High levels of QoF Exclusion rates are justified in Nursing home residents
We would like to challenge one of the conclusions in the study by
Shah et al (1) who state that high use of exception reporting, (43% in
Nursing home residents), may compromise care for vulnerable patient
groups. Their study included people from both residential and nursing
homes. It is important to recognise that the majority of nursing home
residents have very significant levels of disability and nursing need with
high levels of co-morbid illness and frailty (2) . In addition if the
definition of terminal illness is based on a negative answer to the
question "would I be surprised if my patient were to die in the next
twelve months" (3) it is likely that many individuals living in nursing
homes would be classified as being terminally ill. In a recent study of
people with diabetes resident in Nursing Homes in Coventry 43% of
residents were bedbound, had no speech or incoherent speech, were
doubly incontinent or had a catheter in situ, and were unable to feed
themselves or had a PEG or nasogastric tube in situ (4). In this latter
group for example, exception reporting in primary care would be entirely
appropriate and in keeping with the needs of these residents.
The emphasis in this very disabled group with huge nursing needs, most of
whom would be regarded as terminally ill, must surely be on the quality of
any remaining life. The Clinical Indicators in the Quality and Outcomes
Framework (QoF) are largely concerned with interventions that have been
shown to improve the quantity of life in younger fitter populations.
Applying this approach and aiming to achieve these indicators in many
nursing home residents is likely to impair the quality of any remaining
life. We therefore feel that high exclusion rates from QoF in nursing home
populations may, in many circumstances, be the right decision, for the
right reasons, in the right population.
References
1 Shah S, Carey IM, Harris T, DeWilde S, Cook DG Quality of chronic
disease care for older people in care homes and the community in a primary
care pay for performance system: retrospective study BMJ 2011 342d912
2 Bowman C, Whistler J, Ellerby M A national census of care home residents
Age and Ageing 2004 33: 561-566
3 Murray SA, Boyd K, Sheikh A. Palliative Care in chronic illness BMJ
2005 330:611-612
4 Gadsby R, Barker P, Sinclair A People living with diabetes resident in
nursing homes - assessing levels of disability and nursing needs Diabetic
Medicine 2011 (in press)
Dr Roger Gadsby GP & Associate Clinical Professor, Warwick
Medical School
Professor Alan Sinclair, Professor of Medicine, and Director of IDOP,
University of Bedfordshire
Rapid Response:
High levels of QoF Exclusion rates are justified in Nursing home residents
We would like to challenge one of the conclusions in the study by
Shah et al (1) who state that high use of exception reporting, (43% in
Nursing home residents), may compromise care for vulnerable patient
groups. Their study included people from both residential and nursing
homes. It is important to recognise that the majority of nursing home
residents have very significant levels of disability and nursing need with
high levels of co-morbid illness and frailty (2) . In addition if the
definition of terminal illness is based on a negative answer to the
question "would I be surprised if my patient were to die in the next
twelve months" (3) it is likely that many individuals living in nursing
homes would be classified as being terminally ill. In a recent study of
people with diabetes resident in Nursing Homes in Coventry 43% of
residents were bedbound, had no speech or incoherent speech, were
doubly incontinent or had a catheter in situ, and were unable to feed
themselves or had a PEG or nasogastric tube in situ (4). In this latter
group for example, exception reporting in primary care would be entirely
appropriate and in keeping with the needs of these residents.
The emphasis in this very disabled group with huge nursing needs, most of
whom would be regarded as terminally ill, must surely be on the quality of
any remaining life. The Clinical Indicators in the Quality and Outcomes
Framework (QoF) are largely concerned with interventions that have been
shown to improve the quantity of life in younger fitter populations.
Applying this approach and aiming to achieve these indicators in many
nursing home residents is likely to impair the quality of any remaining
life. We therefore feel that high exclusion rates from QoF in nursing home
populations may, in many circumstances, be the right decision, for the
right reasons, in the right population.
References
1 Shah S, Carey IM, Harris T, DeWilde S, Cook DG Quality of chronic
disease care for older people in care homes and the community in a primary
care pay for performance system: retrospective study BMJ 2011 342d912
2 Bowman C, Whistler J, Ellerby M A national census of care home residents
Age and Ageing 2004 33: 561-566
3 Murray SA, Boyd K, Sheikh A. Palliative Care in chronic illness BMJ
2005 330:611-612
4 Gadsby R, Barker P, Sinclair A People living with diabetes resident in
nursing homes - assessing levels of disability and nursing needs Diabetic
Medicine 2011 (in press)
Dr Roger Gadsby GP & Associate Clinical Professor, Warwick
Medical School
Professor Alan Sinclair, Professor of Medicine, and Director of IDOP,
University of Bedfordshire
Competing interests: No competing interests