QOF 23/24 problems

Entering Q4 2023/24 a number of issues exist with QOF, some caused by EMIS and others due to national changes. These have led to widespread concern regarding the ability of Practices to work towards achieving QOF indicators and being able to accurately monitor achievement. This article has been written to summarise the problems and what you could do. Our technical article of known system issues describes the problems in terms of codes and business rules.

There are 4 known types of problem.

1. A patient is on a drug, but QOF shows that the patient hasn't achieved the indicator
   
2. A COPD patient has been reviewed and offered pulmonary rehab, and the alert went away but QOF shows that the patient hasn't achieved COPD014
   
3. The Learning Disability register is suddenly bigger
   
4. Blood pressures below target threshold not being recognised for various indicators

Drugs not being counted for QOF

This problem appears to be isolated to EMIS, and became evident when MKB203 (the dictionary update of codes and drugs) was released. There are a number of indicators which have been affected:

Indicator	Main drugs missing
AF008	Apixaban tablets, warfarin tablets
CHD005	Apixaban tablets, warfarin tablets, aspirin tablets
CHOL001	Rosuvastatin tablets, simvastatin tablets, Ezetimibe tablets
DM006	Almost all generic ACEi and ARB tablets
DM022 / DM023	Rosuvastatin tablets, simvastatin tablets
HF003	Almost all generic ACEi and ARB tablets
HF006	Almost all generic beta blocker tablets
STIA007	Apixaban tablets, warfarin tablets, aspirin tablets, dipyridamole tablets

EMIS has acknowledged that a number of drugs disappeared from the QOF searches after MKB203 (and later MKB205) was released. They initially made some changes to the QOF searches to mitigate the impact, but there is still work to be done to properly restore the drugs into the reference sets.

Staff will notice these problems arising via searches rather than the red box alert. PCIT has reviewed the alerts and found that they are unaffected as all missing codes are included.

Trust the red box alert!

16th January: EMIS appears to be rolling out a manual fix for affected QOF indicators in V47 Release 1.5. Drug refsets have been replaced by lists of drugs. 

What does this mean for me?

Primary Care IT released its own searches with the drugs added back in (004 GP Contract Pro v3.3). Any previous versions may return incorrect results where patients on certain drugs are still excluded from the indicator numerator. We recommend using these latest PCIT searches for the remainder of the contract year, or at least until EMIS confirms that all drugs have been restored. Remember an advantage of using PCIT searches over the built-in QOF searches is that they can be run whenever you want.

COPD Pulmonary rehab

The indicator for pulmonary rehab (an offer of referral for pulmonary rehab is made to patients with MRC score of 3 or more) has dropped significantly. This is due to the code for Pulmonary rehabilitation offered being removed at national level (not EMIS). Any patient who has had that code added since April 2023 now appears on the exclusion list.

Unfortunately the ability to code that the patient had declined pulmonary rehab was removed in April 2023 (when COPD008 became COPD014). Currently the only viable method of excluding a patient is to use Excepted from COPD indicators... 

What does this mean for me?

As of 4th January 2024 there is no clear indication of planned changes or fixes. Assume that COPD014 will continue to only count patients who have been referred.

Primary Care IT has produced a search to help identify affected patients. 

16th January: EMIS appears to be rolling out a manual fix to QOF, seen in Rule 5 of denominator [COPD014].

Learning Disabilities register

The Learning Disabilities register increased in numbers following the MKB205 update. A lot of new codes were added - many of which are relatively new SNOMED codes - but unfortunately there were a number of codes added for conditions which do not automatically mean the patient has a learning disability. The two codes that Practices noticed the most were Retinitis pigmentosa and Neurofibromatosis type 1.

NHS England responded to concerns in mid-December and directed clinical system suppliers to remove 15 codes from the Learning Disabilities cluster.

16th January: TPP SystmOne has completed this work, while the work is resolved in EMIS Web for Practices on MKB206.

What does this mean for me?

Whilst the new codes have affected the QOF register, this has no direct bearing on any achievement indicators. The IIF indicator HI-03 is affected, and Practices noticed a decrease in their achievement associated with the sudden increase in size of the register.

Primary Care IT released modified searches in 025A to offer an accurate achievement. 

Phenylketonuria

While PKU can lead to a learning disability if left unmanaged, the UK actively screens for PKU shortly after birth so patients with the condition can hopefully receive treatment and lead a life without a learning disability.

One new code that was added was Classical phenylketonuria [7573000]. This term in itself should not be an issue since it is strongly associated with learning disabilities. Digging deeper into the code synonyms we found that there are some terms for Phenylketonuria which may have been added to records prior to the implementation of SNOMED CT, and the adding user intended to record that the patient had been diagnosed with Phenylketonuria (usually at birth). Nowadays, the parent of Classical phenylketonuria, Phenylketonuria [190687004] is likely to be used for this.

