004B Routine QOF work

004B Routine QOF work

004B Routine QOF work

The 004B Routine QOF work search folder is located within population reporting under the 004 GP Contracts Pro folder. The 004 Routine QOF work folder is divided into 7 main folders (shown in the screenshot below), as well as a denominator folder (z Denominators) where our supporting searches are held (which do not need to be accessed). Please continue reading this article for further details on folders a – g.
Info
Throughout this article PCA is mentioned, this stands for Personalised Care Adjustment and with regards to QOF, has replaced the term ‘exception reporting’. A PCA is when a patient is not included in a QOF target because they have declined a review/drug or a review/drug is not indicated, etc. By coding a PCA, it will reduce the number of patients eligible for the QOF target (decreasing the prevalence), making it easier to meet the QOF target.  For more information about PCAs see our separate support article.




a ) Early contract actions

This folder includes a search as well as 3x reports (as shown in the screenshot below). You can run and work through these early in the contract year to boost QOF points.


AF with no CHA2DS2-VASc

This search includes patients with AF who do not have a valid code for CHA2DS2-VACs score. The CHA2Ds2-VASc score adding tool (HP212) protocol, included in your subscription, can be used to bulk add CHA2DS2-VASc scores to all the patients' records that are included in this search. Click this link to view the article providing further information on how to use the protocol HP212.

The below 3 reports all show whether the drug has been declined, contraindicated, not indicated or not tolerated in previous QOF years and the date associated with these codes. After running the reports, you can work through the patients included to check whether the appropriate code can be added to exception report them again for this QOF year, making it easier to meet the QOF targets stated below.

Diabetic proteinuria or microalbuminuria previously declined ACEI/ARB

This report is in relation with DM006. When run, it includes diabetic patients with proteinuria or microalbuminuria who in previous years have declined, been contraindicated, or not tolerated ACE inhibitors or angiotensin II receptor blockers (ARBs).

Heart failure not on a B-blocker previous PCAs

This report is in relation to HF006. When this report is run, it will include heart failure patients who in previous years have declined, been contraindicated, or not tolerated a beta blocker, therefore have been exception reported with regards to QOF. PCAs stand for personalised care adjustments. It is advised to review these patients to check if they become eligible, if they are not eligible they may be suitable for exception reporting, using the relevant code.

Heart failure not on ACEI/ARB and previously declined

This report is in relation to HF003, once run, it will show Heart Failure patients who are not on ACEI or ARBs because they have declined them in previous QOF years.

Idea
You can check the PCA code for each QOF indicator by looking at the relevant denominator search in the appropriate QOF search folder. E.g. for the report above (Heart failure not on ACEI/ARB and previously declined), go to the ‘Heart Failure’ QOF search folder, then select HF denominator populations, then select the search ‘[HF003] - Heart failure due to LVSD eligible for ACE-I or ARB’ and look at the definition. For this specific search, if you want to code ACE and ARB declined, these codes are found in rule 4 of this search.

b ) Weekly activities

The reports in this folder can be run and reviewed weekly to keep up to date with QOF targets.


Info
The column (Previous actions) at the end of each of these reports will pull through information which has been added/coded using our OneTemplate Admin through the text entry on the first page of the template, called Searches Admin. You would have to tick the relevant code and type any actions you have taken in the text box provided. See screenshot below which shows this page of the template.

Asthma with incomplete review

Once run, this report will include patients with an incomplete asthma review, you will be able to identify from the report which section on the asthma review is incomplete so you can then action accordingly. The elements required for a complete asthma review include, ACT score, recording of the number of exacerbations, and a written personalised asthma action plan. There are critical windows of time when this information must be coded. The report has been designed to highlight all relevant codes recorded within the window relative to the asthma review so information may appear on multiple lines for a single patient. The column headers will show the timeframe requirements. Any blank cells represent data which has not been collected or coded within the timeframe. When the review is completed, the patient will be counted towards the AST007 QOF indicator and the patient will no longer appear in this report. Therefore, by running this report regularly/weekly you can keep on top of these reviews and action it as soon as possible after their Asthma review.

