1. General format
2. Exception reporting

1. General format

The clinical indicators are organised by disease category. The disease categories have been selected for the following reasons:

1. where the responsibility for ongoing management rests principally with the general practitioner and the primary care team
2. where there is good evidence of the health benefits likely to result from improved primary care – in particular if there is an accepted national clinical guideline
3. where the disease area is a priority in a number of the four nations.

Where evidence-based national guidance has not been included, this has usually either been to limit the size and complexity of the framework, or because it would be particularly hard for practices to record the relevant information in a reliable way.

A summary of the indicators for each disease category is provided at the beginning of each section.

Indicators across all disease categories are numbered. In the guidance they are prefixed by the disease category to which they belong and contained in a box eg


A number of patients will have multiple diseases: for instance, a significant number of patients with diabetes will also have coronary heart disease (CHD) or hypertension. While it could be argued that the quality framework fragments the care that one individual receives, in complex patients important process issues can be missed during follow-up. The separation of disease categories in the Quality and Outcomes Framework will allow clinicians to check that, for example, the hypertensive diabetic with developing CHD continues to have his or her diabetes monitored while the clinician focuses on the developing CHD.

The term PCO (Primary Care Organisation) is used throughout, as the structures responsible for the organisation and management of primary care differ in the four countries.

For each indicator, three descriptions are given:

1.1 Rationale
This sub-section explains why the indicator has been selected. Wherever possible, the evidence source is described and if available a web address (hyperlink in the electronic version) is provided. When available, National Guidelines have been used as the main evidence source. A small number of individual papers are also quoted.

In some areas, more extensive information is provided. It has been difficult to achieve a balance of providing helpful information without providing a textbook of medicine or replicating guidelines.

The indicators are not intended to cover all the process issues or outcomes indicators for each disease category. The indicator sets are designed to encourage more structured care of patients with chronic diseases. Inevitably, in order to meet the requirement that indicators should be retrievable from GP computer systems, a significant number have been discarded which are not easily recorded in an IT format. In some instances, for example monitoring lifestyle factors in CHD, one indicator has been selected to reflect the care being undertaken by that practice.

In some areas, the indicators cover only a very small part of the care for those conditions. The most obvious example of this is mental health, where it was not possible to develop indicators that could be rewarded in this type of framework for many of the most important aspects of mental health care. Mental health care is however an example of a number of conditions where some markers of good clinical care have been included in the organisational indicators (eg through the inclusion of significant event auditing for mental health problems).

In many of the indicators an additional time factor is incorporated, recognising that in practice it may be difficult to ensure that all patients have attended for review and have completed the review process within any particular timescale. For example, concerning indicator 33, national guidance recommends that all patients with hypertension should have their blood pressure measured at least annually. The actual indicator looks at the number of patients with hypertension who have had a blood pressure measured in the last 15 months.

1.2 Preferred Coding
It is believed that the current trend towards the increasing use of electronic patient records will continue. It is also anticipated that electronic transfer of patient data and records will increasingly be the norm. The opportunity has therefore been taken to produce a set of preferred Read codes. This will mean that many practices will store electronic information against the same code, which will in future facilitate data retrieval and record transfer.

At this stage it is not anticipated that utilisation of other codes will disadvantage practices as the electronic retrieval queries which are being developed will search for a wide range of codes that may have been used to record information.

While it is anticipated that practices will increasingly move towards electronic clinical records, there is nothing in the framework that prevents practices collecting the information from manual records. While certain Read codes have been recommended, this is generally to suggest the codes that practices will find easiest and most clinically relevant. There is no requirement to use these codes, for example in the construction of disease registers.

A % following a Read code signifies that any code lower in the hierarchy may be utilised.

1.3 Reporting and Verification
This section defines the audit information which practices will be required to submit annually. The term 'notes' is used throughout to indicate either electronic or paper records.

