SAPC 2012 - exception reporting

[Poster title]
[Replace the following names and titles with those of the actual contributors: Helge Hoeing, PhD1; Carol Philips, PhD2; Jonathan Haas, RN, BSN, MHA3, and Kimberly B. Zimmerman, MD4
1[Add affiliation for first contributor], 2[Add affiliation for second contributor], 3[Add affiliation for third contributor], 4[Add affiliation for fourth contributor]
Background
Methods
Results
Summary
Exempting dissenting patients from pay for
performance schemes
retrospective analysis of exception reporting in the UK Quality
and Outcomes Framework
Tim Doran1 Evan Kontopantelis1 Catherine Fullwood1
Helen Lester2 Jose Valderas3 Stephen Campbell1
1Centre for Primary Care, Institute of Population Health
Faculty of Medicine, University of Manchester
2School of Health and Population Sciences, University of Birmingham
3Department of Primary Care Health Sciences, University of Oxford
RSS Annual ConferenceKontopantelis, Reeves Exception reporting under QOF

[Poster title]
Background
Methods
Results
Summary
Outline
1 Background
2 Methods
3 Results
4 Summary
Kontopantelis, Reeves Exception reporting under QOF

[Poster title]
Background
Methods
Results
Summary
Improving quality of care
a (very) juicy carrot...
A P4P program kicked off in April 2004 with the
introduction of a new GP contract
General practices are rewarded for achieving a set of
quality targets for patients with chronic conditions
The aim was to increase overall quality of care and to
reduce variation in quality between practices
The incentive scheme for payment of GPs was named
Quality and Outcomes Framework (QOF)
Initial investment estimated at £1.8 bn for 3 years
(increasing GP income by up to 25%)
QOF is reviewed at least every two years

[Poster title]
Background
Methods
Results
Summary
Quality and Outcomes Framework
details for years 1 (2004/5) and 5 (2008/9)
Domains and indicators in year 1 (year 5):
Clinical care for 10 (19) chronic diseases, with 76 (80)
indicators
Organisation of care, with 56 (36) indicators
Additional services, with 10 (8) indicators
Patient experience, with 4 (5) indicators
Implemented simultaneously in all practices (a control
group was out of the question)
Practices are allowed to exclude patients from the
indicators and the payment calculations
Into the 9th year now (01Mar12/31Apr13); cost for the ﬁrst
8 years was well above the estimate at ≈£8 bn

[Poster title]
Background
Methods
Results
Summary
Some of the indicators for diabetic patients
Percentage of diabetics...
with a record of HbA1c in previous 15 months (3p)
in whom last HbA1c is ≤7.4 in previous 15m (16p)
who have a record of BP in the past 15m (3p)
in whom the last BP is ≤145/85 (17p)
with a rec of serum creatinine testing in previous 15m (3p)
who have a record of total cholesterol in previous 15m (3p)
whose last measured total cholesterol in previous 15m is
≤5mmol/l (6p)
who have had inﬂuenza immunisation in the preceding
1Sep-31Mar (3p)

[Poster title]
Background
Methods
Results
Summary
Exception reporting
For each indicator practices are permitted to remove
inappropriate patients from achievement calculations
The process is known as ‘exception reporting’ (ER) and
reasons are:
logistical
clinical - contraindication or intolerance
clinical - patient unsuitable
informed dissent
In place to protect patients from coercion or refusal of care
Principal drawback is that it allows practices to receive
maximum remuneration without necessarily providing the
required care for all eligible patients

[Poster title]
Background
Methods
Results
Summary
Exception reporting reasons
Logistical
Patient has recently received a diagnosis or recently
registered with the practice
A speciﬁed investigative service is unavailable to the
practice
Clinical - contraindication or intolerance
Patient has had an allergic or other adverse reaction to a
speciﬁed drug or has another contraindication to the drug
Patient has not tolerated the drug
Patient is taking the maximal tolerated dose of a drug, but
the levels remain suboptimal

[Poster title]
Background
Methods
Results
Summary
Exception reporting reasons
Clinical - patient unsuitable
The indicator is judged inappropriate for the patient
because of particular circumstances, such as terminal
illness or extreme frailty
Patient has a supervening condition that makes the
speciﬁed treatment clinically inappropriate
Patient has received at least three invitations for a review
during the preceding 12 months but has not attended
Informed dissent
Patient refuses to be reviewed
Patient does not agree to a speciﬁc investigation or
treatment
Not all reasons are available for every indicator e.g. no
contraindication option for measurement indicators

[Poster title]
Background
Methods
Results
Summary
The question
To examine the reasons why practices exempt patients
from the UK Quality and Outcomes Framework
To identify the characteristics of general practices
associated with informed dissent