COPD with incomplete review

Once run, this report will include patients with an incomplete COPD review, you will be able to identify from the report which section on the COPD review is incomplete so you can then action accordingly. Unlike the asthma with incomplete review, there are not critical timeframes for recording the additional information of the number of COPD exacerbations or the MRC score. The latest entry for each component is displayed on the report, therefore the missing information is where the blank cells are found. When the review is completed, the patient will be counted towards the COPD010 QOF indicator and the patient will no longer appear in this report. Therefore, by running this report regularly/weekly you can keep on top of these reviews and action it as soon as possible after their COPD review.

Dementia review or care plan but not QOF code

Once run, this report will include patients who have a new depression diagnosis within the last 56 days, but have not had a review within the specified timeframe (10 – 56 days after the date of diagnosis). This supports the DEP004 QOF indicator. The report displays the date of the depression diagnosis, any future appointments the patient has, and previous actions which have been recorded using The OneTemplate Admin. Click here to view the article for further information on the OneTemplate Admin

Heart failure with incomplete review

Once run, this report will include patients with an incomplete heart failure review, the report will identify which section of the review is incomplete so you are able to action the patients accordingly and add the relevant codes to include them in the HF007 QOF indicator. The report displays the review date and the latest medical review date to save you having to look through individual patients’ records to find this information.

New depression diagnosis but no review done

Once run, this report will include patients who have a new depression diagnosis within the last 56 days, but have not had a review within the specified timeframe (10 – 56 days after the date of diagnosis). This supports the DEP004 QOF indicator. The report displays the date of the depression diagnosis, any future appointments the patient has, and previous actions which have been recorded using The OneTemplate Admin. Click here to view the article for further information on the OneTemplate Admin.

c ) Monthly activities







Idea
Sometimes aspects that should be coded are instead written within a consultation, but not added as a code, you may or may not already know that you can search within consultations for words, therefore if you are checking whether something has been actioned but not coded, you can search for the word by going to the consultation page and clicking the ‘Text search’ icon in the EMIS ribbon.
AF needs CHA2DS2-VASc
This report supports AF006, it displays patients who need a CHA2DS2-VASc score calculating. The report will show when the patient received the AF diagnosis, and their precious CHA2DS2-VASc score. The CHA2Ds2-VASc score adding tool (HP212) protocol, included in your subscription, can be used to bulk add CHA2DS2-VASc scores to all the patients' records that are included in this search. Click here to view our support article, providing further information on how to use the protocol. It is worth running and checking this report throughout the year, even if you have bulk added the code using the HP212 protocol, because newly diagnosed AF patients are included and will require a CHA2DS2-VASc score adding to their records.

Cholesterol on alternative lipid-lowering therapy without statin PCA

This report includes patients who are diagnosed with Cholesterol who have had a recent issue of an alternative lipid lowering drug but haven’t been coded with a statin PCA. If patients are taking an alternative lipid-lowering drug, they would need a PCA code adding to exclude them from the CHOL001 QOF indicator.

COPD and MRC >=3 NOT offered pulmonary rehab

This report includes patients diagnosed with COPD who should be offered pulmonary rehab. On the report there is a column to show any pulmonary rehab codes added within the last year. It is worth reviewing the records for patients who have been referred or declined multiple times to double check whether they have attended but pulmonary rehab hasn’t been coded as completed. By coding this, it will ensure QOF indicator COPD014 is more easily achieved, as once coded with this it doesn't need adding each subsequent year.

New asthma diagnosis without objective tests

These patients have been diagnosed with Asthma within the last 6 months or have a recent diagnosis of asthma and have registered with the practice recently, but they do not have a Spirometry or FeNO / Peak Flow coded (objective tests). This relates to the AST011 QOF indicator. You can review the records for the patients included in this report to double check they haven’t had the objective tests or to invite patients for these tests within the inclusion timeframe (3 months before or 6 months after diagnosis). The report displays the registration date as well as the information for the objective tests. The objective tests date may exceed the 6 month limit due to the eligibility criteria including both the diagnosis and registration dates.

New cancer diagnosis but support not yet offered

To meet the CAN005 indicator, cancer support has to be offered within 3 months of diagnosis. This report will include patients who have had a cancer diagnosis within the last 3 months but have not yet been coded as having support offered. The report will show the date of diagnosis, so you can review the records and double check support hasn’t been offered or to ensure the patient is offered support or has a PCA coded within the correct timeframe. This report runs in line with our protocol HP097 Time Limited Cancer Care Review Needed. Click here to view the support article for this protocol. 

