Professor Tim Stokes discusses the introduction of new clinical indicators in the QOF 2012/13 and also highlights those that have been replaced or refined
  • There are two new clinical domains in the QOF 2012/13 indicators: osteoporosis and PAD
  • The indicator set for osteoporosis focuses on the identification and management of patients who have a fragility fracture
  • The indicator set for PAD aims to:
    • improve the identification and management of people with this disease
    • ensure that all patients, including those without established risk factors already covered in the QOF, are managed for their cardiovascular risk
  • Replacement indicators have been developed for asthma and atrial fibrillation
  • The smoking domain has been extended to include recording of smoking status:
    • for patients with PAD (to include record of offer of support and treatment for current smokers)
    • in all patients aged over 15 years in the preceding 27 months (to include record of offer of support and treatment for current smokers).

NICE has managed a new process for developing QOF indicators since April 2009. This process has led to a number of significant changes to enable the QOF to deliver more rigorously developed indicators and act as a vehicle for quality improvement. NICE manages the process of developing clinical and health improvement indicators for the QOF and reviews the current indicator set.1,2 This includes consultation with individuals and stakeholder groups to publish an annual ‘menu’ of new, evidence-based indicators and making recommendations about existing indicators, including those that should be retired.

It is important to emphasise that NICE does not decide which indicators are to be included in the QOF, how many points they are worth, or what the thresholds should be. These continue to be negotiated by NHS Employers on behalf of the Department of Health and the British Medical Association General Practitioners’ Committee.

This article discusses the key changes to the QOF clinical indicators for 2012/13 (see Table 1). 3 The full list of clinical indicators is available on eguidelines.co.uk/qof. The new and replacement indicators were the subject of piloting in a representative sample of GP practices and subject to consultation in advance of their inclusion in the NICE menu of QOF indicators. It is outside the remit of NICE to change the value of QOF points or thresholds and these are not discussed. NICE also had no involvement in decisions to retire organisational domain indicators or in the development of Quality and Productivity (QP) indicators (these are summarised for completeness).

Retirement of existing QOF indicators

A key principle of the NICE-led QOF process is that indicators should be retired as appropriate. Two indicators have been retired in QOF 2012/13 (excluding those in the QP domain), releasing points to fund new and replacement indicators:3,4

  • CHD13—the percentage of patients with newly diagnosed angina (diagnosed after 1 April 2011) who are referred for specialist assessment
  • AF4—the percentage of patients with atrial fibrillation diagnosed after 1 April 2008 with electrocardiogram or specialist confirmed diagnosis).

CHD13 was retired due to technical problems with the indicator denominator.The rationale behind retiring indicator AF4 is that it has a stable level of achievement and that it relates to an activity promoting correct diagnosis of atrial fibrillation as opposed to one directly improving the health outcomes of affected people (e.g. antiplatelet or anticoagulation use).


Table 1: Key changes to QOF 2012/13: replacement and new indicators3,4*

2012/13 QOF ID

2011/12
QOF ID

2012/13 indicator wording

Points

Threshold

ASTHMA 9

ASTHMA 6

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%

AF5

NEW

The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHADS2 risk-stratification scoring system in the preceding 15 months (excluding those whose previous CHADS2 score is greater than 1)

10

40–90%

AF6

AF3

In those patients with atrial fibrillation in whom there is a record of a CHADS2 score of 1 (latest in the preceding 15 months), the percentage of patients who are currently treated with anticoagulation drug therapy or antiplatelet therapy

6

50–90%

AF7

AF3

In those patients with atrial fibrillation whose latest record of a CHADS2 score is >1, the percentage of patients who are currently treated with anticoagulation therapy

6

40–70%

OST1

NEW

The practice can produce a register of patients: 1. Aged 50–74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan; and 2. Aged 75 years and over with a record of a fragility fracture after 1 April 2012

3

OST2

NEW

The percentage of patients aged between 50 and 74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, who are currently treated with an appropriate bone-sparing agent

3

30–60%

OST3

NEW

The percentage of patients aged 75 years and over with a fragility fracture, who are currently treated with an appropriate bone-sparing agent

3

30–60%

PAD1

NEW

The practice can produce a register of people with peripheral arterial disease

2

PAD2

NEW

The percentage of patients with peripheral arterial disease with a record in the preceding 15 months that aspirin or an alternative antiplatelet is being taken

2

40–90%

PAD3

NEW

The percentage of patients with peripheral arterial disease in whom the last blood pressure reading (measured in the preceding 15 months) is ?150/90 mmHg

2

40–90%

PAD4

NEW

The percentage of patients with peripheral arterial disease in whom the last measured total cholesterol (measured in preceding 15 months) is ?5.0 mmol/l

3

40–90%

SMOKING 5

SMOKING 3

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

SMOKING 4

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%

SMOKING 7

RECORDS23

The percentage of patients aged 15 years and over whose notes record smoking status in the preceding 27 months

