Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Qof provided equity for patients
- Rupert A Gude (8 June 2009)
-
Role of Pharmaceutical Care in Diabetes Management
- Ajay G. Pise, Shilpa Pise, D. Sreedhar, Manthan J., Virendra L, N. Udupa (10 June 2009)
-
Coding Changes
- Gavin M Jamie (12 June 2009)
-
Improvements in glycaemic control and cholesterol concentrations associated with the Quality and Outcomes Framework.
- Christopher D Byrne, Isaac Oluwatowoju, Emmanuel Abu, Sarah H. Wild (12 June 2009)
-
QOF Effects Across Lothian
- Kieran Montgomery, Ian JB Young, Dan Pugh, Manreek Basi, Bruce T McLintock (27 October 2009)
-
Pre-cognition
- L Sam Lewis (29 October 2009)
|
|
|||
|
Rupert A Gude, VSO Doctor Kagondo Hospital, Kagera, Tanzania
Send response to journal:
|
Dr Calvert et al are to be congratulated on this major analysis of Qof in relationshop to Diabetes. There is no doubt that the READ codes caused a headache for all practices and this is not the fault of Qof but of the technicians who implemented it. It can be sorted. I did my first diabetic audit in my British general practice in 1982 and my last one in 2006 when I retired. There is no doubt that all parameters that we measured improved over time. However what will not be seen by large analyses is the behaviour of different doctors in a practice. By the end of the nineties half of my partners were embracing the findings of UKPDS and other trials and improving their management of their diabetics. However the other half were reluctant to change hanging on to a outmoded concept of 'professional independence' and treating 'everyone as an individual'. When Qof was offered the therapeutic decisons about cholesterol and blood pressure were now embraced by all doctors and at last the greatest cause of inequality of health care in our practice was not the doctor you were registerd with. Alongside this we had been training our practice nurses in diabetic care over many years and when qof was introduced they were well placed to take over much of the routine followup with much greater attention to detail than the doctors. Qof did not suddenly change the way our practice worked but it did provide some reward for the heavy financial investment we had made in education and employment. More fundamentally it made more reluctant doctors embrace newer tretments and aim for better outcomes. In the hurly burly of practice the last thing on my mind was whether we had acheived a ceiling. We strove to give as good a care as possible to all our diabetics whether on a register or not. That the hospital failed to supply us with a considerable amount of data about the type 1 diabetics they were supposedly looking after was a continual source of aggravation. In my last audit I looked at those with HbAic over 10 and found the majority were patients who we had sought to influence but were failing. Several needed insulin and were adamant that they were not going to take it and others were poor attenders, had alcohol problems and chaotic lifestyles. All had been several times to our clinic but we had not be succesful in changing their behaviour. Qof revolutionsed the care that our patients received, ironed out inconsistencies within the practice and will be of lasting benefit to the patients. The doctors still have professional independence and can look after each patient as an individual but at least the patients are receiving appropriate therapy. Competing interests: None declared |
|||
|
|
|||
|
Ajay G. Pise, Lecturer Manipal College of Pharmaceutical Sciences, Manipal-576104, Shilpa Pise, D. Sreedhar, Manthan J., Virendra L, N. Udupa
Send response to journal:
|
We read this interesting research on “Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study” by Melanie Calvert and team. Findings and conclusion from this research are very informative and valuable. Today, worldwide it is observed that diabetic cases are growing very fast. Many Pharmaceutical companies have started pouring more and more money into the development of novel anti diabetic drugs, but development of such drugs would require an approximate time of eight years. In such a scenario Pharmaceutical Care is an important tool in the management of diabetes. In connection to this, the findings of this above discussed research are more important and relevant. In the conclusion of this research authors have observed significant improvement in all of the quality and outcome framework clinical indicators over the time for diabetic care in U.K. Findings and conclusion of this study can be used as a basic model to be implemented in developing countries where diabetes is most prevalent. Competing interests: None declared |
|||
|
|
|||
|
Gavin M Jamie, GP Whalebridge Practice, Swindon Health Centre, Carfax Street, Swindon, SN1 1ED
Send response to journal:
|
The challenge of assessing the impact of an intervention without a control group is not to be underestimated and the authors are to be congratulated on the attempt. However the choice of diabetes as the area to be looked at has added additional complication to the analysis which has not been completely acknowledged in the paper. Firstly may I point out an error in the type two diabetes prevalence chart in figure one where the scale is wrong by an order of magnitude. Secondly the method of data extraction is not specified. A snapshot of the medical record will give dates of diagnosis rather than dates of entry. For instance a patient could be labeled today with a diagnosis of type one diabetes from the first of January 2004. It cannot be assumed from the snapshot that this code was present in, say, 2005. This is very apparently when looking at the diagnostic codes. The diagnostic codes changes from 2005 to 2006 to a smaller list of codes that was largely homonymous with many of the codes that were used before. It was predicted that, without code changes, there would be a 22% drop in prevalence[1]. This did not occur, indeed it would appear that diabetes continued to rise in prevalence at about the same rate as previously. What actually happened was the most practices used their practice systems to change their previous codes to the new ones with the same date. The data presented here shows no sudden shift to the new codes - there is not "step" on the graph. The conclusion that I would draw is that the data in this study does not reflect the actual data used in 2003 and 2004 but rather subsequently altered coding. This in turn makes drawing conclusions about these two years rather more difficult. 1. Hippisley-Cox J, O’Hanlon S. Identifying patients with diabetes in the QOF—two steps forward one step back. www.bmj.com/cgi/eletters/333/7570/672-a. Response to: Tanne J. Diabetes, not obesity, increases risk of death in middle age. BMJ 2006; 333: 672 Competing interests: General Practitioner working under QOF I run the QOF Database website at http://www.gpcontract.co.uk |