Recent cancer diagnosis but no care review

This report is similar to the above report, however, a cancer care review is due within 12 months of the cancer diagnosis, which is relating to indicator CAN004. The report displays the cancer diagnosis date to save you looking through individual records to identify this and work out the review due date.

Recent diabetes but not referred to structured education

Once diagnosed with diabetes, patients need to be referred to a structured education programme within 9 months of diagnosis. This report will show patients who have had a recent diagnosis, and the date of this, but not had a code for referral to the structured education programme. The report displays the diabetes diagnosis date to save you looking through individual records to identify this. Making sure these referrals are coded within the set timeframe will help you achieve the DM014 QOF indicator.

Recent heart failure diagnosis but not yet referred for echo

This report supports the QOF indicator HF005. An echocardiogram or a specialist assessment is required 3 months before or up to 6 months after the patient has received a heart failure diagnosis. In the situation where a patient newly registers with the practice who has a diagnosis of heart failure without an echocardiogram or specialist review coded, this is required to be done within 6 months of them registering. This report will display the date of the heart failure diagnosis, as well the patients’ registration date so you are easily able to identify the time limit for when the echocardiogram or specialist review is due for each patient included. Coding the patient with an PCA code (declined, etc.), where appropriate, will remove them from the HF005 indicator, making the target easier to achieve.

d ) Expired Time Limited QOF


We have produced some helpful searches and reports which highlight patients where work needs to be done, either as a one-off exercise to improve a denominator (eligible) population, or where there is a time-critical period to achieve the indicator. We recommend setting a schedule on this folder so that it runs at least weekly and to add a process for checking the folder on a regular basis into your business-as-usual processes.
Alert
We advise against using a relative run date on the search folders as it might produce misleading results where patients appear in the Expired folder when they are actually still within the qualifying window.
The below reports all show the time expired QOF indicators. These reports pull in information from records, to save the user time looking through individual records to find specific information. The patients included in the reports are those who have gone beyond the time limit and are overdue a review, referral, or necessary action to meet the QOF targets. We would recommend you review these reports regularly (you can set schedules for them, depending on the timeframes for each one) and if the patient declined, is unsuitable, or has another reason to warrant a PCA, the appropriate code can be added for this. Some declined, etc. codes will need to be backdated to the correct date, depending on the time restriction for the specific indicator (it is mentioned below which indicators require the code to be backdated). Sometimes, these time limited actions have been completed, but not coded, in this case a backdated review or the appropriate code can be added to correctly record the review, referral, or other necessary action (helping to achieve the QOF indicators).

Info
Asthma, diabetes, and heart failure only pick up patients whose first ever diagnosis code was in the specified timeframe. Cancer and depression pick up the most recent problem diagnosis (First, New) so consider incorrect problem management before trying to achieve the indicator

Time expired Cancer diagnosis but no care review 

This search is to support to the CAN004 QOF indicator. A cancer care review is due 12 months post diagnosis. We have created this report to include patients who were not been offered a cancer care review within the timeframe specified. The report displays the date of the cancer diagnosis.

Time expired Cancer diagnosis but support not offered 

This search is to support to the CAN005 QOF indicator. Cancer support must be offered within 3 months post diagnosis. The patients included in this report were not offered support within the timeframe specified. The report displays the date of the cancer diagnosis.

Time expired Depression diagnosis but no review done 

This report is to support to the DEP004 QOF indicator. The report includes patients ages 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March who have not yet received a review. A depression review must have been completed within 10 – 56 days post diagnosis.

Time expired diabetes dx but not referred to struct. educatn

This report is to support to the DM014 QOF indicator. A referral to the structured education programme must be made within 9 months post asthma diagnosis. The report displays the date of diagnosis to save you having to look through individual patients’ records to find this information.

Time expired Heart failure diagnosis but no echo

This report is to support to the HF008 QOF indicator. We have created this report to identify the number of patients who have received a diagnosis of heart failure on or after 1 April 20** (current year) but do not have an echocardiogram or specialist assessment coded 6 months prior to them being added to the heart failure register. The report will show the date of diagnosis for each patient, so you can review the records back to check whether this was done and not coded, or not done and declined, or not indicated, etc. If you are adding a code to achieve the QOF target it will need backdating to the appropriate date to be included in the indicator.