It is hoped that all reporting will be possible through the use of GP clinical systems and that practices will be able to run a report annually which can be submitted to the PCO. Separate guidance is being produced on the electronic queries which can be used to report on the Quality and Outcomes Framework.

Practices that do not hold all the required information on computer may utilise the reporting criteria to undertake a manual audit. However, it is recommended that information be transferred to an electronic format as part of that audit process.

Criteria are also provided under a number of indicators that may be used by a PCO on a verification visit to a practice. In general, those that have been chosen have an identifiable source in the clinical record.

In general, PCOs will not expect or be expected to conduct detailed or intrusive verification procedures, unless they suspect that incorrect figures may have been returned, or where there is suspicion of fraud. PCOs may, however, select cases for more detailed investigation from time to time on a random basis.

2. Exception reporting

The Quality and Outcomes Framework includes the concept of exception reporting. This has been introduced to allow practices to pursue the quality improvement agenda and not be penalised, where, for example, patients do not attend for review, or where a medication cannot be prescribed due to a contraindication or side-effect.

The following criteria have been agreed for exception reporting:

1. patients who have been recorded as refusing to attend review who have been invited on at least three occasions during the preceding twelve months
2. patients for whom it is not appropriate to review the chronic disease parameters due to particular circumstances eg terminal illness, extreme frailty
3. patients newly diagnosed within the practice or who have recently registered with the practice, who should have measurements made within three months and delivery of clinical standards within nine months eg blood pressure or cholesterol measurements within target levels
4. patients who are on maximum tolerated doses of medication whose levels remain sub-optimal
5. patients for whom prescribing a medication is not clinically appropriate eg those who have an allergy, another contraindication or have experienced an adverse reaction
6. where a patient has not tolerated medication
7. where a patient does not agree to investigation or treatment (informed dissent), and this has been recorded in their medical records
8. where the patient has a supervening condition which makes treatment of their condition inappropriate eg cholesterol reduction where the patient has liver disease
9. where an investigative service or secondary care service is unavailable.

In the case of exception reporting on criteria A and B this would apply to the disease register and these patients would be subtracted from the denominator for all other indicators. For example, in a practice with 100 patients on the CHD disease register, in which four patients have been recalled for follow-up on two occasions but have not attended and one patient has become terminally ill with metastatic breast carcinoma during the year, the denominator for reporting would be 95. This would apply to all relevant indicators in the CHD set.

In addition, practices may exception-report patients relating to single indicators, for example a patient who has left ventricular dysfunction (LVD) but who is intolerant of ACE inhibitors could be exception-reported. This would again be done by removing the patient from the denominator.

In some instances, a patient may have been referred to a specialist with the expectation that a test or investigation would be carried out. Where this has not been done (eg a specialist has ordered an alternative test to an echocardiogram for a patient with heart failure), than that patient would be exception-reported (as in I above). In other cases, eg a diabetic with a hospital summary of an annual review which had no record of fundoscopy, it would be the GP's overall responsibility to ensure that appropriate care had been given.

Practices should report the number of exceptions for each indicator set and individual indicator. An IT solution is currently being devised for exception-reporting, but at this stage, practices may need to devise a paper based or separate spreadsheet recording system for exception-reporting. Whether or not computer-based systems are used, practices will not be expected to report why individual patients were exception-reported. So, for example, a single new Read code is likely to be developed for exception reporting, rather than one for each of the categories above. However, practices may be called on to justify why they have excepted patients from the quality framework and this should be identifiable in the clinical record. Top

Summary of all Clinical Indicators

Secondary Prevention in Coronary Heart Disease (CHD)

Stroke and Transient Ischaemic Attacks

Hypertension

Diabetes Mellitus (Diabetes)

Chronic Obstructive Pulmonary Disease (COPD)

Epilepsy

Hypothyroidism

Cancer

Mental Health (MH)