Note the description IDs of the lower terms in particular [13501019] which appears to be the term used the most, presumably in EMIS LV, PCS, and Web Read v2. What has happened is that this term had its own Read code, but during the migration to SNOMED, it was mapped to the SNOMED concept ID 7573000.

What does this mean for me?

The effect of this mapping is that patients with well managed PKU have now been included on the LD register, and by extension HI-03 for IIF. We urge Practices to carefully review newly added patients. Primary Care IT has produced some searches to help identify patients now included on the LD register due to Phenylketonuria.

We have raised concerns with NHSE and EMIS regarding the mapping and await an initial response. Re-coding affected entries may be the pragmatic solution, although such a decision to alter the record would need to be taken by clinicians on a case-by-case basis.

This issue is resolved in EMIS Web on MKB206.

Blood pressures

An emerging area of concern as Practices ramp up their QOF activities prior to the end of the year is blood pressures not being recognised. These are being found where Practices follow up on patients with CHD/diabetes/hypertension/stroke who have not had a blood pressure for indicators, or their blood pressure this year was above the threshold.

The 2023/24 contract year saw some a change to the blood pressure target business rules by introducing a lower threshold for blood pressures recorded at home (135/85 for patients aged 79 or younger ; 145/85 for patients aged 80 and above). Some EMIS Practices have begun to notice that some patients have a blood pressure recorded at home below the threshold who are not being counted toward the relevant indicator; the common factor is that these results have been coded from a returned AccuRx Florey.

Primary Care IT has thoroughly reviewed the QOF rules for both EMIS Web and TPP SystmOne. Recognising the way searches are written in each system are different, EMIS' approach appears to put Practices at a disadvantage compared to SystmOne neighbours.

AccuRx

AccuRx offers 3 different Floreys for reporting home blood pressure readings. "Blood Pressure Questionnaire" (not the versions labelled -7d Home Monitoring or -4d Home Monitoring) writes back 3 codes:

Blood pressure recorded at home      [413153004]

Systolic arterial pressure      [72313002]

Diastolic arterial pressure      [1091811000000102]

The problem here is that the QOF rules do not count "Systolic arterial pressure" or "Diastolic arterial pressure" as valid home BP codes. The other two Floreys use "Average home systolic blood pressure" and Average home diastolic blood pressure".

Due to the different approaches between systems, SystmOne at this point will accept the reported blood pressure readings, NOT as home readings, but as surgery readings. S1 Practices are given another small advantage in that results above 135/85 but below 140/90 are still counted as below threshold!
EMIS Web takes a different approach to surgery based blood pressure readings - see the next section.

We know that some Practices have taken to manually recoding these results using o/e - Blood pressure reading and adding some free text to state the result was recorded at home. This approach levels the playing field compared to the SystmOne advantage previously described, although some effort is required to achieve it. The more correct approach would be to recode from ...arterial pressure to Average home .... blood pressure.

UPDATE 08/02/24: AccuRx worked with Primary Care IT to understand the coding challenges and how best to address them moving forward. PCIT and AccuRx continue to press EMIS for an amendment to the rule logic of their QOF searches so previous readings are counted.

Other blood pressures

There are approximately 27 systolic codes that can carry a value, and a similar number of diastolic codes. In addition to this set there are 4 "panel" codes which can carry both a Value and a Secondary Value.
Those who were invested in IIF's CVD-01 from 2022/23 will remember a similar situation where only 4 codes were valid to record a blood pressure.

o/e - blood pressure reading      [163020007]

Standing blood pressure reading      [140247000]

Sitting blood pressure reading      [140248005]

Lying blood pressure reading      [140246009]

EMIS has written a number of QOF sub searches in a way that only allows the above 4 codes to be recognised as a blood pressure result. Below is a partial screenshot demonstrating the systolic part of the surgery based result for 140/90. Note the top requirement for a blood pressure code within Refset 999035981000230105 that has both a Value and Secondary Value.

In the case of the AccuRx problem, the individual Systolic arterial pressure and Diastolic arterial pressure both only have a Value (not a Secondary Value), so they fail.

As was the case with CVD-01 other blood pressures recorded using separate codes aren't counted, such as ambulatory blood pressure results where typically you might be using codes such as Ambulatory systolic blood pressure or Average 24 hour systolic blood pressure or Average day interval systolic blood pressure alongside their diastolic equivalents.

What does this mean for me?

There is a chance that some blood pressures recorded this contract year which are below threshold have not been counted towards various QOF indicators.

Primary Care IT has developed some searches and reports in folder 004B to help identify patients affected by either the AccuRx problem, or separately coded blood pressures in a surgery based consultation.

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