Copperfield offers NICE his brainwave for a new QOF indicator: ‘Retrospective analysis of medication compliance in newly dead patients’
On the back of the fact that I’m sometimes criticised for being an angry man dementedly shouting from the sidelines rather than ever suggesting anything constructive, plus because it’s been really quiet this morning, I decided to email this suggestion for a new QOF indicator to NICE.
In case you didn’t realise, you can do it too. You’ve got until September 20. My nightmare scenario, of course, is that it’s accepted. I’ll let you know….
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Retrospective analysis of medication compliance in newly dead patients
Description of topic suggestion idea
Please use this box to provide a description of your suggested topic for new QOF indicators based on NICE or other NHS Evidence accredited sources.
The idea would be that the GP should do a post-death review, within one month of the event, of a patient’s pre-death compliance with medication*.
It is well recognised that failure to comply with therapeutic regimes is common (Royal Pharmaceutical Society of Great Britain 1995; Kafka, F, A Country Doctor, 1919). When this affects drugs used for primary or secondary cardiovascular prevention, such as antihypertensives, or statins, the end result may be premature death.
* The idea would be not to use practice computer records as this skews the figures by revealing only whether the patient has been collecting prescriptions. Actual assessment of compliance would require a home visit to check kitchen cupboards, backs of sofas etc for unused drugs/unopened packs. This would need to take placed unannounced, otherwise the relatives might have time to hide the evidence and therefore might require legislation to enable GPs to break into the homes of the recently bereaved in the dead of night.
How common is the condition relating to the recommendation(s) or suggestion?
Death is universally recognised as being common and 100% fatal.
Medication used in primary or secondary cardiovascular prevention reduces morbidity and mortality and, when taken correctly, for long enough and in large enough quantities, may enable patients to live forever.
Is the condition commonly diagnosed/treated/monitored in primary care?
Death is commonly diagnosed in primary care, although treatment remains controversial. The diagnostic use of time is not these days recommended, largely on account of the smell. Death rates are monitored by the PCT, but this is merely to pick up homicidal GPs rather than spot poor compliance in patients.
Which UK health priority area (if any) does the recommendation or suggestion link to?
This is an area of major public health and economic concern. The negative health impact of poor compliance has been outlined above. The waste of money arising from unused medication has been well documented.
A QOF indicator of this sort would address these areas in the following way:
1) Reminding GPs of the importance of compliance
2) Empowering GPs to perform robust follow up of the freshly dead and rewarding them for so doing
3) Providing leverage for GPs in their interactions with the pre-dead and their compliance on the basis that patient will be aware that they will be subject to post-death scrutiny
4) Potential powerful public health message – I could envisage a hard-hitting poster campaign featuring a recently deceased cardiac patient and the message: ‘THESE ARE THE PILLS THAT THIS MAN DIDN’T TAKE – NOW HE’S DEAD’
Relevance to health inequalities
Dead patients are cruelly neglected in current health care services and represent a large but buried example of health inequality. Indeed, GPs have no contractual obligation to provide general medical services of any sort to patients after they’ve died, and this QOF initiative would be the first step in resolving this anomaly.
Clinical Effectiveness evidence
The vast number of QOF points related to medication use and monitoring for primary and secondary prevention provides overwhelming evidence that this approach must make sense.
Cost Effectiveness evidence
Helping people to live long enough to be able to sit drooling in front of Jeremy Kyle in nursing homes rather than sit in an urn on the fireplace has got to be financially prudent, though I haven’t actually worked out the figures.
Is the recommendation(s) or suggestion already part of current clinical practice?
Can the recommendation(s) or suggestion be measured in a clear, reproducible and precise manner?
I believe I just have.
Is there any other information you would like to provide in support of your suggestion that does not relate to the above areas?
The above outline represents a process QOF. If successful, it could be broadened to encompass outcomes eg ‘The proportion of kitchen cupboard space filled with unused drugs should be less than 50% of the total kitchen storage space (including bread bin)’ (4 points).
‘Sick Notes’ by Dr Tony Copperfield is out now, available from Monday Books.
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