Time expired New asthma diagnosis

This report is to support to the AST011 QOF indicator. Patients with a new diagnosis of asthma should have two objective tests; the first is spirometry and the second can either be a Fractional exhaled Nitrous Oxide (FeNO) test, or a peak flow. Both tests must be done between 3 months prior to the diagnosis, and up to 6 months after diagnosis. Patients who recently registered with a recent asthma diagnosis where the objective tests were not previously done have 6 months from the date of registration to complete the tests. This report includes patients who did not have the objective tests within the specified timeframe. The report displays the registration date as well as the information for the objective tests. The objective tests date may exceed the 6 month limit due to the eligibility criteria including both the diagnosis and registration dates. If you are adding an appropriate code (once the record has been reviewed) with the aim of achieving the AST011 QOF target this may need to be backdated to count towards the indicator.

e ) Remote data collection



AST008 Smoking questionnaires to send out

This search identifies patients with Asthma, aged 19 or under who require a smoking questionnaire to be sent out because there is no smoking status or exposure coded on their records. You can run and select the relevant report underneath the search (depending on your practice policies) to send out the questionnaire. Recording the smoking status for these patients will help to achieve the AST008 QOF indicator. 

CHD005 Antiplatelet questionnaire to send out (later in contract year)

This search includes patients with coronary heart disease with no record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken. Therefore, they require a questionnaire to be sent out. You can run and select the relevant report underneath the search to use to send out the questionnaire. It is advised to do this later in the contract year. This is relating to the CHD005 QOF indicator. 

STIA007 Antiplatelet questionnaire to send out (later in contract year)

This search identifies non-haemorrhagic stroke or TIA patients who have no record in the preceding 12 months that an anti-platelet agent, or anti-coagulant has been taken. You can run and select the relevant report underneath the search to send out the questionnaire. It is advised to do this later in the contract year. This is relating to the STIA007 QOF indicator.

f ) QOF targeted help



These searches and reports are helpful to use as you get further into the QOF year. 

Idea
The "Quick wins" can be helpful to help boost QOF performance quickly and easily in areas where you aren't hitting the target.  Looking at your current performance and then deciding which of these reports you need to use to target your own needs is advised.

The searches and reports are broken up into the following areas:
  1. ACTION - where a specific action just needs be done
  2. HIGH RISK - where patients have had results or values in previous contract years that are out of range but haven't been followed up in the current year
  3. QUICK WIN - these are further broken up into :
    1. Bloods - where a blood test is just needed (usually HbA1c)
    2. Coding - where a simple code being added will achieve an indicator
    3. Value - where values last year were normal (for BP, cholesterol or HbA1c) but haven't been done in the current contract year
  4. REVIEW - where patients need more detailed review

ACTION | Diabetes no HbA1c this QOF year

This report gives you a list of patients who have diabetes but haven't had an HbA1c within the current QOF year.  The report shows you the latest HbA1c, whether the patient is frail (as this affects the HbA1c target for QOF) and details of any invites sent in the QOF year.

HIGH RISK | CHD no BP reading this QOF year but latest was raised

This report gives you a list of patients who have CHD who haven't had a BP within the current QOF year where the most recent BP reading on record was raised.  This helps to identify patients for CH015 and CHD016.  The report shows you the latest systolic and diastolic blood pressure values and details of any invites sent in the QOF year.  The age of the patients is shown in the "Patient details" column - don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

HIGH RISK | Chol not on therapy, no result this year but previously raised

This report gives you a list of patients who are NOT on lipid lowering therapy. Patients included haven't had a cholesterol coded within the current QOF year, but the most recent value on record was above the threshold.  The report helps to identify patients for CHOL002.  The report shows you the latest non HDL and LDL results, previous lipid lowering therapy, Statin or lipid PCAs in the last 5 years and will show you the disease register that has added the patient to the eligibility criteria for CHOL002.  The existence of any non-HDL result overrides an LDL result.

HIGH RISK | Chol on therapy, no result this QOF year but previously raised

This report gives you a list of patients who are on lipid lowering therapy, patients included haven't had a cholesterol coded within the current QOF year, but the most recent value on record was above the threshold.  The report helps to identify patients for CHOL002.  The report shows you the latest non HDL and LDL results, previous lipid lowering therapy, Statin or lipid PCAs in the last 5 years and will show you the disease register that has added the patient to the eligibility criteria for CHOL002.  The existence of any non-HDL result overrides an LDL result.