Asthma

Secondary Prevention in Coronary Heart Disease (CHD) ...
Indicator	Points	Payment Stages
Records
CHD 1. The practice can produce a register of patients with coronary heart disease	6
Diagnosis and initial management
CHD 2. The percentage of patients with newly diagnosed angina (diagnosed after 1 April 2003) who are referred for exercise testing and/or specialist assessment	7	25-90%
Ongoing Management
CHD 3. The percentage of patients with coronary heart disease whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status need be recorded only once	7	25-90%
CHD 4. The percentage of patients with coronary heart disease who smoke, whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the last 15 months	4	25-70%
CHD 5. The percentage of patients with coronary heart disease whose notes have a record of blood pressure in the previous 15 months	7	25-90%
CHD 6. The percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less	19	25-70%
CHD 7. The percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months	7	25-90%
CHD 8.The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in last 15 months) is 5 mmol/l or less	16	15-60%
CHD 9. The percentage of patients with coronary heart disease with a record in the last 15 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded)	7	25-90%
CHD 10. The percentage of patients with coronary heart disease who are currently treated with a beta blocker (unless a contraindication or side-effects are recorded)	7	25-50%
CHD 11. The percentage of patients with a history of myocardial infarction (diagnosed after 1 April 2003) who are currently  treated with an ACE inhibitor	7	25-70%
CHD 12. The percentage of patients with coronary heart disease who have a record of influenza immunisation in the preceding 1 September to 31 March	7	25-85%
Sub Set - Left Ventricular Dysfunction
Records
LVD 1. The practice can produce a register of patients with CHD and left ventricular dysfunction	4
Diagnosis and initial management
LVD 2. The percentage of patients with a diagnosis of CHD and left ventricular dysfunction (diagnosed after 1 April 2003) which has been confirmed by an echocardiogram	6	25-90%
Ongoing Management
LVD 3. The percentage of patients with a diagnosis of CHD and left ventricular dysfunction who are currently treated with ACE inhibitors (or A2 antagonists)	10	25-70%

Stroke and Transient Ischaemic Attacks
Indicator	Points	Payment Stages
Records
STROKE 1. The practice can produce a register of patients with Stroke or TIA	4
STROKE 2. The percentage of new patients with presumptive stroke (presenting after 1 April 2003) who have been referred for confirmation of the diagnosis by CT or MRI scan	2	25-80%
Ongoing Management
STROKE 3. The percentage of patients with TIA or stroke who have a record of smoking status in the last 15 months, except those who have never smoked where smoking status should be recorded at least once since diagnosis	3	25-90%
STROKE 4. The percentage of patients with a history of TIA or stroke who smoke and whose notes contain a record that smoking cessation advice or referral to a specialist service, if available, has been offered in the last 15 months	2	25-70%
STROKE 5. The percentage of patients with TIA or stroke who have a record of blood pressure in the notes in the preceding 15 months	2	25-90%
STROKE 6. The percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in last 15 months)  is 150/90 or less	5	25-70%
STROKE 7. The percentage of patients with TIA or stroke who have a record of total cholesterol in the last 15 months	2	25-90%
STROKE 8. The percentage of patients with TIA or stroke whose last measured total cholesterol (measured in last 15 months) is 5 mmol/l or less	5	25-60%
STROKE 9. The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded)	4	25-90%
STROKE 10. The percentage of patients with TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March	2	25-85%

Hypertension
Indicator	Points	Payment Stages
Records
BP 1. The practice can produce a register of patients with established hypertension	9
Diagnosis and initial management
BP 2. The percentage of patients with hypertension whose notes record smoking status at least once	10	25-90%
BP 3. The percentage of patients with hypertension who smoke, whose notes contain a record that smoking cessation advice or referral to a specialist service, if available, has been offered at least once	10	25-90%
Ongoing Management
BP 4. The percentage of patients with hypertension in whom there is a record of the blood pressure in the past 9 months	20	25-90%
BP 5. The percentage of patients with hypertension in whom the last blood pressure (measured in the last 9 months) is 150/90 or less	56	25-70%