[Poster title]
Background
Methods
Results
Summary
Data
In 2008/9 (year 5), 62 clinical activity indicators across 15
clinical areas, for which exceptions applied
Data from the QMAS system on 8,229 English practices
Data on practice and patient characteristics from the ONS
and the GMS database
Informed dissent could be accurately measured only for 37
of the 62 indicators (measurement and outcome only)

[Poster title]
Background
Methods
Results
Summary
Analyses
For each practice and clinical indicator we calculated the
rate of exception reporting:
ERi = Ei /(Ei + Di )
Ei , number of patients exception reported for that indicator
Di , number of patients meeting the criteria for the indicator
and not excepted by the practice
Calculated overall rates and separately for each of the
main reasons
Focused on overall scores and informed dissent
Multilevel multiple linear regression used to identify
practice & population predictors of exception reporting
Estimated average ﬁnancial gain from exception reporting

[Poster title]
Background
Methods
Results
Summary
Overall rates of exception reporting
In 2008/9 the median exception reporting rate across all 62
clinical indicators was 4.5% (IQR: 3.4-5.8%)
Median rates for individual indicators ranged from 0.0% (for
seven indicators) to 24.4% (CHD 10: β blocker therapy for
patients with coronary heart disease)
Median rates were generally lower for measurement
indicators (2.4%) than for treatment (10.0%) and
intermediate outcomes indicators (5.7%)
For the 37 indicators for which reasons of ER were
ascribable, median overall exception rate was 2.7% (IQR:
1.9-3.9%)

[Poster title]
Background
Methods
Results
Summary
Rates of informed dissent exception reporting
37 indicators
Median rate was 0.44% (IQR: 0.14-1.1%)
10% of practices excepted over 2.2% of patients for
informed dissent and 1% of practices excepted over 5.7%
Median rates for individual indicators ranged from 0.0% (25
ind) to 1.2% (DM20, HbA1C control ≤ 7.5%)
Table 2| Proportion of exception reports attributable to each exception reporting category, by type of indicator
Type of indicator (%)
Reason for exception report AllIntermediate outcomeMeasurement
2.92.23.5Unknown*
40.645.935.9Logistical
7.616.20.0Clinical—contraindication
18.713.823.1Clinical—patient unsuitable
30.121.937.4Informed dissent
2 184 8111 026 0761 158 735Total No of exceptions
Based on 37 indicators for which reasons for exception reporting were ascribable (see table 1).
*In these cases a “general” exception was applied to the patient and the exact reason for the exception report is not recorded.
BMJ 2012;344:e2405 doi: 10.1136/bmj.e2405 (Published 17 April 2012) Pa
RES

[Poster title]
Background
Methods
Results
Summary
Rates of informed dissent exception reporting
37 indicators
Figure 1: Proportion of patients exception reported by indicator and reason, 2008/9
For 37 indicators for which reasons for exception reporting were ascribable (see table 2a).
Indicators ordered by i) type of activity (measurement or outcome); ii) rate of exception reporting attributable to informed dissent.
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Unknown
Logistical
Clinical - unsuitable
Clinical - contraindication
Informed dissent
[--------------------------------------Measurement----------------------------------] [------Outcome------]

[Poster title]
Background
Methods
Results
Summary
Factors associated with exception reporting
Table 3| Results of regression analysis—factors associated with exception reporting rates
Informed dissentAll exceptions
Variable 95% CIP valueCoefficient95% CIP valueCoefficient
Indicator characteristics
−0.02 to −0.02<0.001−0.02−0.10 to −0.09<0.001−0.09Upper payment threshold (per 1% increase)
−0.14 to −0.07<0.001−0.10−0.15 to 0.050.321−0.05Indicator type (intermediate outcome)
0.00 to 0.000.0450.000.11 to 0.11<0.0010.11Maximum points/remuneration available
−0.04 to −0.04<0.001−0.04−0.64 to −0.62<0.001−0.63No of eligible patients (per 100 increase in disease register size)
Practice characteristics
-0.37 to −0.29<0.001−0.33−2.44 to −2.22<0.001−2.33Maximum points scored in previous year (2007/8)*
−0.00 to 0.000.449−0.00−0.01 to −0.00<0.001−0.00% of doctors aged ≥55†
−0.00 to 0.000.054−0.00−0.00 to 0.000.2440.00% of women doctors†
−0.05 to 0.070.7850.010.06 to 0.290.0040.17Personal Medical Services contract
0.06 to 0.08<0.0010.070.26 to 0.29<0.0010.28No of patients (per 1000 increase in list size)†
Patient and area characteristics
−0.00 to 0.010.3270.000.02 to 0.04<0.0010.03% of patients aged ≥65†
−0.02 to 0.010.685−0.00−0.02 to 0.020.987−0.00% of female patients†
−0.01 to −0.00<0.001−0.01−0.01 to 0.000.197−0.00% of patients from ethnic minority groups†
0.00 to 0.00<0.0010.00−0.00 to 0.000.1780.00Population density in locality†
Material deprivation in locality‡:
——————1st fourth (most affluent)
0.02 to 0.180.0210.10−0.02 to 0.280.0820.132nd fourth
0.09 to 0.27<0.0010.180.27 to 0.60<0.0010.443rd fourth
0.23 to 0.42<0.0010.330.51 to 0.87<0.0010.694th fourth (most deprived)
Based on 37 indicators for which reasons for exception reporting were ascribable (table 1).
*For each specific indicator.
†Data for 2006/7.
‡Measured by index of deprivation 2007.
BMJ 2012;344:e2405 doi: 10.1136/bmj.e2405 (Published 17 April 2012) Page 10 of 11
RESEARCH
Most inﬂuential factor
was previous
performance on the
scheme
Factors associated
with higher levels of
informed dissent
exceptions were
broadly comparable
with those for overall
exceptions

