SECTION 1:

Case Study & Requirements of the Quality and Outcomes Framework (QOF)
Case study

Alice, age 46, was diagnosed with type 2 diabetes a year ago. She is currently treated with metformin 2g daily and takes atorvastatin 20mg. Her latest HbA1c is 45 mmol/mol, and her non-HDL cholesterol has improved by 44% and is now 2.5mmol/l. Her BP is 132/78 mmHg and her eGFR is >90ml/min/1.73m2. Her ACR is 0.6mg/mmol. In the past year she has attended a weight loss group and her BMI has dropped from 28.6kg/m2 to 25.2kg/m2.

Requirements of the Quality and Outcomes Framework (QOF)

The Quality and Outcomes Framework (QOF) awards points for the provision of certain indicators, which are linked to improved outcomes. Practices are expected to hold a register of people aged 17 and over who have diabetes, along with the type of diabetes they have been confirmed to have.1

A record of the number of people who have the influenza vaccination each year should be maintained.1 The aim should be to immunise 95% of patients in order to offer the greatest protection and to maximise the number of points achieved.1

As structured education is known to impact positively on self-management,2 referral to structured education programmes should be aimed for within 9 months of the individual being added to the register.1

In view of the fact that a significant proportion of the money spent on diabetes care goes on treating the complications of diabetes – 80% of the total NHS spending on diabetes,3 points are awarded for screening for microvascular complications, specifically nephropathy and neuropathy.1

In the case of nephropathy, QOF recommends that people living with diabetes (PLWD) should be on an ACE inhibitor – or an angiotensin receptor blocker (ARB) – if they are known to have microalbuminuria or proteinuria. Points are awarded for the number of people who meet these criteria. However, this assumes that all PLWD have had an albumin/creatinine ratio (ACR) checked to assess for the presence of protein, something which may not be the case.4 This is an example of where the DUK guidance can complement the QOF recommendations.

With regard to the feet, QOF advises that annual foot checks should be carried out with a record of the risk stratification included.1

Cardiovascular risk factors

Both blood pressure (BP) and lipid management are seen as key areas for attention in QOF. Currently, QOF awards points if PLWD have a BP of 140/80 mmHg or less unless they are moderately or severely frail.*1 The recent NICE guidelines on the management of hypertension advocate a BP of 140/90 mmHg or less in people under the age of 80, including in those with diabetes.5

Lipid levels should be treated with a statin in anyone with a previous history of cardiovascular disease (CVD), including haemorrhagic stroke but otherwise atorvastatin 20mg should be initiated if the PLWD is aged 40 or above and has a CVD risk score of 10% or more in the past 3 years.1

Frailty

People with moderate or severe frailty* are exempted from some of these recommendations – in particular the HbA1c target and the BP target.1 With regard to HbA1c, the general target for QOF is to get the HbA1c down to 58mmol/mol or less, but this is relaxed to 75mmol/mol or less in people with moderate to severe frailty because the risks of tight control are likely to outweigh the benefits.1

*Frailty is defined as a health state related to the ageing process in which multiple body systems gradually lose their built-in reserves, increasing the risk of adverse outcomes.6 Characteristics of frailty include unintentional weight loss, reduced muscle strength, reduced gait speed, self-reported exhaustion and low energy expenditure.6

Job code: UK/DIA-19020e DOP: April 2020

References

  1. NHS England (2019) 2019/20 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF) https://www.england.nhs.uk/wp-content/uploads/2019/05/gms-contract-qof-guidance-april-2019.pdf [Accessed April 2020]
  2. NICE QS6. Diabetes in adults Quality Standard Quality Statement 2: Structured education programmes for adults with type 2 diabetes; 2011, updated 2016 https://www.nice.org.uk/guidance/qs6/chapter/Quality-statement-2-Structured-education-programmes-for-adults-with-type-2-diabetes [Accessed April 2020]
  3. Diabetes UK. Us, diabetes and a lot of facts and stats. https://www.diabetes.org.uk/professionals/position-statements-reports/statistics [Accessed April 2020]
  4. Feakins B, Oke J, McFadden E, et al. Trends in kidney function testing in UK primary care since the introduction of the quality and outcomes framework: a retrospective cohort study using CPRD. BMJ Open 2019;9:e028062 https://bmjopen.bmj.com/content/9/6/e028062 [Accessed April 2020]
  5. NICE NG136. Hypertension in adults: diagnosis and management; August 2019. https://www.nice.org.uk/guidance/ng136 [Accessed April 2020]
  6. British Geriatrics Society. Fit for Frailty Part 1; 2014 (Updated 2018). https://www.bgs.org.uk/sites/default/files/content/resources/files/2018-05-23/fff_full.pdf [Accessed April 2020]