General Practice - Quality & Outcomes Framework
27th February 2007
SUMMARY OF RELEASE:
This publication presents, for the first time, exception reporting information for Scottish General Practices in 2005/06 under the Quality & Outcomes Framework (QOF). This information is published at www.isdscotland.org/qof
The concept of exception reporting was included in the QOF 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.
Exception reporting information is presented for Scotland as a whole and also for NHS Boards, Community Health Partnerships (CHPs/CHCPs) and individual practices.
It is crucial to note that observed exception reporting rates, particularly at practice level, are highly influenced by small numbers. Some apparently very high, or very low, rates may be so because only a very few patients are involved. This is particularly likely to affect small practices and/or instances where indicators relate to a relatively small number of patients in the practice.
Commentary on the observed exception reporting rates:
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Overall levels of exception reporting in Scotland varied considerably between the clinical indicators, ranging from less than 1% to over 27%.
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In general, indicators with the lowest levels of exception reporting include those that involve recording information in the patient records (e.g. taking blood pressure, recording smoking status, offering smoking cessation advice), whereas the highest are seen in those that involve clinical treatments, influenza immunisation, or clinically measurable outcomes.
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The lowest level of exception reporting overall (0.7%) was seen in the indicator that involves recording that patients with high blood pressure have been offered smoking cessation advice (BP03).
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The indicator with the highest level of exception reporting overall (27.6%) relates to heart patients being treated with a beta-blocker drug (CHD10). This is to be expected, as many patients on the CHD register are unsuitable for beta-blockers.
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There is also a high level of exception reporting overall (26.7% - the second highest level) for flu immunisation for asthma patients (ASTHMA07). This is because not all patients who are included in the QOF asthma register are recommended for flu immunisation. Because of this anomaly, this indicator was removed from the QOF from April 2006.
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Overall exception reporting levels for the flu immunisation indicators for other conditions (CHD12, DM18, STROKE10, COPD08), although not as high as for ASTHMA07, are still fairly high relative to other indicators. The reasons for this are likely to be complex as these patients form a varied group, some of whom are likely to be frail and elderly (e.g. some patients with stroke or CHD) and some of whom may be young and perceive themselves to be healthy and not in need of flu immunisation (e.g. some patients with diabetes or CHD). Those patients aged over 65 are likely to be targeted for flu immunisation due to their age, but for younger patients the attendance rates may not be so high.
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The indicator EPILEP04, which refers to the percentage of patients with Epilepsy who have remained seizure free for the past year, has the third highest exception reporting rate overall (21.6%). Remaining seizure free is difficult to achieve for many patients with epilepsy, e.g. where the cause is brain damage or where side effects of drug treatment preclude increases in dosage.
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There is substantial variation between practices in the level of exception reporting within many of the individual indicators. Whilst the highest variability tends to be seen in the indicators that relate to clinical outcomes, it is also more pronounced for indicators where there are often small numbers of patients involved at practice level (e.g. the Mental Health indicators). The widest variation for a single indicator is seen for the level of exception reporting for seizure control (EPILEP04); as discussed above this outcome is difficult to achieve for many epilepsy patients.
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MAIN CONTACTS:
Julie Kidd,
Principal Information Analyst,
tel 0131 275 6450,
email Julie.Kidd@isd.csa.scot.nhs.uk
Alistair Smith,
Senior Information Analyst,
tel 0131 275 6784,
email Alistair.Smith@isd.csa.scot.nhs.uk
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GLOSSARY:
Registers - The numbers of patients within each of the QOF clinical indicator groups, as reported for 14th February (National Prevalence Day).
Denominator - The number of patients for whom the QOF points for the indicator could reasonably have been obtained. Denominators for clinical indicators are subsets of the relevant registers, with some patients EXCLUDED due to the indicator definition, and some patients EXCEPTION REPORTED on the basis of defined criteria.
Numerator - An indicator numerator is the number of those in the denominator who meet the specific indicator success criteria.
Exclusions - Patients who are included on a particular register, but who for definitional reasons, can not be included in a specific QOF indicator denominator. For example, an indicator 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.
Exclusion rate - The number of exclusions, as a percentage of the number of people with the condition on 31st March. This may differ from the National Prevalence Day register due to timing. Calculated as: exclusions/(exclusions+exceptions+denominator) x 100.
Exceptions - Patients who are on the disease register, and fall within the indicator definition, but are not included in the indicator denominator because they meet at least one of the exception criteria outlined in the GMS contract.
Exception rate - The number of exceptions as a percentage of the number of people eligible to be included in the indicator denominator, i.e. calculated as exceptions/(exceptions+denominator) x 100. (Note on comparisons of practice exception rates - Rates should not be compared in isolation, but considered in conjunction with numbers of patients involved, because some rates are based on very small numbers. For example, an exception rate of 50% would be less significant if 1 of 2 patients was excepted than if 250 of 500 were excepted).
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PRE-RELEASE ACCESS TO THIS PUBLICATION WAS GIVEN TO:
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Scottish Executive Health Department - Policy and QOF leads
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NHS Boards - individual QOF/GMS/Primary Care contracting lead(s)
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HISTORY OF THIS PUBLICATION:
Last Published: N/A - this is the first publication of this type
Next Due: September 2007
Julie Kidd
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