QOF exception reporting for Scotland 2013/14
Published at www.isdscotland.org/qof on 30th September 2014
“Questions & Answers” explanatory document
List of questions and topics
Click on a topic or question in the list below to go straight to that section. This document can be read sequentially, or in any order using the hyperlinks provided.
1 Introduction 2
1.1 What is this text about? 2
1.2 What is Exception Reporting? 2
1.3 Which parts of the QOF does exception reporting apply to? 3
2 Some Data Definitions 4
2.1 Registers 4
2.2 Denominators 5
2.3 Numerators 5
2.4 Exclusions 5
2.5 Exceptions 6
3 Presentation of data within this publication 7
3.1 Which QOF indicators are included in this publication? 7
3.2 How are patients counted as exclusions or exceptions? 8
3.3 Why can a breakdown of exceptions by exception reason not be shown? 8
3.4 What numbers do the tables contain? 8
3.5 Why are small numbers important? 10
3.6 Why are some practices not included in these data? 10
4 Commentary on the observed exception reporting rates 12
5 Annex A: Full list of criteria for exception reporting 14
6 Annex B: QOF Business Rules and exception reporting 15
Users of Scotland’s exception reporting data are strongly urged to read the text provided here before accessing the exception reporting tables
1 Introduction
1.1 What is this text about?
This text has been prepared to accompany QOF exception reporting data for Scotland for 2013/14. The nature and contents of the QOF are explained at www.isdscotland.org/qof and elsewhere, and are not reintroduced here. Although many of the concepts discussed in this text are applicable across the UK, data availability and detailed interpretation may vary from country to country. Those wanting to use exception reporting data from elsewhere in the UK should consult the relevant web pages for that country. Links to QOF reporting for other UK countries are available through www.isdscotland.org/qof.
QMAS (the IT system that originally supported the QOF payment process in Scotland between 2004/05 and 2009/10) was not originally designed to deliver information about exception reporting. However, the functionality was revised in time for the 2005/06 QOF year to allow summary information on the levels of exception reporting to be generated. From 2010/11 QMAS has been replaced by the QOF Calculator system which has been designed to deliver information on exception reporting from implementation. Therefore, exception reporting data are available from 2005/06 where relevant to the indicator.
Users of Scotland’s exception reporting data are strongly urged to read the text provided here before accessing the exception reporting tables
1.2 What is Exception Reporting?
The concept of exception reporting was included in the Quality and Outcomes Framework in order that practices, whilst pursuing the quality improvement agenda, would not be penalised for patient characteristics that were beyond their reasonable control.
When patients are exception reported from an indicator, they are not included in the calculation of a practice’s achievement against that indicator. Reasons why a patient might be exception reported include: - the treatment not being clinically appropriate for the patient, the patient not attending for treatment, the patient refusing to have the treatment, or the patient only having been diagnosed/registered with the practice very recently. A fuller list of the criteria, as agreed within the new General Medical Services contract, with links to QOF exception reporting guidance, are shown in Annex A: Full list of criteria for exception reporting
1.3 Which parts of the QOF does exception reporting apply to?
To see which parts of the QOF exception reporting applies to, please refer to Which QOF indicators are included in this publication?
2 Some Data Definitions
The QOF exception reporting data for the QOF need to be understood within the context of other concepts applicable to these data. The following is a summary of key terms and definitions as relevant to exception reporting during 2013/14.
2.1 Registers
Registers relate to each of the indicator groups within the clinical domain of the QOF, there is only one indicator group which has more than one register in 2013/14. The Heart Failure indicator group has two registers, Heart Failure and a second register refers specifically to Left Ventricular Dysfunction (LVD). In years prior to 2013/14 Depression, had separate registers for indicators referring to a new diagnosis of depression and for conditions assessed for depression but this is no longer the case and only new diagnosis of dementia features in the 2013/14 QOF registers.
