Bone Sparing Agents (BSAs). These are also excluded. However, just as a final flourish, for some reason, evidence of the valid Read codes demonstrating the issue of these drugs is required to be between 30 months and 24 months before the Reference date (group 3).

Hopefully, most practices will have relatively small numbers of patients with rheumatoid arthritis, so the work involved to score these points should be relatively easy – once you understand the coding requirements.

Additional BSA valid codes

Some new valid codes have been added to accommodate patients being given bisphophonates in hospital. These additional codes apply equally in the rheumatoid ruleset & the Osteoporosis one. So, all previous BSA drugs from last year (version 24) are still valid, together with:

  • fo7..% (Zolendronic acid) (intravenous infusion)
  • 8BP1. Teriparatide therapy (subcutaneous injection)
  • 8B6c. Intravenous bisphosphonate prophylaxis. (This code could probably also be used where Ibandronic acid and Zolendronic acid are being given intravenously by hospital.)
  • 8B6b. Osteoporosis medication prophylaxis

You could also use the code,  fo7..% (zolendronic acid, intravenous infusion), but it seems highly unlikely that you would need to print a script for zolendronic acid rather than simply recording your patient’s hospital treatment details. 

This should allow practices to avoid being penalised for the odd patient who does have osteoporosis but who is being treated elsewhere.

For information on Dr Clay’s QOF Resource Disc go to

Dr Simon Clay is a GP in Erdington, Birmingham.