|||
|
|
|||
|
Christopher D Byrne, Professor Institute of Developmental Sciences, (University of Southampton), Southampton General Hospital, Isaac Oluwatowoju, Emmanuel Abu, Sarah H. Wild
Send response to journal:
|
We congratulate Dr Calvert and colleagues for their work describing diabetes management from repeated cross-sectional primary care data. Ascertaining whether changes in the quality of diabetes care have occurred since the implementation of QoF targets is crucial to refine the processes for delivering future diabetes care in the UK. We are concerned that the results of Calvert et al suggesting limited beneficial impact of the QoF in people with type 2 diabetes, and specifically in people with an HbA1c >10%, might lead readers to conclude that the QoF has not been associated with improved diabetes care in the UK. We have just completed an audit to determine whether the proportion of patients with diabetes meeting glycaemic control and lipid targets changed over a 2 year period. We retrieved computer held biochemical measurements of HbA1c and total cholesterol for 9022 adults with diabetes whose biochemical tests were performed at Southampton General Hospital for whom data were available for both 2006 and 2008. In 2006, 39.6% of adults (n=3562) had glycaemic control below the more stringent QOF DM6 threshold (HbA1c < 7.5%); by 2008, this proportion had risen to 47.7% (n=4290) (p<0.001). These data are not comparable to those presented by Calvert et al who used the DM20 criterion of HbA1c <7.5%. The table below summarises comparable data.
Calvert et al Southampton
2006 2007 2006 2008
HbA1c<10% 83.4 82.7 88.1 90.6
Chol <=5 mmol/l 66.7 74.2 76.5 84.1
In contrast to Calvert and colleagues we have examined HbA1c levels and cholesterol concentrations in the same individuals over a 2 year time frame. We conclude there has been marked improvement in the management of hyperglycaemia and hypercholesterolaemia among people with diabetes over a 2 year period among people for whom repeated measurements were available. Absolute values and improvements in these intermediate measurements among individuals over time may differ between populations and may be masked by making comparisons across whole populations. Competing interests: None declared |
|||
|
|
|||
|
Kieran Montgomery, Medical Student Edinburgh Medical School EH16 4SB, Ian JB Young, Dan Pugh, Manreek Basi, Bruce T McLintock
Send response to journal:
|
Since the introduction of the QoF system in 2004, studies either promoting or negating its effect have been relatively frequent. Even if we refine this to the QoF impact upon diabetes care alone, there is still a wealth of interest, suggesting that this is an area of much controversy. This controversy has recently been amplified further by the amendment of one the QoF HbA1c targets for diabetics (HbA1c ≤7.0% as of April 1st 2009). A recent study carried out by my colleagues and I aimed to examine this in more detail. In your article it is said that "the impact of the quality and outcomes framework on care [of diabetes] is not straightforward" and in our opinion this hits the nail on the head. Previous work done by Tahrani et al (2007) found there to be "significant improvements" in all quality indicators after the introduction of QoF. However, this study also suggests that the QoF system itself "may not have been responsible" for such a change, and therein lies the rub. Can we really give credit to the QoF system for our 21st century health improvements? Our study looked at GP practices across Lothian to assess the impact of the new QoF HbA1c target of ≤7.0% on the 29,934 diabetic patients in the area. In particular, we aimed to discover if the new target would disproportionately disadvantage the deprived population of Lothian. Before the revised target, despite the discernable differences in HbA1c attainment between affluent and deprived practices, this could not be said to disproportionately disadvantage deprived practices as both sets met the HbA1c target of ≤7.5%. We found that the introduction of an HbA1c target of ≤7.0% would reduce the proportion of patients in both affluent and deprived practices meeting the QoF target. However, significantly, the introduction of this target will mean practices in deprived areas failing to reach the target. This outcome suggests that deprived practices will be disproportionately disadvantaged by the revision of the HbA1c target. This is just one example of how the QoF system is anything but "straightforward", and highlights the need for further investigation into its effect. 1. Tahrani et al. Diabetes care and the new GMS contract: the evidence for a whole county. Br J Gen Pract. 2007;57(539):483–85. No Competing Interests Competing interests: None declared |
|||
|
|
|||
|
L Sam Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
Send response to journal:
|
Calvert et al. demonstrate clearly how care of diabetes has improved annually in general practice, and rightly question the influence of QOF as 'not straightforward'. The knee-bend in all trends in 2005 is readily visible in Figure 2. QOF actually appears to be associated with a relative flattening-off. This could be a ceiling-effect, a 'good-enough' effect, or a quirk of retrospective data -editting ? It reminds me of the early 1990's when vaccination target incentives were introduced. That same levelling-off just above threshold (90%) was visible in trends. What struck me as particularly noteworthy was not only the knee-jerk DoH claims for the effects of performance-management, but also the strong evidence for GP precognition.. How come GPs knew to aim their efforts perfectly toward that 90% level, even before they knew the QOF rules ??! Is it further proof of the power of retrospective prayer ?? references. Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomised controlled trial BMJ Dec 2001; 323: 1450 - 1451; doi:10.1136/bmj.323.7327.1450 Competing interests: None declared |
|||