11

50–90%

SMOKING 8

NEW

The percentage of patients aged 15 years and over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months

12

40–90%

*Not all changes to the indicators are shown in this table (full tables can be found here)
RCP=Royal College of Physicians; DXA=dual energy X-ray absorptiometry; CHD=coronary heart disease; PAD=peripheral arterial disease; TIA=transient ischaemic attack; COPD=chronic obstructive pulmonary disease; CKD=chronic kidney disease

Replacement QOF indicators

Asthma

Patients with asthma now need to have a review that specifically includes the requirement to assess asthma control using the three Royal College of Physicians (RCP) questions (ASTHMA 9) as recommended in the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) guideline on asthma.5 Patients should be asked the following:

  • In the last month:
    • have you had difficulty sleeping because of your asthma symptoms (including cough)?
    • have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, or breathlessness)?
    • has your asthma interfered with your usual activities (for example, housework, work/school, etc)?

The questions must be asked at the same time and as part of the asthma review. A response of ‘No’ to all questions is consistent with well-controlled asthma.4 Use of the three RCP questions should mean that the patient’s own reported symptoms are recorded systematically and this should lead to better management of uncontrolled asthma.

Atrial fibrillation (AF)

Indicator AF3 (the percentage of patients with atrial fibrillation [AF] who are currently treated with anticoagulation drug therapy or antiplatelet therapy) has been replaced with two new indicators that promote appropriate management with antiplatelet or anticoagulant therapy (AF6 and AF7) (see Table 1). 4 There is also a new indicator (AF5), which promotes the systematic assessment of stroke risk in people with a diagnosis of AF.3,4

A key decision in the management of AF is whether or not to use anticoagulant rather than antiplatelet therapy and there is evidence that many patients with AF would benefit from anticoagulants, yet are not prescribed them.6 Assessment of future stroke risk is needed to make the correct decision as to whether anticoagulants should be used and AF5 therefore promotes the use of a validated and easy-to-use stroke risk stratification tool (CHADS2) for patients with atrial fibrillation. The revised CHADS2 system scores 1 point, up to a maximum of 6, for each of the following risk factors (except previous stroke or transient ischaemic attack, which scores double, hence the ‘2’):4

  • C—congestive heart failure (1 point)
  • H—hypertension (1 point)
  • A—age 75 years or over (1 point)
  • D—diabetes mellitus (1 point)
  • S2—previous stroke or TIA (2 points).

A score of 0=low risk, 1=moderate risk, and 2 or more=high risk.4

The first replacement AF indicator (AF6) promotes the use of either anticoagulant or antiplatelet therapy in people who are at moderate risk of future stroke as assessed by CHADS2 (score=1). The second replacement AF indicator, AF7, promotes the use of anticoagulant therapy in people at high risk of future stroke as determined by CHADS2 (score=2 or more).3,4 The use of a risk stratification tool is in line with NICE guidance7 and recent European Society of Cardiology (2010) guidance.8


New QOF indicators

Osteoporosis: secondary prevention of fragility fractures

Osteoporosis is a new clinical domain in the QOF.3,4 The focus of this indicator set is on the correct identification and management of patients who have had a fragility fracture. This should ensure that the risk of a subsequent osteoporotic fragility fracture is reduced (i.e. secondary prevention). Fragility fractures are fractures that result from low-level trauma—the World Health Organization has described this as a force equivalent to a fall from a standing height or less.9 Osteoporosis is a major risk factor for fragility fractures.

Indicator OST1 requires practices to produce a register of new patients aged over 50 years with a record of fragility fracture (after 1 April 2012)—for those aged 50 to 74 years, the diagnosis of osteoporosis needs to be confirmed by a dual-energy X-ray absorptiometry (DXA) scan.3,4 It is important that patients who have common osteoporotic fragility fractures—vertebral, hip (proximal femur) and wrist (distal radius) fractures—are assessed as to the nature of the injury and are referred for DXA scanning if fragility fracture has been clinically diagnosed. While the QOF does not require those aged over 75 years to have had a DXA scan prior to starting treatment for osteoporosis, it is good clinical practice to consider requesting such a scan in this group of patients.

The other two indicators for osteoporosis (OST2 and OST3) promote the use of bone-sparing agents (e.g. alendronate) in both age groups (50 to 74 years and over 75 years) to reduce subsequent fracture risk as recommended by both NICE10 and SIGN11 guidance. Bone-sparing agents should be used in combination with calcium and vitamin D supplementation.4 It is also important that patients with an osteoporotic fragility fracture also receive advice to reduce other modifiable risk factors such as the need to maintain adequate nutrition, perform regular weight-bearing exercise, stop smoking, and reduce excessive alcohol intake.