HIGH RISK | Diabetes no BP reading this QOF year but latest reading was raised

This report gives you a list of patients who have Diabetes, patients included are not coded as moderately or severely frail, they haven't had a BP within the current QOF year, but the most recent BP reading on record was raised.  This helps to identify patients for DM033.  You may also want to consider if the patient is frail, in which case a BP target doesn't apply.  The report shows you the latest systolic and diastolic blood pressure values and details of any invites sent in the QOF year.  The BP target is less than 140/90.

HIGH RISK | Hypertension no BP reading this QOF year but latest was raised

This report gives you a list of patients who have Hypertension, patients included don't have a BP recorded within the current QOF year but the most recent BP reading on record was raised.  This helps to identify patients for HYP008 and HYP009.  The report shows you the latest systolic and diastolic blood pressure values and details of any invites sent in the QOF year.  The age of the patients is shown in the "Patient details" column - don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

HIGH RISK | Stroke no BP reading this QOF year but latest was raised

This report gives you a list of patients who have a history of stroke or TIA. Patient included haven't had a BP within the current QOF year but the most recent BP reading on record was raised.  This helps to identify patients for STIA014 and STIA015.  The report shows you the latest systolic and diastolic blood pressure values and details of any invites sent in the QOF year.  The age of the patients is shown in the "Patient details" column - don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

QUICK WIN BLOODS | Non-Diabetic Hyperglycaemia no HbA1c this QOF year

This report gives you a list of patients who have a history of NDH who haven't had an HbA1c within the current QOF year.  This helps to identify patients for NDH002.  The report shows you the latest HbA1c and fasting glucose values and details of any invites sent in the QOF year.  

QUICK WIN CODING | Chol on alternative lipid-lowering therapy without statin PCA

This report gives you a list of patients who are not achieving CHOL001. Patients included are on a lipid lowering therapy that isn't a statin, therefore, need a statin PCA adding in order to achieve CHOL001.  

QUICK WIN VALUE | CHD no BP reading this QOF year and latest was normal

This report gives you a list of patients who have CHD and haven't had a BP within the current QOF year, but the most recent BP reading on record was normal.  The likelihood is if you get these patients in for a BP check it will be within the normal range again and make it easy to improve your performance for CH015 and CHD016.  The report shows you the latest systolic and diastolic blood pressure values and details of any invites sent in the QOF year.  The age of the patients is shown in the "Patient details" column - don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

QUICK WIN VALUE | Chol not on therapy, no result this year and previously normal

This report gives you a list of patients who are eligible for CHOL002. The patients included haven't had a cholesterol within the current QOF year, but the most recent value on record was normal.  The likelihood is if you get these patients in for a cholesterol check, it will be within the normal range again which makes it easy to improve your performance for CHOL002.  The report shows you the latest non HDL and LDL results, previous lipid lowering therapy, Statin or lipid PCAs in the last 5 years and will show you the disease register that has added the patient to the eligibility criteria for CHOL002.  The existence of any non-HDL result overrides an LDL result.

QUICK WIN VALUE | Chol on therapy, no result this yr and previously normal

This report gives you a list of patients who are eligible for CHOL002. The patients included are on lipid lowering therapy, they haven't had a cholesterol within the current QOF but the most recent value on record was normal.  The likelihood is if you get these patients in for a cholesterol check the result will be within the normal range again, which makes it easy to improve your performance for CHOL002.  The report shows you the latest non HDL and LDL results, previous lipid lowering therapy, Statin or lipid PCAs in the last 5 years and will show you the disease register that has added the patient to the eligibility criteria for CHOL002.  The existence of any non-HDL result overrides an LDL result.

QUICK WIN VALUE | Diabetes no BP reading this QOF year and latest was normal

This report gives you a list of patients who have Diabetes and are not moderately or severely frail. These patients haven't had a BP within the current QOF year but the most recent BP reading on record was normal.  The likelihood is if you get these patients in for a BP check this will be within the normal range again and make it easy to improve your performance for DM033.  You may also want to consider if the patient is frail, in which case a BP target doesn't apply.  The report shows you the latest systolic and diastolic blood pressure values and details of any invites sent in the QOF year.  The BP target is less than 140/90.

