Dr Dominic Horne reviews the asthma indicators in the QOF 2012/13 and highlights how their implementation could help to reduce asthma morbidity and mortality
Asthma is a common chronic condition that affects over 4 million adults and 1 million children in the UK.1 It is associated with significant morbidity and mortality: in 2009, more than 1000 deaths were related to asthma, 12 of which occurred in children.1 It is estimated that 75% of hospital admissions for asthma and 90% of deaths related to the condition are preventable with optimal care.1 The National Review of Asthma Deaths, led by the Royal College of Physicians (RCP), started on 1 February 2012 and continues until 30 January 2013. Its aim is to evaluate systematically every death related to asthma in the UK during this 12-month period in order to better: '… understand why people of all ages die from asthma so that recommendations can be made to prevent deaths from asthma in the future … and to provide a more robust body of evidence on which to build our understanding of how life-threatening situations arise and how they can be avoided in future.'2
Asthma has been included in the quality and outcomes framework (QOF) since its inception in 2004. The latest set of QOF indicators (see Table 1), which came into effect on 1 April 2012, includes two new indicators for asthma; these replace two retired indicators and include a change to the threshold for another indicator.3
The overall number of points allocated to asthma remains unchanged at 45. The average number of points achieved nationally for asthma increased slightly from 98.1% in 2009/10 to 98.7% in 2010/11.4
NICE has been responsible for the development of new indicators for QOF since 2009.5 This allows for a systematic evaluation of all available evidence including NICE clinical guidelines, and increasingly, its quality standards. The quality standard for asthma is currently in preparation—a draft version will be published for consultation on 28 August 2012, with the final version due for release in February 2013.6 Another valuable source of evidence for asthma is the well-established guideline from the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN), which was most recently updated in January 2012.7 The new version includes updates relating to monitoring, pharmacological management, and emergency treatment.
|Table 1: QOF indicators for and relating to asthma3|
|No.||Clinical indicator||Points||Payment stages|
|ASTHMA 1||The practice can produce a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months||4||-|
|ASTHMA 8||The percentage of patients aged 8 years and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility||15||45–80%|
|ASTHMA 10||The percentage of patients with asthma between the ages of 14 and 19 years in whom there is a record of smoking status in the preceding 15 months||6||45–80%|
|ASTHMA 9||The percentage of patients with asthma who have had an asthma review in the preceding 15 months that includes an assessment of asthma control using the three RCP questions||20||45–70%|
|SMOKING 5||The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder, or other psychoses whose notes record smoking status in the preceding 15 months||25||50–90%|
|SMOKING 6||The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder, or other psychoses who smoke whose notes contain a record of an offer of support and treatment within the preceding 15 months||25||50–90%|
|MEDICINES 6||The practice meets the PCO prescribing adviser at least annually and agrees up to three actions related to prescribing||6||-|
|MEDICINES 10||The practice meets the PCO prescribing adviser at least annually, has agreed up to three actions related to prescribing and subsequently provided evidence of change||4||-|
|RCP=Royal College of Physicians; CHD=coronary heart disease; PAD=peripheral arterial disease; TIA=transient ischaemic attack; COPD=chronic obstructive pulmonary diseae; CKD=chronic kidney disease; PCO=primary care organisation|
ASTHMA 1 is the only indicator in the asthma domain that remains unchanged. It is imperative to have an accurate and up-to-date register of patients diagnosed with asthma to ensure that they are reviewed regularly. Due to the possibility of variable and intermittent symptoms in individuals with asthma, it has been pragmatically decided, for the purposes of QOF, to exclude patients with a diagnostic label of asthma who have not been prescribed any inhalers in the previous 12 months.3 Conversely, it is worth searching for patients who have been prescribed inhalers, but have no formal diagnosis.
For verification of QOF claims, a practice's reported prevalence may be compared with expected levels. It is possible for practices to check this for themselves by referring to the Association of Public Health Observatories (APHO) website, which offers detailed data on this and many other comparators, including achievement of QOF targets.8
The content of indicator ASTHMA 8 has not been changed, but the minimum threshold has been increased from 40% to 45%. It is necessary to have an objective assessment of variability—over time or in response to therapy—in order to minimise the risk of under- and overdiagnosis and under- and overtreatment. Such objective assessment can be very difficult to achieve in younger children, hence the age cut-off of 8 years for this indicator.
A proportion of patients on the chronic obstructive pulmonary disease (COPD) register (usually no more than 15%) will have a co-existing diagnosis of asthma, and it is perfectly legitimate for these individuals to be recorded in both registers.3 Such patients will demonstrate reversibility of at least 400 ml of forced expiratory volume in 1 second (FEV1), but will not return to 80% of predicted normal and will almost inevitably have a significant smoking history.
