Statistical Publication Notice

26 June 2007

Quality & Outcomes Framework (QOF) of the new GMS Contract - National Prevalence Day Scotland - Level Estimates for 2006/07

INTRODUCTION

The Quality & Outcomes Framework (QOF) is a system to remunerate general practices for providing good quality care to their patients, and to encourage further improvement of the quality of health care delivered.  It is a fundamental part of the new General Medical Services (GMS) contract, introduced on 1st April 2004.

The QOF, which is a voluntary part of the new GMS contract, measures achievement against a range of evidence-based indicators, with points and payments awarded according to the level of achievement.

This release reports the national raw prevalence of the individual diseases and conditions within the clinical domain of the QOF for 2006/07, as at ?National Prevalence Day?. Prevalence data collected as QOF ?registers? forms an integral part of the framework in determining the level of payment awarded to individual practices. To allow sufficient time for the data to be finalised, full achievement and exception reporting information from the QOF for 2006/07 will be published on 25 September 2007.

A number of revisions were implemented to the QOF in April 2006, most significantly affecting the clinical domain. Revised definitions were implemented in specific areas and a number of entirely new clinical areas were introduced. No clinical areas have been dropped from the framework, although specific individual indicators may no longer exist.

KEY POINTS

The QOF covered ten clinical domain areas in the first two years of the new GMS contract but has since expanded to include eighteen areas as from April 2006. Within the eighteen clinical domain areas of the current QOF, twenty-one registers are recorded and form the basis of prevalence calculations. Previously, within the ten clinical domain areas of the initial QOF, eleven registers were recorded. At that time, the clinical domain areas concentrated on distinct disease areas but the wider scope has brought in conditions such as obesity and patients in need of palliative care.

Definitions for seven of the current registers are directly comparable over time, and for the first three years of the QOF all have shown either constant or rising prevalence. Note that the trends in part may be influenced by improved ascertainment and that prevalence rates are not adjusted by age and sex as this level of detail is not collected on the system.

Four registers were subject to revision for the QOF commencing April 2006 and ten are entirely new and being published for the first time.

INTERPRETATION

The national prevalence estimates are required for the purposes of the payment calculations and are based on the prevalence data recorded in the payment calculation system (QMAS), as at a date referred to in the QOF as ?National Prevalence Day?. National Prevalence Day was the 14th February 2007 for 2006/07 and the same date in 2005 and 2006 for the previous QOF years.

Individual practices submit their register sizes to QMAS and national raw prevalence is the cumulative total presented as rates per 100 registered patients. The total practice list sizes used to determine the rates are supplied to QMAS directly from another payment system and are not split by age or sex. The data collection only allows raw prevalence to be determined as further demographic information relating to the age/sex profile of the QOF registers and the practice populations is not available within the QMAS system.

There are more registers than clinical domain areas. Some areas include multiple registers and there can be more than one national prevalence associated with a single clinical domain area. For 2004/05 and 2005/06, this applied only to coronary heart disease, as it included a second register of those patients with CHD and left ventricular dysfunction (LVD). In 2006/07 LVD remained a defined register, but nested within the heart failure clinical domain area. The national prevalence of LVD in 2006/07 of 0.6% relates to patients with heart failure and LVD, which is not directly comparable to the previous definition, in which the register was nested within the CHD clinical domain area.

Depression was introduced to the QOF in 2006/07 and is the only other clinical domain area subject to the recording of multiple registers. There are two individual indicators related exclusively to depression, but each is based on quite different patient registers. The first indicator relates to depression among patients with diabetes and CHD and the second indicator to patients in general, newly diagnosed with depression between 1st April 2006 and 31st March 2007.

Although there are registers that serve indicators related to smoking, there is not a register from which the national prevalence of smoking can be determined. The current indicators relate to the smoking status of people with chronic conditions. The register definition, under which a prevalence rate of 20.4% has been calculated for 2006/07, applies to people with any of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD or asthma.

