Maximising your QOF income: Diabetes mellitus

GP Dr Gavin Jamie looks at how practices can attain maximum points within the diabetes area of QOF’s clinical domain

Summary – indicators and value

• Indicators: 9
• Points:  67
• Prevalence*: 6% (this is an estimate based on latest available QOF data and current trends))
• £/patient on the register (estimated.): £24.80

Background

Diabetes has been part of the QOF since its inception and its prevalence has increased every year. It is the largest disease area in QOF, accounting for around more than 10% of both indicators and points. It is also an area with a high rate of exception reporting.

Summary of indicators

Indicator DM017: Maintain register of patients over 17 years (6 points)

Indicator DM033: Blood pressure under 140/90 mmHg in patients w/o frailty (10 points)

Indicator DM022: Patients over 40 w/o CHD or frailty on statin (4 points)

Indicator DM023: Patients with CHD on statin (2 points)

Indicator DM006: Proteinuria or microalbuminuria diagnosis, with ACE-I or ARB prescription after October in 97% of patients (3 points)

Indicator DM020: HbA1c is 58 mmol/mol or less in patient w/o frailty (17 points)

Indicator DM021: HbA1c is 75 mmol/mol or less in patients with frailty (10 points)

Indicator DM012: Foot check: risk/presence of ulcers (4 points)

Indicator DM014: Referred for a structured education programme (11 points)

Indicators in detail

Indicator DM017: Maintain patient register (6 points)

There are six points for maintaining the register. Only patients 17 years or older will be included. The description says that the type of diabetes (normally Type 1 or Type 2) should be specified, although in practice this does not seem to be checked. Patients with gestational diabetes do not appear on the register.

Drugs used in diabetes are pretty specific to the condition, so it is relatively easy to search for patients who are being treated but not appearing on the register. Blood results supporting diagnosis are also well defined, so it is useful to check these for any diagnosis that may have been missed.

Most of the rest of the indicators will be met during an annual review. It is important that patients are called and that the person conducting the review is aware of all the measurements and thresholds that must be achieved. Computer templates can help with this.

For blood pressure, cholesterol and HbA1c only the last reading in the year will count so there is good reason to measure each early in the year and have a robust system to re-measure after treatment has been changed.

Indicator 2: Blood pressure <140/90 mmHg in patients without moderate or severe frailty (10 points)

There are 10 points for 78% of patients having a reading of 140/90 mmHg or lower. As usual, only the final blood pressure reading of the QOF year counts.

Tips:

• There are exception reporting (now ‘personalised care adjustment’) codes covering the whole diabetes area where patients either do not wish or are unsuitable for treatment. The code for patients on maximal tolerated antihypertensive treatment is the same as for similar indicators in other disease areas. Patients may also decline to have their blood pressure taken.
• The structure of the indicator effectively makes coding moderate or severe frailty a form of exception reporting. There is an incentive here, and in the later blood glucose indicators, to look at whether frailty should be recorded in patients who are not meeting the target. They should certainly be the first patients to have their frailty assessed.
• Similarly there is an incentive to avoid coding frailty in patients who meet the target.

Indicators DM022 and DM023: Statin treatment (4 + 2 points)

Two groups of patients should be prescribed statins.

The first group includes all patients on the diabetes register who do not have cardiovascular disease (CVD) or frailty. There are four points for prescribing to 90% of patients in this group.

The second, and the easiest to capture, is patients with a diagnosis of cardiovascular disease. There are two points if 90% of these patients are prescribed a statin in the final six months of the QOF year.

Tips:

• Once again frailty is effectively a form of exception reporting for the second indicator.
• There is a further exception to this indicator where patients have a CVD risk score (usually QRISK2 or 3) of less than 10% recorded in the previous three years.
• More conventional exception reporting includes allergies or adverse reactions to statins. Allergies to pravastatin or simvastatin count, but at time of writing allergy to atorvastatin does not – the more general code for statins causing adverse effect should be used.

Indicator DM004: Proteinuria or microalbuminuria diagnosis and treatment (3 points)

There is a two-stage indicator carrying three points for recording patients who have a diagnosis of proteinuria or microalbuminuria at any time in the past, and prescribing an ACE inhibitor or an angiotensin II receptor blocker (ARB). As with most prescribing indicators, only prescriptions from October onwards count towards achievement. The maximum threshold is 97%, so there is little room for error.

Exception reports for allergies or when patients are unsuitable or unwilling to take these tablets must be coded separately for ACE inhibitor and ARBs.

Indicators DM020 and DM021: HbA1c testing (27 points)

These reward achievement of the following target HbA1c levels:

• ≤ 58 mmol/mol in 75% of patients without moderate or severe frailty (17 points; payment threshold: 35-75%)
• ≤ 75 mmol/mol in 92% of patients with moderate or severe frailty.

Tips:

• Although the higher level for patients with frailty can be seen as a form of partial exception reporting, the points distribution and the threshold make these patients your top priority. Over a third of the points are allocated to patients with frailty who will likely account for a much smaller proportion of patients with diabetes. Each patient with frailty is therefore worth considerably more in points and cash terms than a typical diabetes patient. An upper threshold of 92% is also fairly challenging.
• Blood tests can be difficult to organise for housebound patients who are much more likely to have a diagnosis of frailty. Due to the relatively high points value of these patients it is worth trying to do these as early in the year as possible so that community phlebotomy services do not become overwhelmed as QOF deadlines approach.
• In a similar way to the blood pressure indicators above, there is effectively an incentive to review patients with HbA1c between 59 and 75 mmol/mol to see whether a diagnosis of frailty would be appropriate.
• The last blood test in the year is the one that counts for this indicator, so when you reach the target, stop checking.
• Formal exception reporting applies here. The diabetes area codes can be used, or a code for the patient having maximal tolerated therapy for diabetes. Lesser used, but valid exception codes include blood test is refused. A further exception is a blood result for fructosamine, which is sometimes used where patients have unusual haemoglobin levels.

Indicator DM012: Foot checks (4 points)

While there may be many things recorded in foot checks, it is the assessment of risk for foot complications that allows patients to pass this indicator. Feet should be classified as at low, medium or high risk of ulcers or to have ulcers. Four points are available if 90% of patients have this assessment.

There are exception codes where diabetic foot examination is declined or not indicated. An automatic exception exists where a patient has bilateral foot amputations.

Depending on local services this may be done in secondary care or community services. Reviewing letters for relevant information and making sure foot checks are coded correctly can save time in the practice and increase achievement.

Indicator DM014: New patients referred for a structured education programme (11 points; payment threshold: 40-90%)

Newly diagnosed patients should be referred for a diabetes structured education programme within nine months after their diagnosis is made. The clock starts as soon as the diagnosis is recorded.

Most commonly referral will be to a DESMOND course, although XPERT and DAFNE are also accepted, as well as a generic code for referral to structured education. As this only applies to newly diagnosed patients, the 11 points for 90% of patients is fairly generous.

Positive achievement is a little odd due to that nine-month window which can often cross from one QOF year to another. You can code referral at any point during that period and it will count in the QOF year that it happened.

Exception codes must be recorded in the QOF year that the nine-month clock stops. For example, if a patient is diagnosed on 1 July but declines the structured education programme, then the exception code must be entered after 1 April the next year.

Dr Gavin Jamie is a GP in Swindon and runs the QOF Database website

Further reading/resources 

NHS England – Quality and Outcomes Framework guidance for 2023/24. Published 30 March 2023.