Maximising your QOF income: COPD

Updated November 2022

Summary – indicators and value

• Indicators: 3
• Points: 19
• Prevalence*: 1.9%
• £/patient on the register (estimated):  £22

*Prevalence is an estimate based on latest available QOF data and current trends. For further explanation read more details here.

Background

Chronic obstructive pulmonary disease (COPD) has been a part of QOF over the past 18 years, with prevalence increasing steadily over that time – likely due to improved diagnosis and management of the condition.

Last year saw one key change in the COPD area, with the retirement of the indicator for flu vaccination – last year worth 12 points. (The QOF flu vaccination incentive is replaced with a target in the PCN DES Impact and Investment Fund.)

Practices may also need reminding that there were two changes to indicators in this area the previous year, which were largely overlooked due to the pandemic, as follows:

• The COPD register and diagnosis indicators were effectively merged, with patients diagnosed after 1 April 2021* requiring confirmation by spirometry within the shorter time frame of between 3 months before and 6 months after the diagnosis;
• The annual review now requires practices to record the number of exacerbations.

*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.

Indicator 1: Maintain register of patients with diagnosis of COPD (8 points)

Entry to the register simply requires a COPD code, which includes codes for emphysema and chronic bronchitis.

The wording of the indicator requires that patients diagnosed after April 2021 have spirometry with an FEV1/FVC ratio of 0.7 within six months of the diagnosis. In practice it is strongly encouraged but if spirometry does not happen the patient will still appear on the register and there will be no impact on payment.

It is possible to remove a patient from the register by coding COPD resolved, but if the diagnosis was accurate this seems unlikely.

To keep your register up to date:

• Do a search for patients who are on inhalers but have no coded diagnosis (this will likely help to boost your asthma prevalence too).
• Make sure patients who have been added to the register since April 2020 have post bronchodilator spirometry (or be referred for spirometry) within the three months before, or six months after, the diagnosis.
• Have a system to ensure any new diagnosis made in hospital is entered. Like other ticking clock indicators, it will be vital to make sure that newly registered patients have this code transferred from previous surgeries or hospital outpatients.

Indicators 2 and 3: Annual reviews (11 points)

There are two indicators for the annual review.

Indicator 2 is worth nine points if 90% of patients have a review. Three codes are required to meet this indicator:

• First is a code that the annual review has been carried out.
• Secondly there should be a record of symptoms according to the Medical Research Council (MRC) Dyspnoea Scale. The scale ranges from 1 to 5, with separate codes for each point on the scale.
• Finally the number of COPD exacerbations in the last year should be coded.

The above codes can be entered at any time in the year and don’t all have to happen on the same day. As this is a functional assessment it would be possible to conduct all parts of the review remotely.

Indicator 3, which was introduced in 2019/20, requires patients with symptoms that reach 3, 4 or 5 on the scale to be offered an onward referral to a pulmonary rehabilitation programme. This carries two points for 90% achievement in a relatively small subsection of patients. Exception reporting (now termed ‘personalised care adjustment’) will be available if the patient does not wish to be referred or if the service is not available locally.

It is easiest to do these in a formal annual review with either a template or other protocol to ensure that all requirements are met. This could also be combined with a flu vaccine in the season. Wakefield CCG has a good example of a template for COPD reviews.

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

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Further reading/resources

• NHS England – Quality and Outcomes Framework guidance for 2022/23. Published 31 March 2022.

Full indicators

Indicator 1: The contractor establishes and maintains a register of:

• 1). Patients with a clinical diagnosis of COPD before 1 April 2021 and
• 2). Patients with a clinical diagnosis of COPD on or after 1 April 2021 whose diagnosis has been confirmed by a quality assured post bronchodilator spirometry FEV1/FVC ratio below 0.7 between 3 months before and 6 months after diagnosis (or if newly registered in the preceding preceding 12 months a record of an FEV1/FVC ratio below 0.7 recorded within 6 months of registration); and
• 3). Patients with a clinical diagnosis of COPD on or after 1 April 2021 who are unable to undertake spirometry (COPD009). Points: 8

Indicator 2: The percentage of patients with COPD on the register who have had a review in the preceding 12 months, including a record of the number of exacerbations and an assessment of breathlessness using the Medical Research Council dyspnoea scale (COPD010). Points: 9. Payment threshold: 50-90%

Indicator 3: The percentage of patients with COPD and Medical Research Council dyspnoea grade ≥3 at any time in the preceding 12 months, with a subsequent record of an offer of referral to a pulmonary rehabilitation programme (COPD008). Points: 2. Payment threshold: 40-90%