Although indicators related to Diabetes Mellitus have existed in the QOF since April 2004, there has been a change in the selection criteria for eligible patients. Since April 2006, the definition includes all patients aged 17 years and over with diabetes mellitus defined by clinical (Read) codes specific to Type 1 or Type 2 diabetes. Previously there was a wider range of Read codes accepted under the definition although the age constraint has remained consistent. Although practices must now record whether the patient has Type 1 or Type 2 diabetes, this level of detail is not recorded in the QMAS system. Therefore the register size or prevalence rates cannot be split by type of diabetes.

Although indicators for Mental Health have existed in the QOF since April 2004, there has been a change in the selection criteria for eligible patients. Since April 2006, the definition has included only patients with serious mental illness, defined as schizophrenia, bipolar affective disorder or other psychoses.  Previously, patient selection was based on more generic Read codes and the further condition that the patient required, and had consented to, regular follow-up. The prevalence statistics for 2006/07 are therefore not directly comparable with those for 2004/05 and 2005/06. The data in fact appear to show an anomaly in that prevalence has increased on implementation of a tightened definition. The coding choices for the new register initially included too many acute codes and these were modified during the course of 2006/07. However practices may not have had time to implement the list of codes and software in time for national prevalence day and so may not have re-coded patients inappropriately included on the register.

Although indicators for Epilepsy have existed in the QOF since April 2004, there has been a change in the selection criteria for eligible patients. Since April 2006, the definition has included patient?s aged 18 and over, whereas previously it was 16 and over.

DETAILED SUMMARY

Seven QOF registers have maintained a consistent definition since April 2004. Directly comparable prevalence statistics across the first 3 years of the framework have been provided in the following areas: asthma, cancer, coronary heart disease, chronic obstructive pulmonary disease, hypertension, hypothyroidism and stroke and transient ischaemic attack (TIA).

National prevalence of cancer, excluding non-melanomatous skin lesions, has shown an increase from 0.5% in 2005 to 0.9% in 2007. This is the greatest rise of all the conditions with directly comparable registers, and reflects the annual accrual of new cases rather than any true increase in cancer prevalence.

National prevalence of coronary heart disease and chronic obstructive pulmonary disease has remained constant for the first three years of the QOF, with the remaining directly comparable registers; asthma, hypertension, hypothyroidism and stroke and TIA, all rising.

The QOF has not shown a fall over time in the national prevalence of any of the diseases and conditions covered by the directly comparable registers. These trends cannot be age/sex adjusted and in part may be influenced by improved ascertainment.

Four registers have existed in the QOF since April 2004 but were subject to changes in selection criteria for the year commencing April 2006. National prevalence rates for 2006/07 are not directly comparable with rates derived from the equivalent 2004/05 and 2005/06 registers for diabetes mellitus, epilepsy, left ventricular dysfunction and mental health.

The ten registers that are new to the QOF for 2006/07 are atrial fibrillation, chronic kidney disease, dementia, depression (two registers), heart failure, learning disabilities, obesity, palliative care and chronic conditions assessed for smoking indicators.

MAIN CONTACTS:

GLOSSARY:

PRE-RELEASE ACCESS TO THIS PUBLICATION WAS GIVEN TO:

HISTORY OF THIS PUBLICATION:

Last Published:  September 2006
Next Due:  Full 2006/07 achievement and exception reporting data due for publication in September 2007
Data Available Since: First year of the new General Medical Services Contract - 2004/05

On 27th May 2005, the first publication of Scotland?s Quality & Outcomes Framework (QOF) data for April 2004 ? March 2005 was released.  Data presented included points and payments achieved by each practice within an NHS Board, as well as prevalence rates across Scotland and at Scotland level for ten diseases or health conditions. An updated publication was released on 29th September 2005.

The structure of the QOF remained the same for the year April 2005 - March 2006 and equivalent data were released biannually in 2006, with the second release of the year updating the previous figures with the data from practices not signed-off by health boards in time for the first publication.

This year, the full achievement and exception reporting data will only be published once (in September). The structure of the QOF for 2006/07 changed significantly from the previous two years with the introduction of a number of new registers and revisions to others.

The prevalence statistics due for publication on 26th June 2007 relate to the new structure of the clinical domain of the QOF and reflect practice register sizes as at 14th February 2007. The validity of this data is not subject to local sign-off.