In all there are 24 registers relating to clinical indicators for 2013/14 QOF data:
· Asthma
· Atrial Fibrillation
· Cancer
· CHD (Coronary Heart Disease)
· CKD (Chronic Kidney Disease)
· COPD (Chronic Obstructive Pulmonary Disease)
· CVD (Primary Prevention of Cardiovascular Disease)
· Dementia
· Depression: new diagnosis of depression
· Diabetes
· Epilepsy
· Heart Failure
· Hypertension
· Hypothyroidism
· Learning Disabilities
· LVD (Left Ventricular Dysfunction). This is part of the Heart Failure indicator group.
· Mental Health
· Obesity
· Osteoporosis
· Palliative Care
· Peripheral Arterial Disease (PAD)
· Rheumatoid Arthritis
· "Smoking" (conditions assessed for smoking)
· Stroke & TIA (Transient Ischaemic Attack)
Information systems underpinning the QOF (currently QOF Calculator in the case of Scotland) hold, for each practice participating in the QOF, the numbers of patients on each of these registers. For example, there is a register count for the total number of people on each practice list who have CHD. Register totals, as a proportion or percentage of the total practice list size, are used as a measure of raw disease prevalence. Scotland’s practice-level prevalence rates for 2013/14 are published as part of the achievement publication at www.isdscotland.org/qof.
2.2 Denominators
An indicator denominator is the number of patients who can appropriately be included in the measurement, monitoring, treatment, outcome etc. as identified for a specific QOF indicator. Conceptually, denominators for clinical indicators are subsets of the relevant registers, the subsets being arrived at as follows:
· Some patients are EXCLUDED from the denominator due to the indicator definition (see the explanation of Exclusions, below).
· Some patients are EXCEPTION REPORTED from the denominator on the basis of one of the criteria agreed as part of the new GMS contract (see What is Exception Reporting? or Annex A: Full list of criteria for exception reporting for more details)
For the cervical screening indicator CS002 and the Sexual Health indicators, CON002 and CON003, the practice “target population” for that service applies, rather than a “register”. The target population for CS002 is the number of females who are aged 20 to 60 and are thus normally eligible to be called/recalled for cervical smear tests (NB the age bracket is different elsewhere in the UK). The target population for Sexual Health is the number of females aged under 55 who have been prescribed any method of contraception at least once in the last year, or other appropriate interval. Note however that CS002, CON002 and CON003 are not included in this publication – refer to Which QOF indicators are included in this publication? for more information.
For indicators BP001 the total number of persons registered with the practice is the baseline from which the denominator is drawn. Note however that the BP001indicator is not included in this publication – refer to Which QOF indicators are included in this publication?
2.3 Numerators
An indicator numerator is the number of those in the denominator who meet the specific indicator success criteria – so if the numerator is 16 and the denominator is 20, the practice will have 80% achievement against that indicator.
2.4 Exclusions
As noted within the explanation of Denominators, above, exclusions are those patients who are included on a particular register, but who for definitional reasons, are not included in a specific QOF indicator denominator. For example, an indicator (and therefore the denominator) may refer only to patients of a specific age group, patients with a specific status (e.g. those who smoke), or patients with a specific length of diagnosis.
To illustrate, the indicator ASTHMA004 refers only to those patients with asthma who are aged between 14 and 19. Therefore, asthma patients who do not fit into this age bracket are excluded from the denominator for this indicator on the basis of the indicator definition.
2.5 Exceptions
Exceptions are patients who are on the relevant QOF register, and who would ordinarily be included in the indicator denominator (after exclusions for definitional reasons, see above). However, they are excepted from the indicator denominator because they meet at least one of the exception criteria outlined in the What is Exception Reporting? above. Although they may meet more than one of the criteria, they will only be counted against the first one found within their clinical record. The total number of exceptions is the total number of patients excepted, NOT the total number of individual reasons for patients being excepted.
It can be seen from this definitional summary that it is not always appropriate to infer levels of exceptions from the differences between QOF register totals and indicator denominators.
