Updated November 2022
*Prevalence is an estimate based on latest available QOF data and current trends. For further explanation read more details here.
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.
Some important changes were made last in 2020/21 but were largely overlooked due to the pandemic – in particular, new criteria for diagnosis with respiratory testing.
Originally this would have applied to all patients diagnosed after April 2020. Because of the suspension of QOF over the past year this has been updated so only patients receiving their diagnosis after April 2021 will be eligible.
The following summarises all the indicator changes made in 2020/21:
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.
All patients who have had a diagnosis of asthma from April 2020 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. https://www.youtube.com/watch?v=baLYBXcgImk
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. This 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 2020 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.
In 2020 there was less respiratory testing performed due to the risks of contamination associated with Covid-19. Practices can code where either spirometry or asthma services are unavailable which will excuse patients from this indicator. It is, however, vital that at least one patient passes this indicator at the end of the year to gain those 15 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
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.
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.
Dr Gavin Jamie is a GP in Swindon and runs the QOF Database website
NHS England – Quality and Outcomes Framework guidance for 2022/23. Published 31 March 2022.
Indicator 1: The contractor establishes and maintains a register of patients with asthma aged 6 years or over, excluding patients with asthma who have been prescribed no asthma related drugs in the preceding 12 months (AST005). 4 points.
Indicator 2: The percentage of patients with asthma on the register from 1 April 2021 with either:
1) a record of spirometry and one other objective test (FeNO or reversibility or variability) between 3 months before or 6 months after diagnosis; or
2) if newly registered in the preceding 12 months with a diagnosis of asthma recorded on or after 1 April 2021 but no record of objective tests being performed at the date of registration, with a record of spirometry and one other objective test (FeNO or reversibility or variability) recorded within 6 months of registration (AST006). 15 points; payment threshold: 45-80%
Indicator 3: The percentage of patients with asthma on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using a validated asthma control questionnaire, a recording of the number of exacerbations, an assessment of inhaler technique and a written personalised action plan (AST007). 20 points; payment threshold: 45-70%
Indicator 4: The percentage of patients with asthma on the register aged 19 or under, in whom there is a record of either personal smoking status or exposure to second-hand smoke in the preceding 12 months (AST008). 6 points; payment threshold: 45-80%
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