ASTHMA 10 replaces ASTHMA 3 from the 2011/12 QOF indicators. Although the wording is identical, the minimum threshold has been raised from 40% to 45%. Smoking is a significant risk factor for the development of chronic respiratory disease and smoking as a teenager increases the risk of developing persistent asthma.3 Sadly, many young people start smoking at this age, so it is important to discuss smoking and its associated risks on a regular basis and to offer age-appropriate smoking-cessation support.9
ASTHMA 9 is new for 2012/13 and is an amendment of the former indicator, ASTHMA 6 (the percentage of patients with asthma who have had an asthma review in the preceding 15 months). It is now necessary to incorporate the three Royal College of Physicians (RCP)questions (see Box 1) into the annual review.10 A response of 'No' to all three questions is consistent with well-controlled asthma.11 For the purposes of reporting, the answers to all three questions must be coded separately and on the same date as the asthma review.
The use of the RCP questions is in line with the BTS/SIGN recommendations,7 as patient-reported measures of control are recognised to be just as important as more objective measures such as peak flow and spirometry. The annual review should also include the following elements:
- asking about smoking status
- assessing inhaler technique
- measuring peak flow (with review and documentation of best peak flow)
- discussing concordance with regular preventer therapy, if appropriate
- enquiring about symptoms of rhinitis.
All of the above factors can have an impact on asthma control and in turn lead to avoidable morbidity and, in a tragic minority, mortality. Other clues to poor control include frequent requests for reliever medication, prescriptions for courses of oral steroids, and attendances at accident and emergency departments or hospital admissions.
The annual review should be carried out by a healthcare professional with appropriate training.12 A degree of flexibility in the timing of appointments for asthma reviews, rather than insisting on attendance at rigid 'asthma clinics', may help to encourage attendance.13
|Box 1: The Royal College of Physicians 'three questions'|
In the last month:
SMOKING 5 and SMOKING 6 replace SMOKING 3 and SMOKING 4, respectively. For both indicators, peripheral arterial disease (PAD) has been added to the list of conditions and the minimum threshold has been raised from 40% to 50%. The number of points allocated to each indicator has been reduced from 30 to 25.3
For MEDICINES 6 and 10, it is possible to look at prescribing of steroid inhalers alone and in combination with long-acting beta2agonists. Two areas are particularly worthy of consideration:
- whether all patients are on the correct management step (see Table 2), as it is common for treatment to be stepped up during an acute episode but not stepped down again once control has improved6
- whether the most cost-effective inhaler is being prescribed; although, of course, a number of factors should be considered when deciding which drug and device to choose, with cost being only one of these.6,14
Asthma would be an eminently suitable condition to look at for the purposes of QOF quality and productivity (QP) 9–11 and the new QP 12–14 indicators relating to accident and emergency attendance. There is great potential to reduce both unscheduled admissions and attendances at accident and emergency departments for patients with asthma by providing consistent, well-structured care.15
|Table 2: Pharmacological management steps7|
|1||Mild intermittent asthma||8794|
|2||Introduction of regular preventer therapy||8795|
|3||Initial add-on therapy||8796|
|4||Poor control on moderate dose of inhaled steroid plus add-on therapy||8797|
|5||Continuous or frequent use of oral steroids||8798|
Currently, NICE is considering two potential new asthma indicators for 2013/14.16 The first is an amendment to ASTHMA 8 to: 'the percentage of patients, 5 years and over, newly diagnosed as having asthma from 1 April 2011 in whom there is a record that the diagnosis of asthma has been made supported by the current BTS/SIGN guidelines.' The second is a completely new indicator proposed by the Primary Care Respiratory Society: 'the percentage of children reaching the age of 5 years after or on 1 April 2011 with an existing diagnosis of asthma in whom there is a record that the diagnosis of asthma has been reviewed and confirmed (supported by the current BTS/SIGN guidelines) within 15 months of becoming 5 years.'
Pilots and much detailed discussion have been held around potential indicators relating to structured asthma education (SAE) and written asthma personal action plans (WAPs).17 Feedback from the practices involved in pilots suggested concerns over workload, issues with regard to targeting of these interventions towards certain subgroups (for example, only patients at or above a certain management step and only patients with brittle or poorly controlled asthma), and the need to standardise the content of SAE and WAPs. Data relating to admission avoidance and to overall cost effectiveness were also felt to be lacking. However, there is good evidence indicating that WAPs can help to reduce asthma-related admissions18 and deaths,19 and in my view it is inevitable that an indicator, which includes WAPs in some form, will be added to the QOF in the foreseeable future.
Worcestershire has an excellent local enhanced service (LES) for asthma, which focuses on the provision of WAPs for patients at step 2 of the BTS/SIGN guideline or above and those who have had a recent admission or attendance at an accident and emergency department. Special training is organised for practice nurses delivering this care. Results from the first year showed a reduction in asthma-related admissions from 0.95 per 1000 in 2010/11 to 0.80 per 1000 in 2011/12 (Nisha Sankey, personal communication, 9 July 2012), although it is too early to demonstrate confidently any causal relation. Nevertheless, the feeling is that the LES has a positive impact and provides a model that could be adopted more widely.
