As primary care teams approach the end of the second year of the Quality and Outcomes Framework (QOF) of the new General Medical Service contract, there is a realisation that the QOF was intended to be a dynamic structure to enable practices to be paid to deliver high-quality care. Reviews were built into the process and were intended to identify clinical indicators that had gained or lost evidence, matters for which the legal status had changed, and items that the NHS no longer wished to purchase (Buckman, 2006).
Part of the impact of the QOF has been to encourage professionals with an interest in diabetes to apply evidence-based medicine. The first QOF (QOF1; Department of Health, 2004) was based almost entirely on evidence or good practice. To ensure that this principle was maintained, the QOF negotiators appointed the University of Birmingham and the Royal College of General Practitioners to act as independent assessors of all the primary care evidence, both old and new. There was a call to submit evidence for review by 30 May 2005. Five hundred and fourteen submissions were received, across all the clinical indicators, from Government departments, academic institutions, learned societies, patient groups and practices (British Medical Association [BMA], 2006a).
Changes to the diabetes indicators
Primary care teams are currently working to maximise QOF points for the year end (31 March 2006), before turning to the revised QOF (QOF2), which will be assessed at the end of March 2007 (BMA, 2006b; for changes relating to diabetes see Table 1 for key points and Table 2 for fuller details; see Table 3 for a full list of diabetes indicators in QOF2).
From 1 April 2006, the QOF is going to be worth 1000 points. The negotiating parties agreed changes to the QOF, which include several new or revised clinical areas and higher thresholds. One hundred and sixty-six points have been recycled, of which 138 have been allocated to new areas and 28 have been incorporated into existing indicators. The value of each point remains at the levels set out for 2005/2006.
Quality Management and Analysis System (QMAS) reports in England, and their equivalents in the other nations, have shown very high achievement rates of indicators in QOF1 (BMA, 2006a), so it has been agreed to raise the payment threshold from 25 % to 40 % for most indicators in QOF2. Most upper limits have been set at 90 % unless evidence suggests that it is unattainable or inappropriate.
Ninety-three points are now available for diabetes (Table 3), down from the previous 99. Eight smoking points from the previous diabetes indicators have been consolidated into a total smoking indicator, rather than awarding the same points across five clinical indicators (diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease and smoking) as before. Two new points to augment the HbA1c and hypertension clinical targets have been added, recognising the difficulty in achieving these outcomes. In the case of hypertension, the upper payment threshold has been set slightly higher.
An important feature of QOF has been the establishment of disease registers. In the case of diabetes, to achieve the same points as before, practices will now have to stratify their patients with diabetes into type 1 and type 2. Accurate READ coding should help with this exercise. In addition, while insulin use is common to the two types, there are several typical differences, which are outlined in Table 4. It is worth noting that other clinical areas have seen the points diminish for forming such registers.
Primary care teams may be surprised to see that the lower indicator for HbA1c levels has gone from 7.4 % to 7.5 %, at a time when many organisations are urging a lowering of HbA1c targets to 7.0 %. There would appear to more pragmatism than science here on the part of the negotiators.
The evidence for the lower HbA1c indicator comes from the Diabetes Control and Complications Trial (DCCT), which found few microvascular complications in those with HbA1c below 7.5 % in people with type 1 diabetes (DCCT Research Group, 1993). The authors of the National Institute for Health and Clinical Excellence (NICE; formerly the National Institute for Clinical Excellence) guidelines on blood glucose control in type 2 diabetes use this to argue for HbA1c levels below 7.5 % in people with type 2 diabetes (NICE, 2002).
Based on the rationale that estimated glomerular filtration rate (eGFR) is reported to be a better method than serum creatinine for detecting and monitoring early renal disease – as it takes plasma creatinine, sex, age and weight into consideration – it has been included in diabetes indicator 22. In the long term, eGFR should be easier for people with diabetes to understand because log transformation is not needed to assess change in renal function.
There have been no changes to the rules around exception reporting. However, there has been some speculation that primary care organisations may publish exception reporting within practices in a primary care trust.
New indicators relevant to diabetes
The process of deciding on the new areas of work to be introduced in QOF2 involved appraising the submitted evidence and then prioritising their clinical importance in primary care. There were 138 points available for new indicators, which were allocated based on supporting evidence (Table 5).
Chronic kidney disease
Diabetes nephropathy is the leading cause of kidney disease in people requiring renal transplant (Gross et al, 2005). In the Western world, type 2 diabetes is the most common condition in people with kidney failure (International Diabetes Federation [IDF], 2006). Primary care teams will recognise that there is considerable overlap between the chronic renal failure registers and their diabetes registers. New indicators for chronic kidney disease are shown in Table 6.
As with diabetes and chronic kidney disease, there will be considerable overlap between diabetes and obesity. The risk of developing type 2 diabetes increases progressively with the level of obesity (IDF, 2004). Over a 10-year period, relative to people with a BMI <22 kg/m2, those with a BMI >35 kg/m2 are up to 80 times more likely to develop the condition. With a BMI >30 kg/m2, people are up to ten times more likely to get diabetes.
In QOF2, the new 8-point indicator for obesity is:
‘The practice can produce a register of patients aged 16 and over with a BMI greater than or equal to 30 in the previous 15 months.’
Primary care teams may be relieved that they are not being judged on their abilities to reduce the prevalence of obesity. These registers may prove useful, though, if targeted screening for diabetes is proposed by the National Screening Committee, and eventually this indicator may be revised to include waist-to-hip ratio measurements.
For some time it has been recognised that there is an increased incidence of depression in people with diabetes, estimated to be between 11 and 15 % (Anderson et al, 2001). Several trials have shown that depression can be adequately treated in patients with diabetes and depression (Lustman et al, 1998; Lustman et al, 2000). New indicators for depression are shown in Table 7.
NICE (2004) guidance on depression suggests that ‘screening should be undertaken in primary care […] for depression in high-risk groups’ and that ‘screening for depression should include the use of at least two questions concerning mood and interest,’ such as the following.
- ‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
- ‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
Primary care teams will want to examine the guidance carefully and decide how best to assess their patients with diabetes. A mixed strategy of opportunistic screening and systematic application of questionnaires may well be used. A more difficult judgment will be whether to add an antidepressant to the overall pill burden of patients with diabetes.
Changes to the QOF should be carefully scrutinised by primary care teams. They will recognise that there have been subtle but important changes to the indicators for diabetes and other clinical areas. New indicators have been introduced, some of which overlap with the diabetes indicators.
While there has been quite a lot of speculation about what might be in QOF2, the overall impression seems to be one of relief that most of the diabetes clinical indicators remain the same. With a systematic approach to the indicators, most teams should be optimistic of achieving as high levels as were previously attained.