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Saturday 1 October 2016
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Exceptional circumstances

Exceptional circumstances

Effective exception reporting can help practices to avoid missing out on vital QOF points

Exception reporting has been part of the quality and outcomes framework (QOF) since the very beginning. It was regarded as an essential part of the package of targets and rewards, preserving a patient-orientated focus. 

The fear when first setting targets was that patients may be treated to targets against their clinical interests, or even contrary to their wishes. At that time, the measles mumps and rubella (MMR) vaccine scare was near its height, and immunisation targets were causing significant problems for practices. There were tales of inappropriate pressure being transferred onto patients.

Exception reporting was introduced for QOF but, interestingly, has never been introduced to the immunisation targets.

Undue pressure on patients has largely been avoided, but exception reporting has continued to be developed and refined over the last few years. While it maintains its original function, the increasing complexity of QOF has increased the need for a means of balancing the effects of the rules.

In the last year, more indicators have been introduced into the QOF, which have been dependant on the availability of external services. In England, only the indicator requiring referral of patients newly diagnosed with diabetes to an education programme has been implemented this year. Already implemented in Wales and due to come to England next year are two further indicators. Firstly, for an annual referral to an exercise-based course for patients with more severe chronic obstructive pulmonary disorder (COPD) and referral of patients with heart failure.

Many factors will affect the take-up of these services, and many will be totally out 

of the control of the GP practice. The ease 

of accessing services, or even their existence at all, will have a major influence on take-up rates.

Thresholds have been raised to 100% for two indicators in England, with several more to follow next year. To get all the points, practices will need to either meet the requirements of the indicator or exception report for every single qualifying patient. Many other indicators have an upper threshold of well over 90% and are in the same situation. It will be almost infeasible to get to a full achievement, and the change in thresholds will require that the reasons for not achieving the target in a given patient are made explicit.

Exception reporting has become slightly more difficult this year as well in England as the time that codes will be recognised has been reduced from 15 to 12 months in line with achievement indicators.

It is worth briefly reminding ourselves about how exception reporting works. The theory is simple - exception reporting applies where it would be unreasonable for the practice to achieve an indicator in a particular patient.

This may be because the patient is not suitable for a specific treatment or test. This is most common in patients who have a limited life expectancy where the interventions would only have an effect in the long-term. The intervention is simply not worthwhile as the benefit to the patient will be negligible.

A treatment may not be appropriate either due to previous adverse reaction to the drug by a particular patient or a drug may not be appropriate due to another diagnosis. Examples of the latter might include anticoagulation in patients with a history of previous gastrointestinal bleeding, or beta-blockers in peripheral arterial disease.

In almost all cases, the exception code will need to be entered anew in each QOF year (although the 15 month timescale continues in Wales and Scotland). In the case of drug allergies the code will only need to be entered once and will count towards all future years. These are described as non-expiring codes. In most cases, the rules will operate correctly if the allergy is recorded in the practice computer system.

Secondly, a patient may not want the test or treatment. They may actively decline the treatment, but in the cases of tests and reviews it is more likely that they simply will not attend. The rules specify that there should be three reminders sent before they can be exception reported.

Sometimes patients are not reaching a target such as blood pressure, despite maximal therapy being used. Maximum therapy may vary between patients and there are three possible limiting factors. Firstly the available treatments, secondly the level of side-effects the patient can tolerate and finally what the NHS, or at least your clinical commissioning group (CCG), is willing to pay for. The latter has become more significant over the past few years, particularly in relation to statin therapy for cholesterol control. National Institute for Health and Care Excellence (NICE) have been reluctant to recommend statins that are not yet available generically.

Hitting maximum therapy is likely to be more common in some disease areas than others. The official guidance is clear, for example, that epilepsy is expected to have a higher rate of exception reporting than some other areas due to the difficulty in obtaining control in some patients and the relatively high risk of side-effects in anti-convulsant drugs.

