Due to constraints of EMIS Web in particular, searches and protocols are not built the same which means in some cases that a patient may show as eligible in a search but not according to the Handy Protocol.

Searches provided by PCIT usually reflect the business rules of an Enhanced Service. This means that anybody identified as eligible and subsequently vaccinated will have the activity remunerated. The business rules for these vaccination programmes specify a set of conditions such as coding on a patient's record to confer eligibility, and these are ultimately used by GPES/CQRS to determine whether or not a vaccination should be counted for payment purposes. The business rules would have been developed by the NHS based on criteria laid out in the relevant chapter of the Green Book.

Searches for flu

1. 001 CQRS: Seasonal Influenza
   
2. 016 Seasonal Influenza

Coding

To mitigate not including all codes, 016 Seasonal Influenza contains an additional search, SIV-A22 which identifies patients who are not in SIV-A21 (the payable at-risk group) but who have codes within a range of other code clusters reflecting the groups described in the Green Book. This is still not exhaustive, but should pull up a number of patients who clinicians are likely to say should receive a flu vaccine. Any patient in SIV-A22 who is given a vaccine MUST also have the code Needs influenza immunisation adding.

If Practices have not acted on patients appearing in SIV-D99, they have a second opportunity at the beginning of the following month by using the Missed Activity reports in 001 CQRS. Again, Needs influenza immunisation MUST be coded to ensure payment.

Searches for pneumo

The following resources fall under the scope of this section:

1. 001 CQRS: Pneumococcal PPV
   
2. 020C Eligible for Pneumococcal vaccination

Coding

Historic coding can be a factor - old local codes will not be captured by the national searches unless they have been mapped to an appropriate code.

The procedure or diagnosis is too specific - sometimes a condition will have a number of child codes beneath it, but not all of them have been included in the national cluster.

Unlike flu, clinical at risk PCIT searches for pneumo stick to the proscribed list of codes for the CQRS Enhanced Service. This keeps things simple and ensures that patients invited and subsequently vaccinated will be paid.
Other patients identified by a clinician to receive a pneumo vaccination should be coded with Requires a pneumococcal vaccination.

High risk patients

Eligibility of high risk patients eligible for a booster dose is not checked by CQRS, simply that another pneumococcal vaccination has not been given in the previous 4 contract years (5 including the current year). The search in 020C takes two groups of patients described in the Green Book (patients with Chronic renal disease and those with asplenia/splenic dysfunction) to generate a cohort of patients who could be offered a booster dose. It is entirely possible that a clinician believes that a patient not in PA-323c should have a booster dose. Most queries to PCIT about this cohort tend to be asking why a patient is included, so they are directed to the Green Book.

Age

Eligibility by age is similar to flu in that technically 64 year olds whose 65th birthday falls before the end of the contract year are eligible. The PCIT search for CQRS applies this rule, but to keep recalls straightforward the 020C Eligible searches use a simple age is at least 65 rule.

At the younger end of at risk patients, 2 year olds are also subject to a fixed date of birth rule. Eligibility at the younger end can be complicated by the patients receiving their childhood PCV doses only 12 months earlier.

The CQRS searches for pneumo are specific for the contract year as dates of birth are fixed. Check the description of the denominator cohort searches to confirm validity. If using these searches in the following contract year (a relative run date of 1st April is acceptable to check March of the previous contract year), a likely outcome is that patients at the bottom end of the age range (2 and 65) may not be included in monthly reports. Remember these searches should not be used for invitation.

Searches for shingles

The following resources fall under the scope of this section:

1. 001 CQRS: Shingles
   
2. 004 GP Contract Pro (QOF VI004)
3. 020C Eligible for Shingles vaccination

Coding

Historic coding can be a factor - old local codes will not be captured by the national searches unless they have been mapped to an appropriate code.

For QOF VI004, coding of Shingles (herpes zoster) vaccination declined is important. When the shingles vaccination was introduced, EMIS provided an interim code [1863751000006104]. This EMIS code is not valid for removing patients from the VI004 denominator for QOF. Practices have reviewed their population excluded and found an identical code term in the care record, but did not appreciate that the SNOMED concept ID was different.

The procedure or diagnosis is too specific - sometimes a condition will have a number of child codes beneath it, but not all of them have been included in the national cluster.

Immunocompromised

1. Some of these reasons like graft versus host, haematological malignancy, HIV, persisting immunosuppression condition, lymphoproliferative disorders are unlikely to raise any queries for inclusion or exclusion unless there is a problem with coding.
   
2. The time limited reasons radiotherapy treatment and stem cell transplant in the previous 2 years are also less likely to trigger queries unless the event took place more than 2 years ago but has been coded as a review more recently.
3. Expiring immunosuppression condition and immunosuppression procedures are mirrored by a rule for flu eligibility, and covers a number of conditions and procedures coded recently. These codes are perhaps less likely to be coded, but could give rise to some queries as to whether shingles vaccination is appropriate.
   
4. DMARDs is an unusual search in that it looks at coding for DMARD therapy in the past 6 months rather than medication issues. Patients captured in this group will be determined by how a Practice records administration of DMARD therapy.
   
5. This leaves Immunosuppression medication. The CQRS business rules are unable to replicate the criteria specified in the Green Book. Here, the question is almost always going to ask why a patient has been included when a nurse says they shouldn't be. This is where clinical review is needed to calculate daily dose of certain medications, or to check combinations (and strengths) of medications.
   A reason for a patient on a particular medication not captured by this search is likely to be because it is issued by a hospital and the Practice has not recorded this on the patient's medication screen as a Hospital issue (even if it has been added, it must have been 'issued' in the 6 months prior to the search running). 

Queries to PCIT often come in the form of "this patient has been invited due to your eligible search but we think they shouldn't have been". If the patient's reason for eligibility was due to medication Practices would be right to question this, and PCIT has been careful in both searches and support articles to warn that the Immunocompromised cohort requires clinical review before invitation. 

Age

1. Patients aged 70-79 is by age so there should be few causes for questioning
   
2. Patients in the 65 year old catch up cohort must have been born AFTER a certain date (01/09/1958) and have reached their 65th birthday. The criteria remains the same each year until patients turn 70, so the cohort will technically continue to increase until September 2028. Patients aged exactly 65 but born before 01/09/1958 are not eligible and must wait until their 70th birthday.
   
3. Patients aged 50 who are immunocompromised must have had their 50th birthday before they are eligible.
   

PCIT recognises that shingles is going to generate the majority of queries, and we have been working to refine the searches and supporting resources to make the process as easy as possible to follow. If there are queries arising please do read the supporting resources carefully, but our technical support team is happy to provide additional support and guidance.

Searches for COVID

Patients with asthma are often queried as to why they are not eligible. The Green Book defines poorly controlled asthma as those requiring 2 or more courses of oral corticosteroid in the preceding 24 months or at least 1 admission (for exacerbation) in the preceding 24 months. For a respiratory illness, it does not make sense why any patient with actively managed asthma cannot automatically receive a COVID vaccination. Whilst there are not yet payment mechanisms based on business rules, data about eligible and vaccinated patients is routinely extracted from the clinical system so it is possible that vaccinating well controlled asthmatics with no other co-morbidities may be identified as breaching the Green Book guidelines.