NICE Indicator Programme. Consultation on proposed amendments to current QOF indicators

Transcription

1 NICE Indicator Programme Consultation on proposed amendments to current QOF s Consultation dates: 18 July to 1 August 2018 This document outlines proposed amendments to a small number of QOF s in the diabetes domain and a minor change to the current atrial fibrillation register. We welcome comments from stakeholders about the proposed changes to these s. Feedback from this consultation will be reviewed by the NICE Indicator Advisory Committee in August The proposed s may change following consultation. If you have any questions about this consultation please contact the NICE Indicator Team (s@nice.org.uk). QOF forms part of the GMS contract, and as such proposed changes to QOF are subject to negotiations between NHS Employers on behalf of NHS England and the BMA s General Practitioners Committee. 1 of 13

2 Contents Introduction... 3 NHS England s review of the QOF... 3 How to submit your comments... 3 Proposed changes to the QOF diabetes s... 4 Amendments to QOF s for diabetes explained... 6 Diabetes - Blood pressure in people without moderate or severe frailty... 6 Diabetes - HbA1c in people without moderate or severe frailty... 7 Diabetes - HbA1c in people with moderate or severe frailty... 8 Diabetes - Primary prevention of CVD in people without moderate or severe frailty.. 9 Diabetes Secondary prevention of CVD Proposed changes to the QOF atrial fibrillation s Atrial fibrillation AF resolved code References Appendix A: Consultation comments of 13

3 Introduction NHS England s review of the QOF In the Five Year Forward View Next Steps NHS England agreed to undertake a review of the QOF. The Report of the Review of the Quality and Outcomes Framework (NHS England, 2018) concluded that aspects of the current QOF are both valued and valuable, but noted a need to refresh the scheme. The review recommended that changes to the QOF should increase the likelihood of improved patient outcomes, decrease the likelihood of harm from overtreatment and improve the personalisation of care. In developing the report, a technical working group explored the feasibility and practical implications of developing diabetes s so that they differentially apply to patient groups with different care needs. In line with that work, this consultation proposes amending a small number of s in the diabetes domain. In addition we are also consulting on a minor change to the current business rules for the atrial fibrillation (AF) register. How we develop s and the purpose of the consultation All NICE s are developed in accordance with the NICE development process. A key part of this process is giving stakeholders the opportunity to comment on the proposed s and their intended use. How to submit your comments Please send your comments using the form available on the NICE website to s@nice.org.uk by 5pm on Wednesday 1 August of 13

4 Proposed changes to the QOF diabetes s The current QOF s for diabetes are applied across all people with diabetes aged 17 years and above. By applying the s to all people with diabetes regardless of co-morbidities it may inadvertently lead to both under-treatment and overtreatment (Kearney et al. 2017). People with diabetes with less complex care needs may be undertreated, whilst people with complex care needs may be at risk of overtreatment. Strain et al (2018) highlighted that intensive glucose lowering treatment has limited benefits for people with type 2 diabetes and may be dangerous for older people, commenting that the target should be modified to allow an individualised approach to care. They propose a care management approach that adjusts care according to an individual s frailty status with the intention of reducing complications and improving quality of life. Kearney et al (2017) highlighted that treatment that is not tailored to the individual can lead to polypharmacy, reduced quality of life and serious adverse effects. This is consistent with recommendations within the NICE guideline on multimorbidity, which highlights the importance of improving quality of life by reducing treatment burden and adverse events. From 1 July 2017, general practices are required by the GMS contract to use an appropriate tool, such as the Electronic Frailty Index (efi) to identify patients over the age of 65 who are living with moderate and severe frailty 1. The output from the tool should be seen as a guide only, the decision to use a moderate or severely frail code should be made by an experienced clinician. The introduction of routine identification of frailty can provide an opportunity to target and improve care and support for older people with the greatest need. As presented in table 1, we propose that a small number of diabetes s are stratified using routinely collected frailty data. 1 The efi tool (Clegg et al. 2016) has been validated in people aged years, it is for this reason that the aged of 65 years and over has been used in the proposed s 4 of 13