QUICK WIN VALUE | Hypertension no BP reading this QOF year and latest was normal

This report gives you a list of patients who have Hypertension and haven't had a BP within the current QOF year, but the most recent BP reading on record was normal.  The likelihood is if you get these patients in for a BP check this will be within the normal range again and make it easy to improve your performance for HYP008 and HYP009.  The report shows you the latest systolic and diastolic blood pressure values and details of any invites sent in the QOF year.  The age of the patients is shown in the "Patient details" column - don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

QUICK WIN VALUE | Stroke no BP reading this QOF year and latest was normal

This report gives you a list of patients who have a history of Stroke or TIA. The patients included haven't had a BP within the current QOF year but the most recent BP reading on record was normal.  The likelihood is if you get these patients in for a BP check, it will be within the normal range again and make it easy to improve your performance for STIA014 and STIA015.  The report shows you the latest systolic and diastolic blood pressure values and details of any invites sent in the QOF year.  The age of the patients is shown in the "Patient details" column - don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

REVIEW | Last BMI >30 but not on obesity register

This search identifies patients who have previously had a raised BMI but haven't had one calculated during the current contract year.  This means they will not be included on your obesity register. Adding patients to the obesity register will increase the population count for the OB003 indicator and is in line with best practice.

REVIEW | Mental health review elements missing for this QOF year

This report will help you with achievement of MH021.  For this, you need each of the 6 review elements to be completed or declined - including:
  1. BP
  2. BMI
  3. Alcohol
  4. Lipids
  5. HbA1c
  6. Smoking
The report shows you the date of the last of each of these elements so you can quickly see which ones are missing/need updating.

g ) Clinical review searches


Info
Some of the patients identified in these searches and reports may not necessarily appear in the QOF list of excluded patients. Exclusions due to 2 or more invitations, recent diagnosis, recent registration are all factors which may not be relevant at the end of the contract year. Sometimes targeting these patients for activity can boost the numerator.
Alert
Patients who are currently 79 but are due to have their 80th birthday before the end of the contract year may appear in different searches depending on the run date used. Using 31st March (equivalent to QOF Look Ahead) will put the patient in the 80+ search, even if current QOF searches put them in the under 80 indicator. A difference between these searches and QOF is likely to be observed where the 79 year old's latest blood pressure is above 140/90 but less than 150/90.

CHECK BORDERLINE | Cholesterol non-HDL this year >2.5

This report includes patients with cholesterol whose latest non-HDL reading (taken in the last 12 months) is above target threshold (greater than or equal to 2.5). We have created this report so you can review these patients and their results alongside any current or previous lipid lowering medication courses. The report also shows any relevant PCA (e.g. statin or lipid declined) within the last 5 years. Some patients will also appear in the report below.

CHECK BORDERLINE | Cholesterol non-HDL this year borderline

This report includes patients with cholesterol whose latest non-HDL reading (taken in the last 12 months) is marginally above target threshold (non-HDL 2.5 - 3.5 or LDL 1.7 - 2.8). We have created this report so you can review these patients and their results alongside any current or previous lipid lowering medication courses. The report also shows any relevant PCA (e.g. statin or lipid declined) within the last 5 years. Some patients will also appear in the report above.

CHECK BORDERLINE | Diabetes HbA1c this year and HbA1c >58 mmol/mol (not frail)

This report will include patients on the diabetes register without moderate or severe frailty who have an IFCC-HbA1c of above 58 mmol/mol in the preceding 12 months. We have created this report so you review the patients and easily see whether they have previously been coded as being on maximum tolerated therapy. The patients included may be eligible to have this code added again for this QOF year, reducing the number of patients eligible for DM020, subsequently making the target easier to achieve.

CHECK BORDERLINE | Diabetes HbA1c this year and HbA1c >75 mmol/mol (frail)

This report will include patients on the diabetes register who are moderately or severely frail and have an IFCC-HbA1c of above 75 mmol/mol in the preceding 12 months. We have created this report so you review the patients and easily see whether they have previously been coded as being on maximum tolerated therapy. The patients included may be eligible to have this code added again for this QOF year, reducing the prevalence for DM020, therefore making the target easier to achieve.

CHECK BORDERLINE | CHD/HTN/STIA aged 79 or under BP this year not to target NO previous PCAs

These reports will show patients aged 79 years or under with CHD or hypertension or stroke whose latest blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or more but with no previous PCAs recorded. The report includes the patients and their BP reading so you can review them and take the necessary action to support the CHD015 / HYP008 / STIA014 QOF indicators.