3 Presentation of data within this publication
3.1 Which QOF indicators are included in this publication?
Exception reporting applies to those indicators having numerators and denominators, and for which points are awarded on a sliding scale according to the level of achievement reached by the practice. The main group of indicators for which exception reporting is possible are the clinical indicators, apart from the register indicators (e.g. exception reporting does not apply in ASTHMA001 but it does apply to all the other individual Asthma indicators). This is because achievement for register indicators is not awarded on a sliding scale therefore there is no need to have numerators, denominators, exceptions or exclusions for these indicators. Exception reporting data for all relevant clinical indicators are the focus of this publication.
There are currently two clinical indicator groups where there is no exception reporting. These are Obesity and Palliative Care. For Obesity there is only the register indicator within the group; with no numerator or denominator in this indicator, exception reporting is not applicable. With Palliative Care, neither indicator is such that a numerator or denominator exists, therefore exception reporting again does not apply.
The cervical screening indicator CS002 (within the additional services domain) is also subject to exception reporting. However, it is not included in this publication, as CS002 exception reporting data for Scotland are not consistently available. This is because the data for this indicator are sourced from Scotland’s National Cervical Screening System, the numerators, denominators and exceptions required for QOF being entered manually into QOF Calculator.
Also within the additional services domain, the Sexual Health indicators CON002 and CON003 are subject to exception and exclusion reporting against them in QOF Calculator. However, neither is included in exception reporting tables for this publication. This is because for both of these indicators (CON003 in particular) exclusions dominate those who were omitted from the denominator. The main reason for exclusion was that the initial prescription (oral or patch contraceptive for CON002 and emergency contraception for CON003) was outwith the relevant timescales for the indicators. Both indicators have relatively low numbers of exceptions reported against them and therefore they may be of fairly limited interest from a clinical perspective; however these data are available on request.
Exception reporting also applies to the Blood Pressure indicator (BP001) however this indicator is not included in this publication. This is because the exception reporting rates are influenced entirely by recent registrations to the practice, which means that they are of relatively less interest from a clinical or quality improvement viewpoint.
3.2 How are patients counted as exclusions or exceptions?
The concepts of Exclusions or Exceptions from indicator denominators have been introduced above. However, the distinction between the two is not explicit within QOF Calculator. Therefore, a pragmatic separation of the two has been defined in order to present a clearer picture of exception reporting under the criteria agreed in the GMS contract (see What is Exception Reporting? or Annex A: Full list of criteria for exception reporting). A separate exceptions mapping table (in excel format) shows the detailed exception/exclusion reasons and how they have been grouped into exclusions or exceptions, for the purposes of this and the corresponding exception reporting publications from elsewhere in the UK.
3.3 Why can a breakdown of exceptions by exception reason not be shown?
The potential for publishing exception reporting data is limited due to the way in which the data are recorded. It is possible to use data to obtain the total number of patients excepted from a specific indicator. However, the way in which the data are supplied to means that it is not possible to break exceptions down by each of the individual criteria outlined in Annex A: Full list of criteria for exception reporting nor to more detailed reasons such as individual Read Codes (clinical codes) entered for exceptions.
There are two reasons for this:
1) Any individual patient can be associated with more than one of the exception criteria, but only one such reason needs to be identified during the process of submitting data from GP clinical systems to QOF Calculator in order to except this patient from inclusion in the indicator denominator.
2) The testing of GP clinical system compliance with QOF Business Rules (such that they can supply data appropriately to QOF Calculator and other national QOF systems) is primarily focused on ensuring that data values used for achievement calculations are accurate for payment purposes. Any testing of the order of sequencing (i.e. the order whereby systems check for different exception codes or criteria) is secondary to this purpose. Different GP clinical information systems may follow different sequencing without this impacting on payment accuracy.
Clearly therefore, the QOF Calculator system cannot guarantee to count the total number of individual reasons for a patient being excepted from an indicator denominator; what it counts are the numbers of patients excepted, according to the first reason found when the patient records are queried. Thus, an analysis of the breakdown of exception reporting according to each individual reason is impossible.