Peripheral arterial disease

Cardiovascular disease is defined as coronary heart disease, cerebrovascular disease (stroke/transient ischaemic attack), and peripheral arterial disease (PAD). However, to date the QOF has not addressed the secondary prevention needs of people with an established diagnosis of PAD. The PAD indicator set is based on SIGN12 and NICE13,14 guidance and aims to improve the identification and management of PAD and to ensure that all patients, including those without established risk factors already covered in the QOF (e.g. hypertension, diabetes) are managed for their cardiovascular risk. Thus patients with PAD should receive aspirin or an alternative antiplatelet (PAD2) and have their blood pressure (PAD3) and total cholesterol (PAD4) treated to levels recommended in the other QOF cardiovascular and diabetes domains (see Table 1).

Patients with PAD should also be advised to stop smoking and offered interventions to support them in doing so (referral to NHS stop smoking service plus pharmacotherapy); this is addressed in revisions to the smoking QOF indicator set (SMOKING 5 and SMOKING 6).3,4

Smoking

The QOF smoking clinical domain has been extended to include:3,4

  • an existing organisational domain indicator that promotes the recording of smoking status in all practice patients aged over 15 years (Records 23 has become SMOKING 7)
  • a new indicator that promotes the delivery of interventions to stop smoking in all practice patients (SMOKING 8).15 There is evidence that advice on smoking cessation provided by doctors and other healthcare professionals, particularly when they offer support and treatment, results in people being more likely to quit, and this is therefore recommended by NICE guidance.15

Quality and productivity indicators

The nine Quality and Productivity indicators are aimed at securing a more effective use of NHS resources through improvements in the quality of primary care in terms of peer review of outpatient referral, accident and emergency attendances (new for 2012/13 QOF), and emergency admission data.


Conclusion

Key changes for QOF in 2012/13 are new indicator sets for osteoporosis (fragility fracture) and peripheral arterial disease and changes to indicators in the atrial fibrillation, asthma, and smoking domains.

  1. 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
  2. Sutcliffe D, Lester H, Hutton J, Stokes T. NICE and the quality and outcomes framework (QOF) 2009–2011. Quality in Primary Care 2012 (in press).
  3. British Medical Association, NHS Employers. Summary of 2012/13 QOF changes. Available at: www.bma.org.uk/images/qofsummarychanges2012_v3_tcm41-210421.pdf
  4. British Medical Association. NHS Employers. Quality and outcomes framework guidance for GMS contract 2012/13. London: BMA, NHS Employers, 2012. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qofchanges2012.jsp#.T3rG2u1LKyE
  5. Scottish Intercollegiate Guidelines Network, British Thoracic Society. British guideline on the management of asthma. SIGN 101. Edinburgh: SIGN, 2011. Available at: www.sign.ac.uk/pdf/qrg101.pdf nhs_accreditation
  6. Ogilvie I, Newton N, Welner S et al. Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med 2010; 123: 638–645.
  7. National Institute for Health and Care Excellence. Atrial fibrillation: the management of atrial fibrillation. Clinical Guideline 36. London: NICE, 2006. Available at: www.nice.org.uk/nicemedia/pdf/CG036niceguideline.pdf
  8. The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology. Guidelines for the management of atrial fibrillation. Eur Heart J 2010; 31: 2369–2429. Available at: www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-afib-FT.pdf
  9. World Health Organization. Guidelines for preclinical evaluation and clinical trials in osteoporosis. Geneva: WHO, 1998. Available at: whqlibdoc.who.int/publications/1998/9241545224_eng.pdf
  10. National Institute for Health and Care Excellence. Alendronate, etidronate, risedronate, raloxifene, strontium ranelate, and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. Technology Appraisal 161. London: NICE, 2008. Available at: www.nice.org.uk/guidance/TA161 nhs_accreditation
  11. Scottish Intercollegiate Guidelines Network. Management of osteoporosis. SIGN 71. Edinburgh: SIGN, 2003. Available at: www.sign.ac.uk/guidelines/fulltext/71/index.html
  12. Scottish Intercollegiate Guidelines Network. Diagnosis and management of peripheral arterial disease. SIGN 89. Edinburgh: SIGN, 2006. Available at: www.sign.ac.uk/pdf/sign89.pdf
  13. National Institute for Health and Care Excellence. Hypertension: clinical management of primary hypertension in adults. Clinical Guideline 127. London: NICE, 2012. Available at: publications.nice.org.uk/hypertension-cg127 nhs_accreditation
  14. National Institute for Health and Care Excellence. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Clinical Guideline 67. London: NICE, 2010. Available at: publications.nice.org.uk/lipid-modification-cg67 nhs_accreditation
  15. National Institute for Health and Care Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. Public Health Guidance 10. London: NICE, 2008. Available at: www.nice.org.uk/PH010 nhs_accreditation G