Maximising your QOF income: Asthma area

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

Summary – indicators and value

• Indicators: 4
• Points: 45
• Prevalence: 6.2% (this is an estimate based on latest available QOF data and current trends)
• Estimated £/patient on the register: £6.10

Background

Asthma is an area with relatively high prevalence, but a correspondingly large number of points. It also has some of the most complicated rules in the QOF, so it can be tricky to manage.

New requirements for respiratory testing were introduced in 2020/21. These remain in the indicators but have been updated so that they now apply to all patients diagnosed from April 2023.

The following summarises all the indicator changes made in 2020/21:

• The register for patients diagnosed with asthma was restricted to those aged over 6 years, in line with NICE guidance aimed at reducing potential for over-diagnosis in young children, in whom diagnosis can be particularly difficult.
• The diagnostic indicator was made stricter so that a minimum of two objective tests, including spirometry, are required to confirm diagnosis – and these must have been performed between 3 months before and 6 months after any diagnosis, not just any time after diagnosis. This applied only to patients diagnosed after 1 April 2020 – any new asthma patients joining the practice with a diagnosis after this date must have it confirmed within 6 months of joining.
• The content of the asthma review was amended to incorporate recording of exacerbations, an assessment of inhaler technique and a written asthma plan 
• Recording smoking status now applies to all patients on the register under 19 years (not just those between 14 and 20 years) – and this must include passive smoke exposure, not just personal smoking.

Indicator AST005: Maintain patient register (4 points)

It is not sufficient for patients to have a diagnosis of asthma to be included on the register. There must also be a prescription issued for asthma medication in the QOF year.

This can make automatic reminders less reliable, as patients will not be seen to be eligible until the prescription is produced. So, when patients only need medication infrequently, they may appear on the register – and become eligible for the other indicators – late in the QOF year.

Identifying patients early in the year will not increase your final prevalence but can give more time to conduct reviews.

Only patients who are at least six years old at the end of the year will appear on the register. If you are monitoring the register throughout the year, then children may pop onto the register on their sixth birthday. It would be best to look at patients from five years old as they could turn six during the QOF year.

More generally, if patients have missed the diagnosis code then searching for asthma medications can be a good way to identify them. These medications are quite specific for asthma, especially in younger patients.

Indicator AST011: Spirometry plus one other objective test to confirm diagnosis (15 points)

All patients who have had a diagnosis of asthma from April 2023 onwards will need to have a record of spirometry and one of reversibility, variability or FeNO testing to confirm the diagnosis. This can be three months before the diagnosis, or up to six months after. Once that six months has passed there is no way for the patient to achieve this indicator.

The two stages must both be completed to achieve this indicator. First spirometry must occur with a challenge of a bronchodilator or corticosteroids. Either the procedure or the result can be coded for this indicator. It does not matter where the spirometry took place – in practice or secondary care. Even coding a referral for spirometry is sufficient. Alternatively you may need to record that a spirometry service was not available in line with advice during the pandemic– which will except the patient from this indicator.

There is a choice for the second aspect. Most simply this can be by peak flow measurement. The description of the rule says that this should include a measure of variability, although for the purposes of the QOF calculation almost any peak flow code will do. Peak flow meters can be prescribed on an FP10 for patients to use at home. A short useful video giving instructions for using the meter is available for patients from Asthma UK here.

The second option is the measurement of expired nitrous oxide testing (FeNO testing). Its use is likely to be limited in primary care by the availability of the equipment to carry out the test.

Patients who join the surgery without an appropriate record of testing have been a source of QOF problems in the past. Now year the clock is reset at the time that patients join the practice. If they have not already had spirometry and peak flow testing then there is six months from the date of their registration for this to be carried out. All patients who join the practice whose diagnosis of asthma is after April 2023 will need to have their records reviewed and be invited for tests. Unfortunately, if they have had only one of the tests already then they will have to have both in that first six months.

Make sure that patients have the required testing before asthma is recorded. This will ensure a high rate of achievement in this indicator and is likely to make the diagnosis more reliable. This is more difficult if the diagnosis is made in secondary care but the testing can be done as part of a post-discharge review.

Indicator AST007: Annual asthma review (20 points)

Every patient with asthma should have an annual review. The full 20 points are awarded for reaching 70% of patients.

Four codes are needed, which must be entered with the same date:

1. An asthma review code
2. An Asthma Control Test, or Asthma Control Questionnaire score
3. A record of the number of exacerbations
4. A written asthma management plan.

You could use templates to make sure that all the items are recorded together.

It is also worth checking records of any previous patient annual reviews to find items that may have been delivered but not coded. Searching for an annual review code or appointment and then checking the free text entry for information recorded but not coded could save both patient and practice time.

All of the above elements could be performed remotely, with support from a parent or guardian in children.

There is also a non-coded requirement to assess inhaler technique. While using an inhaler and a phone camera at the same time could be challenging it might be possible – suggest the patient enlists the help of a friend where appropriate.

Indicator AST008: Percentage of young smokers (6 points)

The final indicator applies only to patients aged under 20 years old at the end of the QOF year. Smoking status should be recorded and this must be updated every year.

This indicator has been expanded to include patients from age 6 to 19. Recording smoking status in 80% of them will gain the full points. As usual, patients must be recorded as having never smoked, currently smoking or being an ex-smoker. Coding as currently not smoking is not acceptable.

There is now an additional requirement to record passive smoking or exposure to tobacco smoke. If a patient is neither a smoker nor exposed to tobacco smoke then they should be counted as ‘never smoked tobacco’. This might seem a little odd in a 7-year-old but it seems to be the only way to do this at the moment.

Electronic cigarette use does not count either for first- or second-hand smoke exposure.

Patients in this group should be having an annual review (unless they are no longer receiving medication in which case they will automatically come off the register) so this is a good time to record smoking history. This can be done remotely, over the phone or email.

Key tips

• Have a robust system to invite patients to have an asthma review.
• Make sure that your asthma reviews all include a questionnaire, a record of exacerbations and a plan.
• Have a system to check reviews and ensure that all codes have been entered.
• All patients over six years old with a new diagnosis of suspected asthma should need to have spirometry and either peak flow reversibility or FeNO testing.
• Avoid recording the diagnosis before testing – this will ensure accurate diagnosis as well as boosting achievement.
• Have a system for arranging testing where the diagnosis has been made elsewhere or new patients register with the practice.
• Remember to ask about smoking history, including passive smoking in younger children.
• Reviewing a patient’s prescribed inhalers but without a coded diagnosis is a good way to increase income and improve care.

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.