Finally there is automatic exception reporting. In these cases no code is entered by the practice - the exception report is built into the business rules. All patients are exception reported for three months after registration with the practice. They are also exception reported from a specific disease area for three months after their diagnosis with that disease. In the case of outcome indicators, such as hitting a blood pressure or blood sugar target, both of these times are increased to nine months.

For this reason, practices that have a more rapid turnover of their patient list, or who are more actively seeking out chronic disease will have higher exception rates than their peers. Indeed this may be the largest single reason for exception reporting in a practice.

As with all exception reporting the exception is ignored if the patient ‘passes’ a particular indicator.

Finding information about how exception reporting is used is a little difficult. Exception reporting figures are given in the annual reports published by the Department of Health (DH) but there are significant limitations. If a code has been entered and ignored because the patient meets the target, that will not be reported. While there is some publication of the reasons for exception reporting, it is difficult to interpret, not least because only one reason will be recorded for each patient, and the order of precedence is not completely specified.

Other reasons for exception reporting have been introduced in recent years. The official QOF guidance is explicit that patients may be exception reported where a secondary care service is unavailable, although there are no codes that practices can use to indicate this in patient records. Other codes should be used with appropriate text explaining the reason for its use.

The increasing complexity of the QOF means that other reasons are needed. This year’s depression indications state that a biopsychosocial assessment should be made on the same day that depression is diagnosed and coded. Where the diagnosis is made in secondary care, this may not happen, and patients should be exception reported. The same will be true for the review indicator where the patient is receiving ongoing care from specialist services.

Originally, exception reporting was highest in outcomes indicators. This was partly because of the longer timescale for automatic exception reporting described above but also because these were some of the most difficult areas to attain. This has changed over the last few years and the top ten indicators with the highest rate of exception reporting do not include any outcomes indicators.

Complex indicators feature heavily on the list. Where there are several individual tests or actions required to achieve an indicator, exception reports are high. The area with the highest exception reporting rate in 2011/12 was Dementia 3. This indicator requires eight different things to be tested in a blood test within six months of the date of diagnosis. Exception reporting here is over 40%.

A couple of these complex indicators offered much greater scope for exception reporting. Coronary heart disease (CHD) 14 requires the prescribing of four separate drugs to patients who have suffered from a myocardial infarction. If one of these drugs is not indicated in a patient, they will be excepted from the whole indicator, assuming other drugs are given. If any drug is neither prescribed nor has an exception report, this is regarded as a failure of the indicator. Up to four exception codes may be needed for this indicator.

Two of the four drugs - aspirin and beta-blockers - have fairly common contra-indications, so it is not surprising that exception reporting rates are high. Somewhat counter-intuitively, this probably represents a fairly high level of achievement in that indicator as, even in exception reported patients, the other parts of the indicator will have been fulfilled.

There is a similar situation regarding the multiple blood tests required around the time of dementia diagnosis, although the timing requirements here are as likely to be significant if the formal diagnosis is delayed.

Another formal mention of exception reporting in the guidelines is in relation to osteoporosis. As the indicators stand, if patients are over 80 years old at the end of the QOF year and have had a fragility fracture in the past, they should be prescribed a bone-sparing agent. Under this age they should have had a bone density scan and be treated according to the result of that.

There is a small potential problem here. If patients are over 80 and have had a normal bone density scan, either because they were under 80 at the time of the fracture or there were other particular concerns, then the indicator would suggest that they have the medication despite them having been shown not to need it.

The recommended way out of this is through exception reporting treatment, with bone-sparing agents as not indicated. This is much simpler than trying to cover every eventuality in the business rules, and illustrates another important function of exception reporting; it avoids the potential incentive to maltreatment of patients by rigid adherence to the QOF rules. It also allows these rules to be much simpler, and generally simpler rules are better for everybody.

All of the evidence has been that exception reporting is something that is done reluctantly by practices, often at the end of the year and normally only as much as is necessary. As upper thresholds rise this year and in the future, it seems likely that exception reporting rates will rise as their importance increases. The exceptions don’t prove the rules in this case, but they do make sure that the rules work for both patients and practices.