5 Table 1: Proposed amendment of current diabetes QOF s. Current QOF DM017: The contractor establishes and maintains a register of all patients aged 17 or over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed. DM003: The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmhg or less. DM002: The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmhg or less. DM004: The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less. DM006: The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with an ACE-I (or ARBs). DM007: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months. DM008: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 12 months. DM009: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months. DM012: The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 12 months. DM014: The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register. DM018: The percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 August to 31 March. Proposed amendment No amendments The percentage of patients with diabetes, without moderate or severe frailty, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmhg or less. The percentage of patients with diabetes aged 40 years and over, no history of CVD, and without moderate or severe frailty, who are prescribed a statin. No amendments The percentage of patients with diabetes and a history of CVD (excluding haemorrhagic stroke) who are prescribed a statin. The percentage of patients with diabetes, without moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months. The percentage of patients with diabetes, with moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months. No amendments No amendments No amendments 5 of 13

6 Amendments to QOF s for diabetes explained Diabetes - Blood pressure in people without moderate or severe frailty Proposed IND33: The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmhg or less. Existing QOF s DM003: The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmhg or less. DM002: The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmhg or less. Rationale for amending the A focus on people with no or mild frailty aims to: reduce under-treatment and support better control of biomedical targets in people with the greatest capacity to benefit. reduce iatrogenic harm in people with moderate or severe frailty and associated impact upon outcomes and resource utilisation. Indicator purpose allow greater professional engagement in determining individualised, patient centred care for people with moderate or severe frailty. Lowering blood pressure in people with diabetes reduces the risk of macrovascular and microvascular disease. Evidence base Type 1 diabetes in adults: diagnosis and management (2015) NICE guideline NG17, recommendation Type 2 diabetes in adults: management (2015) NICE guideline NG28, recommendation of 13

7 Diabetes - HbA1c in people without moderate or severe frailty Proposed IND34: The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months. Existing QOF s DM007: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months. DM008: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 12 months. DM009: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months. Rationale for amending the Indicator purpose A focus on people with no or mild frailty aims to: reduce under-treatment and support better control of biomedical targets in people with the greatest capacity to benefit. reduce iatrogenic harm in people with moderate or severe frailty and associated impact upon outcomes and resource utilisation. Improved glycaemic control in people with diabetes reduces the risk of macrovascular and microvascular disease. Evidence base Type 1 diabetes in adults: diagnosis and management (2015) NICE guideline NG17 recommendation, and Type 2 diabetes in adults: management (2015) NICE guideline NG28, recommendations and Diabetes (2016) NICE Quality Standard 6 statement 4 7 of 13

8 Diabetes - HbA1c in people with moderate or severe frailty Proposed IND35: The percentage of patients with diabetes with moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months. Existing QOF s DM007: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months. DM008: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 12 months. DM009: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months. Rationale for amending the Indicator purpose A focus on people with moderate to severe frailty aims to: reduce iatrogenic harm in people with moderate or severe frailty and associated impact upon outcomes and resource utilisation. allow greater professional engagement in determining individualised, patient centred care for people with moderate or severe frailty. An HbA1c of 75 mmol/mol or less will serve to avoid osmotic symptoms. Evidence base Type 1 diabetes in adults: diagnosis and management (2015) NICE guideline NG17, recommendation Type 2 diabetes in adults: management (2015) NICE guideline NG28, recommendation of 13

9 Diabetes - Primary prevention of CVD in people without moderate or severe frailty Proposed IND36: The percentage of patients with diabetes aged 40 years and over, no history of CVD, and without moderate or severe frailty, who are prescribed a statin. Existing QOF Rationale for amending the DM004: The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less. A focus on primary prevention in people with diabetes with no or mild frailty aims to reduce under-treatment and support better control of biomedical targets through individualised, patient centred care. It is acknowledged that this is not in line with NICE guideline CG181 recommendation , which advocates statin use when people with type 2 diabetes of any age have a 10-year QRISK2 score of 10% or greater. It is being proposed at consultation as a simple and pragmatic measure using readily available data that would not be dependent on QRISK2 scores being recorded. Indicator purpose Evidence base Statin therapies can help lower LDL cholesterol and prevent future cardiovascular events. Type 1 diabetes: Cardiovascular disease: risk assessment and reduction, including lipid modification (2014) NICE guideline 181, recommendations Type 1 and 2 diabetes: Management of diabetes (2010) SIGN guideline 116, section 8.3. Specific questions for consultation Given this does not wholly align with NICE guideline CG181, would you support it as a pragmatic measure that would reduce under treatment and aid primary prevention of CVD? Alternatively, should the be constructed to align with the NICE guideline and use QRISK2 scores to identify the appropriate people with type 2 diabetes? 9 of 13