CHECK BORDERLINE | CHD/HTN/STIA aged over 80 BP this year not to target NO previous PCAs

These reports will show patients aged 80 year or over with CHD or hypertension or stroke whose latest blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or more but with no previous PCAs recorded. The report includes the patients and their BP reading so you can review them and take the necessary action to support the CHD016 / HYP009 / STIA015 QOF indicators.

CONTROL | Cholesterol not on a statin NO previous PCAs

This report includes patients with cholesterol who are not on a statin and have no previous PCA recorded. The report will show current and past lipid lowering therapy as well as relevant medical history. You can review the patients’ to add a PCS this QOF year, if necessary, or action as appropriate to help achieve the CHOL001 QOF target, or remove the patient from the eligibility criteria

PCA CHECK | Cholesterol not on a statin previous PCAs

This report includes patients with cholesterol who are not on a statin and have a previous PCA recorded. The report will show current and past lipid lowering therapy as well as relevant medical history and the date of the previous PCA. You can review the patients’ to add a PCS again this QOF year, if necessary, or action as appropriate to help achieve the CHOL001 QOF target, or remove the patient from the eligibility criteria.

PCA CHECK | CHD/HTN/STIA aged 79 or under BP this year not to target previous PCAs

These reports include patients aged 79 years or under with CHD or hypertension or stroke whose latest blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or more and with a previous PCA recorded. The report includes the patients, their BP reading, and the previous PCA code, so you can review them and take the necessary action (if appropriate re-code the PCA) to help achieve the CHD015 / HYP008 / STIA014 QOF indicators.

PCA CHECK | CHD/HTN/STIA aged over 80 BP this year not to target previous PCAs

These reports include patients aged 80 year or over with CHD or hypertension or stroke whose latest blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or more and with a previous PCA recorded. The report includes the patients, their BP reading, and the previous PCA code, so you can review them and take the necessary action (if appropriate re-code the PCA) to help achieve the CHD016 / HYP009 / STIA015 QOF indicators.

REVIEW | AF with CHADS2VASC raised but no DOAC

This report shows patients on the QOF Atrial Fibrillation register and with a CHA2DS2-VASc score of 2 or more, who have not been prescribed a direct-acting oral anticoagulant (DOAC), or coded declined, contraindicated, etc. The report columns consist of relevant information to help you review the patients’, including the latest CHA2DS2-VASc score, previous course of DOAC, and OAC (Oral Anticoagulant) not indicated or declined, etc. This report will help to improve performance for the AF008 QOF indicator.

REVIEW | Diabetes but no frailty coded

This report includes all non-frail diabetic patients.  Diabetic patients who are frail have more relaxed treatment targets, they:
  1. don't need a statin
  2. don't have a BP target
  3. have a higher HbA1c target (75 or more)
You can review the patients included in the report and consider whether they need a frailty code added. Adding a frailty code to these patients will remove them from the following indicators: DM020 (HbA1c target of 58), DM022 (need to be on a statin), and DM033 (BP needing to be less than 140/90).

h ) Code reviews



We have identified a number of coding issues during the 2023/24 QOF contract year many of which persist through into the 2024/25.  These searches help practices to identify if they are affected and then take action with these.

BP issues

See our separate article for a detailed description of the issues.  These reports will show you patients with a below target threshold result for whom recoding (because of the BP issues identified) will assist with QOF achievement.

COPD Pulmonary rehabilitation issues

See our separate article for a detailed description of the issues.  These searches will show you patients who require recoding because of the removal of "Pulmonary rehabilitation offered" and the persistence of "Pulmonary rehabilitation declined"

Learning disability coding issues

See our separate article for a detailed description of the issues.  These searches will show you patients who have been removed from or added to the Learning disabilities register.  You can also see your old register for learning disabilities "LD LD004 - Patients on the learning disabilities register [PCIT]" to allow you to confidently recall patients for review at this time of the year.  The particular issue about Phenylketonuria has a separate report so you can review these coding issues.

i ) Cohort QOF management


Care home identification

This search needs to be localised with the details of any care homes, where you may be doing rounds and want to identify what QOF work is outstanding.
To add your care home details, right click the search above (Care home identification) and click “Edit”.