The Department of Health 2011 outcomes strategy for COPD and asthma states as an objective: ' ... that people with asthma, across all social groups, will be free of symptoms because of prompt and accurate diagnosis, shared decision making regarding treatment, and ongoing support as they self manage their own condition and to reduce the need for unscheduled health care and risk of death.' 20 The provision of well-planned and well-delivered personalised care for individuals with asthma within primary care is central to achieving this laudable goal. In 2008, mortality from asthma in the UK was 50% higher than the European average.20 Although the QOF helps to ensure certain basic aspects of care, evidence of a reduction in health inequalities is lacking.21 Ensuring that the care delivered is patient centred and based on the best available evidence will help to improve quality of life and outcomes while at the same time achieving financial savings for the NHS.
- Asthma UK website. Facts for journalists. www.asthma.org.uk/news-centre/facts-for-journalists (accessed 23 July 2012).
- Royal College of Physicians website. National review of asthma deaths. www.rcplondon.ac.uk/projects/national-review-asthma-deaths (accessed 23 July 2012).
- British Medical Association. NHS Employers. Quality and outcomes framework 2012/13. London: BMA, NHS Employers, 2012. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qofchanges2012.jsp#
- The NHS Information Centre. Quality and outcomes framework achievement data 2010/11. London: The Information Centre for Health and Social Care, 2011. Available at: www.ic.nhs.uk/webfiles/publications/002_Audits/QOF_2010-11/QOF_Achievement_and_Prevalence_Bulletin_2010_11_v1.0.pdf
- National Institute for Health and Care Excellence. Developing clinical and health improvement indicators for the quality and outcomes framework (QOF). Interim process guide. London: NICE, 2009. Available at: www.nice.org.uk/media/742/32/QOFProcessGuide.pdf
- National Institute for Health and Care Excellence website. Asthma (including children and young people). www.nice.org.uk/guidance/qualitystandards/indevelopment/Asthma.jsp (accessed 30 July 2012).
- British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 101. Edinburgh: SIGN, 2012. Available at: www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx
- Association of Public Health Observatories website. APHO general practice profiles. www.apho.org.uk/PRACPROF/ (accessed 10 July 2012).
- National Institute for Health and Care Excellence. Smoking cessation in young people: should we do more to help young smokers to quit? London: NICE, 2000. Available at: www.nice.org.uk/nicemedia/documents/smokingcessation_youngpeople.pdf
- Pearson M, Bucknall C, editors. Measuring clinical outcomes in asthma: a patient focused approach. London: Royal College of Physicians, 1999.
- Thomas M, Gruffydd-Jones K, Stonham C et al. Assessing asthma control in routine clinical practice: use of the Royal College of Physicians '3 questions'. Primary Care Respiratory J 2009; 18: 83–88.
- Upton J, Madoc-Sutton H, Sheikh A et al. National survey on the roles and training of primary care respiratory nurses in the UK in 2006: are we making progress? Primary Care Respiratory J 2007; 16: 284–290.
- Primary Care Respiratory Society UK. Opinion No. 23: asthma review. Leeds: PCRS-UK, 2011. Available at: www.pcrs-uk.org/opinions/asthma_review_final.pdf
- National Collaborating Centre for Primary Care. Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. London: RCGP, 2009. Available at: publications.nice.org.uk/medicines-adherence-cg76/patient-centred-care
- Purdy S. Avoiding hospital admissions: what does the research evidence say? London: The King's Fund, 2010. Available at: www.kingsfund.org.uk/publications/avoiding_hospital.html
- National Institute for Health and Care Excellence. QOF Advisory Committee recommendations for indicator development for potential inclusion on the NICE menu for the 2013/14 QOF. London: NICE, 2011. Available at: www.nice.org.uk/media/916/9D/TopicsForFurtherDevelopment201314QOF.pdf
- National Institute for Health and Care Excellence. Primary care quality and outcomes framework indicator advisory committee meeting June 2011. London: NICE, 2011. Available at: www.nice.org.uk/media/717/DD/QOF_Independent_Primary_Care_QOF_Indicator_Advisory_Committee_080611_unconfirmed_minutes.pdf
- Gibson P, Powell H, Coughlan J et al. Self-management education and regular practitioner review for adults with asthma (Cochrane Review). The Cochrane Library, Issue 1, 2003. London: John Wiley & Sons Ltd.
- Abramson M, Bailey M, Couper F et al. Are asthma medications and management related to deaths from asthma? Am J Respir Crit Care Med 2001; 163 (1): 12–18.
- Department of Health. An outcomes strategy for chronic obstructive pulmonary disease (COPD) and asthma in England. London: DH, 2011. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127974
- Dixon A Khachatryan A, Wallace A et al. Impact of quality and outcomes framework on health inequalities. London: The King's Fund, 2011. Available at: www.kingsfund.org.uk/publications/impact_of_quality.html G