10 Diabetes Secondary prevention of CVD Proposed IND37: The percentage of patients with diabetes and a history of CVD (excluding haemorrhagic stroke) who are prescribed a statin. Existing QOF Rationale for amending the Indicator purpose Evidence base DM004: The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less. A focus on secondary prevention in people with diabetes aims to reduce under-treatment and support better control of biomedical targets through individualised, patient centred care. Statin therapies can help lower LDL cholesterol and prevent future cardiovascular events. Cardiovascular disease: risk assessment and reduction, including lipid modification (2014) NICE guideline 181, recommendation of 13

11 Proposed changes to the QOF atrial fibrillation s Recently published research (Adderley et al 2018) has found that people with resolved AF remain at higher risk of stroke or transient ischaemic attack (TIA) than people without AF and continue to benefit from anticoagulation therapy. Under the current business rules for the QOF, people coded as having resolved AF are removed from the AF register and therefore also excluded from the associated s intended to help prevent people with AF having a stroke or TIA. Section AF001.2 of the QOF guidance states: Where a patient has been diagnosed with AF and been subsequently successfully treated, if there is an 'AF resolved code' present in their record after the latest AF recording, they will be removed from the register. In response to the research, it is proposed that the QOF business rules for the AF register are amended to include people with resolved AF. Atrial fibrillation AF resolved code QOF ID and business rule current wording AF001: The contractor establishes and maintains a register of patients with atrial fibrillation. Proposed amendment to business rules Rationale for amending the business rule Evidence base Include people coded with an AF resolved code in the AF register. Evidence shows that people with resolved AF are at higher risk of stroke and TIA than people without AF. To help prevent these people from having a stroke or TIA it is proposed to include them in the AF register and associated s intended to prevent people from experiencing these conditions. Adderley, N. Nirantharakumar, K and Marshall, T (2018). Risk of stroke and transient ischaemic attack in patients with a diagnosis of resolved atrial fibrillation: retrospective cohort studies BMJ 361 k of 13

12 References Adderley, N. Nirantharakumar, K and Marshall, T (2018). Risk of stroke and transient ischaemic attack in patients with a diagnosis of resolved atrial fibrillation: retrospective cohort studies BMJ 361 k1717 Clegg, A. Bates, C. Young, J. et al (2016). Development and validation of an electronic frailty index using routine primary care electronic health record data. Age and Ageing 45 (3) Kearney, M. Treadwell, J and Marshall, M. (2017). Overtreatment and undertreatment: time to challenge our thinking. Br J Gen Practice 67 (663): National Institute for Health and Care Excellence (2016) Multimorbidity: clinical assessment and management, NICE guideline NG56 NHS England (2018). Report of the Review of the Quality and Outcomes Framework. Available online, accessed Strain, W. Hope, V. Green, A. (2018). Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabetic Medicine 35: of 13

13 Appendix A: Consultation comments Consultation dates: 18 July to 1 August 2018 General comments: Stakeholders are asked to consider the following questions when commenting on the proposed changes: 1. Do you think there are any barriers to implementing the care described by these s? 2. Do you think there are potential unintended consequences to implementing/ using any of these s? 3. Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group. 4. If you think any of these s may have an adverse impact in different groups in the community, can you suggest how the might be delivered differently to different groups to reduce health inequalities? 5. Can you suggest other s on our NICE menu or in the Quality and Outcomes Framework that could be improved by applying patient stratification to tailor targets for different cohorts of patients? How to submit your comments: Please send your comments using the form available on the NICE website to s@nice.org.uk by 5pm on Wednesday 1 August of 13