Double click on the rule noted with *PCode*  and * Insert Street No. of institution here *  :



Then double click on each of the elements and add in the details for one care home, removing the asterisks (*):




Use one rule for each care home, completing both Postcode and Number & Street


Warning
Note: This is case specific, if postcodes are recorded in your systems with lowercase characters, you will need to add these as a rule as well. All formatting used for postcodes and street names will need to have its own rule e.g. Nr152uy, NR15 2UY, NR152UY.

Adding Additional Care Homes

More rules can be added if you have more than 1 facilities by clicking on one of the rules and pressing copy and paste in the top menu bar


 


Once you have done this, the "Care home QOF identifier" is ready to use


Homeless register

Homeless QOF identifier is based on a homeless register which can be found in the z Denominators folder. This is any patient coded as homeless / sleeping rough / squatting / sofa surfing. They can be removed from the homeless register by adding a code from the hierarchy Housing ownership and tenure - finding that suggests they live in conventional accommodation. Examples of this include: Lives in flat; Lives in rented accommodation; Lives in own home.

Care home QOF identifier & Homeless QOF identifier

Info
Patients will only be identified in this search if they have any outstanding QOF targets in the current year.                                                                                                                  
These identical big reports include every patient in the parent cohort, displaying a list of QOF areas that usually require actions, with corresponding information to show if the patient is hitting the target or not.  It needs somebody who understands the QOF requirements and business rules to be able to identify what remaining work is needed for the current year.  You will need to scroll across the report using the bottom scrolling bar:


If you have more than 20 patients, you may need to go to further pages using the page navigator at the bottom right of the screen:


You may wish to export this report to Excel, where you can colour code the cells where action is needed, to help summarise which patients need which actions.  We would not suggest giving this output to a clinician without some interpretation being done first.

In order to help you with interpretation of this report, in the following sections, we will work through the columns shown in the report:

Exception reporting

The first two columns in the report will show you if the patient has had a PCA coded in this QOF year, or in previous QOF years.  It may be that some patients will be on multiple disease registers and so these columns can be helpful so you can see if the patient has a current or past PCA coded.  These columns also include PCAs for hypertension, diabetic HbA1c and cholesterol so if maximal tolerated therapies has been recorded you can also see this.


Asthma

To see if any of the patients need an asthma review, you can look down the column with "Asthma diagnosis" and if any of these are "Yes" you can see the date of the last asthma review that was undertaken.  You can therefore decide if a review is needed for this year.
Any diagnosis needing a BP

The column "Any diagnosis needing a BP" will show "Yes" where a patient has any QOF area that needs a BP.  You can then look at the age of the patient to decide what the BP target should be (<140/90 for under 80's <150/90 for over 80's or <140/90 for non-frail diabetics) and see if the patient is achieving that target.
Cholesterol

The "Should be on a statin" column will show you if the patient is on a statin and then the next column shows you any current cholesterol lowering medications.  You can then see the HDL and LDL results if these targets are needed.
COPD

To see if any of the patients need a COPD review, you can look down the column with "COPD diagnosis" and if any of these are "Yes" you can see the date of the last COPD review that was undertaken.  You can therefore decide if a review is needed for this year.  You can also see any MRC scores and if an appropriate pulmonary rehabilitation code has been added.
Dementia

To see if any of the patients need a Dementia review, you can look down the column with "Dementia diagnosis" and if any of these are "Yes" you can see the date of the last Dementia review that was undertaken.  You can therefore decide if a review is needed for this year. 
Diagnoses that need an HbA1c

You can see if the diagnoses of diabetes, NDH, or mental health exist and therefore if an HbA1c is needed. In the next column you can see the date of the last reading.  You can then in the next two columns see the last foot check date, and any coding of frailty.  With this and the BP, statin and cholesterol information you should be able to see what is outstanding for diabetes.
Heart failure

You can see if a heart failure diagnosis exists in the "HF Diagnosis" column and then in the next two columns the review and medication review codes (both are needed).   You can then see if the patient is on an ACEI/ARB and a B-blocker.
SMI

You can see if any SMI diagnosis exists in the column "SMI diagnosis". If it does, you can see the following columns:
  1. Care plan
  2. BMI
  3. Alcohol
  4. Lipids
  5. Smoking
You also need to look at the blood pressure earlier in the sheet.  If a diagnosis exists, you can see what is missing.  All 6 elements need completing for MH021


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