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QOF: Bundling care


19 October 2012

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I wrote a few months ago about the proposal to have one indicator in the Quality and Outcomes Framework (QOF) which covered much of the current diabetes area.

This had been proposed by government as a response to the national diabetes audit which reported on the proportion of patients who had received all nine diabetes care processes. My concern at the time was about the patients who were left behind. If there is no difference between receiving eight of the process and none many of these patients could be left behind.

I wrote a few months ago about the proposal to have one indicator in the Quality and Outcomes Framework (QOF) which covered much of the current diabetes area.

This had been proposed by government as a response to the national diabetes audit which reported on the proportion of patients who had received all nine diabetes care processes. My concern at the time was about the patients who were left behind. If there is no difference between receiving eight of the process and none many of these patients could be left behind.

It is always useful to attach some numbers to this sort of thing and that is exactly what a recent paper in BMC Health Services Research does. Normally we can’t link QOF data up to see what care a particular patient has received. We can’t know if a patient who had a cholesterol blood test also had an influenza vaccination. Each indicator is measured separately and only the total numbers leave the practice.

By searching the data within nine practices in the West of Scotland, the researchers from NHS Scotland were able to see how the interventions were spread across patients. As well as looking at diabetes they also looked at coronary heart disease, kidney disease, stroke and COPD.

In many individual QOF indicators we see achievements of 90% or more. What is not clear before this study is whether 90% of patients get all of these interventions with 10% getting none or whether they are spread more evenly across all patients with a diagnosis.

The answer seems to be the latter. Figures for patients having all of the treatment interventions tended to be quite a bit lower than the figures for individual indicators. Generally two thirds or more achieved all of their required indicators. Where patients were exception reported they were counted as having met that indicator.

Personally I find this quite reassuring. It seems that practices are pretty even in their efforts and, although it is difficult to be absolutely sure from the data that has been published in this, it seems that few patients are completely ignored.

The data does show that care is not perfect, and is probably rather less perfect than it may appear to be from the raw QOF data. At the same time improvement seems to be well within our grasp.

Widespread use of care bundles as indicators will require changes to the software that practices use to monitor their achievement and the steps that they need to take. No longer will the indicator be monitored alone but each component of the bundle will require reminders and audit.

This is not an entirely new concept. In the first couple of year the QOF there were points awarded for holistic care. These were based on your three worst clinical areas and encouraged consistency of achievement.

Care bundles, if they can be made comprehensible to the clinician in front of the patient may well be seen as better means to achieve the same goals and with the beginnings of an evidence base around them are likely to be seriously considered by NICE.

BMC Health Services Research 2012, 12:351 doi:10.1186/1472-6963-12-351
Published: 8 October 2012
http://www.biomedcentral.com/1472-6963/12/351/abstract

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