[Poster title]
Background
Methods
Results
Summary
Financial gain associated with exception reporting
Figure 2: Total remuneration for all practices attributable to i) achievement of targets and ii) exception reporting, by indicator
For all 62 clinical indicators.
Total remuneration is based on ‘population achievement’ rates. Remuneration attributable to achieving targets (grey columns) is based on ‘reported achievement’ rates. Remuneration
attributable to exception reporting (black columns, with values in millions) is the difference between total remuneration and remuneration attributable to achieving target
£0
£10
£20
£30
£40
£50
£60
DM11
CKD2
CHD5
THY2
STR5
DM22
DM5
DM16
CHD6
STR6
MH4
SMO3
DM2
AST3
MH6
CHD9
STR7
CHD7
EPI7
CAN3
EPI6
STR12
BP4
DM12
DM15
DM17
DM9
SMO4
DM10
MH7
MH5
STR8
DEP1
DM13
CHD11
AF3
STR10
DEM2
CKD5
STR13
COPD10
CHD8
DM21
DM18
COPD11
HF2
AST6
DM7
CHD2
HF3
DM20
COPD8
BP5
CKD3
AST8
CHD12
EPI8
COPD12
AF4
CHD10
MH9
DEP2
Exception reporting
Achieving targets

[Poster title]
Background
Methods
Results
Summary
overall rates, 62 ind
Overall, 5.4% of clinical points scored by practices were
attributable to exception reporting
This equates to about £30,844,500 for all English practices
£3,834 for the average practice (£3,586-£4,093)
£0.58 per patient
Cost varied widely by indicator, from £1,630 for DM11 (BP
recording for DM) to £4.5m for DEP2 (assessing
depression severity)
DEP2 and MH9 (reviewing physical & social care for
people with psychotic illness), accounted for £8.4m; over a
quarter of the total cost associated with exception reporting

[Poster title]
Background
Methods
Results
Summary
overall & informed dissent rates, 37 ind
4.9% of remuneration received was attributable to overall
exception reporting
This equates to about £19,188,917 for all English practices
£2,386 for the average practice
£0.36 per patient
The gain attributable to informed dissent exceptions was
£2,406,500 nationally
£300 for the average practice (£244-£351)
£0.05 per patient
Cost of informed dissent exceptions was relatively low
since most applied to measurement indicators, which
attract less remuneration

[Poster title]
Background
Methods
Results
Summary
Conclusions
Respecting a patient’s decision to refuse an investigation
or treatment, even if considered wrong or irrational by the
attending clinician, is central to medical professionalism
We found that rates of informed dissent in QOF are low,
with little variation across the spectrum of deprivation
This suggests that activities incentivised in the scheme are
broadly acceptable to patients
Thousands of patients expressed their wish not to receive
interventions under the framework
At relatively low cost, the provision to exception report
enables patients’ voices to be heard and counters some of
the critiques of the scheme

[Poster title]
Appendix Thank you!
Doran T, Kontopantelis E, Fullwood C, et al. Exempting dissenting
patients from pay for performance schemes: retrospective analysis of
exception reporting in the UK Quality and Outcomes Framework. BMJ
2012;344: doi: 10.1136/bmj.e2405
Comments, suggestions: e.kontopantelis@manchester.ac.uk

SAPC 2012 - exception reporting

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