Business Rules for Quality and Outcomes Framework (QOF) 2017/18 Cancer

Transcription

1 Business Rules for Quality and Outcomes Framework (QOF) 2017/18 Cancer Author: Primary Care Domain Specification Development Service, NHS Digital Verison Date: 01/04/2017 Version: 36.0

2 Contents 1. Amendment History Background Document Purpose Business Rules Supporting Information Clinical Codes Guidance Dataset specification Qualifying Dates Patient selection criteria GMS registration status Populations Clinical Code Clusters Clinical Data Extraction Criteria Outputs Indicator(s) CAN CAN Payment Count(s) Management Information Count(s) Patient-level Extract(s) Appendix - Supporting data for NHS Digital SDS The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 2 of 22

3 This document is produced by NHS Digital on behalf of NHS England. It is published in PDF format. If anyone intends to re-use the information contained within it or publish in another format then they should acknowledge the source document, NHS Digital and NHS England. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 3 of 22

4 1. Amendment History Version Date Amendment history Draft June 2003 From Pete Horsfield September 2003 Standard Headers and footers Applied and set to approved November 2003 Added headers and footers to Version 0.4 received from Pete Horsfield on 03/11/ November 2003 Amended following 4 Country review January 2004 Amended following January READ Code Release February 2004 Amended following 4 Country, GPSS and internal review April 2004 SNOMED CT codes added, 4 byte Read codes removed April 2004 Amended following April READ code release September 2004 Amended following 4 Country Review January 2005 Amended following January READ Code Release June 2005 Amended following 4 Country Review April 2005 Signed off following 4 Country review April 2005 Amended following April 2005 Read Code release and January 2005 SNOMED CT release August 2005 Amended following 4 Country review September 2005 Signed off following 4 Country review November 2005 From Phil Brown November 2005 Amended following review by Peter Horsfield December 2005 Draft revised for internal review February 2006 Amended following internal & 4 Countries review The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 4 of 22

5 March 2006 Signed off following 4 Country review April 2006 Responding to queries raised a) Amend wording for Note 3 b) Amend Denominator Rule 3 & Numerator Rule 1 for CANCER3 to remove redundant check May 2006 Approved by NHSE October November 2006 April Read Code Release April SNOMED CT Release October Read Code Release Corrections and amendments following feedback Amend Cancer 3 rules to identify patients that have a cancer diagnosis within the last 6 months and have no cancer review to date. Following the 4 Country Review: Address incorrect cluster hierarchy for Diagnostic Codes and CAN_COD November 2006 Approved by NHSE April 2007 April 2007 Read Code Release June 2007 Following 4 Country Review: Correction in Rule 2 (Cancer 3) to standardise date check June 2007 Signed off following 4 Country review August 2007 April 2007 SNOMED Release September 2007 October 2007 Read Code Release October 2007 SNOMED CT Release November 2007 Signed off following 4 Country review June 2008 April 2008 Read Code Release April 2008 SNOMED CT Release QOF Review April 2008 Signed off following 4 Country review October 2008 October 2008 Read Code Release October 2008 SNOMED CT Release December 2008 Signed off following 4 Country review The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 5 of 22

6 March 2009 QOF Review May 2009 Signed off following 4 Country review June 2009 April 2009 Read Code Release August 2009 Amendment following 4 Country review August 2009 Sign off following 4 Country review October 2009 October 2009 Clinical Code Release October 2009 October 2009 Clinical Code Release review December 2009 Sign off following 4 Country review May 2010 April 2010 Read Code Release following NHS IC review October 2010 October 2010 Read Code Release following NHS IC review December 2010 Signed off following 4 Country review May 2011 April 2011 Read Code Release following NHS IC review November 2011 October 2011 Read Code Release following NHS IC review December 2011 Signed off following 4 Country review May 2012 Awaiting confirmation from UKTC of changes to cancer codes for April 2012 Read Code Release October 2012 October 2012 Read Code Release following HSCIC review March 2013 Signed off following consultation June 2013 April 2013 Read Code Release following HSCIC review October 2013 October 2013 Read Code Release following HSCIC review Dates_ January 2014 Review of proposed date changes for QOF 2014/15 January14_Review 23 January 2014 Internal review of changes for 2014/ March 2014 Signed off following review and negotiations. Changes made to incorporate new date terminology June 2014 April 2014 Read Code Release following HSCIC review The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 6 of 22

7 October 2014 October 2014 Read Code Release following HSCIC review December 2014 Signed off following review and negotiations May 2015 April 2015 Read Code Release following HSCIC review October 2015 October 2015 Read Code Release following HSCIC review March 2016 Signed off following review and negotiations July 2016 April 2016 Read Code Release following NHS Digital review February 2017 Signed off following review and negotiations. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 7 of 22

8 2. Background 2.1. Document Purpose The dataset and business rules documents produced by the NHS Digital Primary Care Domain Specification Development Service are created primarily for the uses of GPES and GP system suppliers. These documents contain specifications to communicate technical details of extracts from Primary Care systems which may be used to provide Practice-level information regarding services and/or allocate rewards, such as payments or QOF points. This document is not intended to be used in place of clinical guidelines, but may be referred to by any individual or organisation to aid understanding of which patients and/or activity are included in each population or output. Non-technical, textual descriptions of business rules can be found in the table columns highlighted in pale blue throughout the document. The business rules registers for QOF and Enhanced Services are constructed solely for the purpose of supporting the practice, GP Suppliers, and NHS England in fulfilling the claims and audit requirements for the indicators. Therefore, while a register may carry the name of a particular disorder for business rules purposes, it may well not be sufficiently precise to encompass all of those patients who might be clinically assessed as requiring follow-up or clinical intervention. It is advised that where a practice wishes to construct a register for the purposes of call, recall and clinical management that it is patient based rather than solely disorder based Business Rules Supporting Information Further information regarding the setup of the business rules, terminology used and the calculation methods can be found in version 1.2 of the supporting information document which can be accessed here: Please note: both hyperlinks above have been provided whilst the NHS Digital website is being updated and these both link to the same location. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 8 of 22

9 2.3. Clinical Codes Any part of the dataset specification which uses clinical codes will have the relevant code cluster ID and version specified. The expanded code lists for each cluster can be accessed from the following location: Please note: both hyperlinks above have been provided whilst the NHS Digital website is being updated and these both link to the same location. Clinical code clusters are applied to the April 2016 release of Read codes version 2 and clinical terms version 3 (CTV3) for this ruleset. There was no Read code release in October Guidance Guidance for all Quality Services can be found on the NHS Employers website through the following links: The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 9 of 22

10 3. Dataset specification 3.1 Qualifying Dates The dataset and rules in this document refer to various dates, which may include any number of the dates from the table below. Further information regarding how to use these dates within calculations can be found in the supporting information document (see section 2.2). Term Definition Timeframe for this Service Quality Service Start Date (QSSD) Quality Service End Date (QSED) The first day of the period during which a GP Practice provides the Quality Service 01/04/2017 The last day of the period during which a GP Practice provides the Quality Service 31/03/2018 Quality Service Period Quality Service Data Extract Frequency Quality Service Payment Period Payment Period Start Date (PPSD) Payment Period End Date (PPED) Achievement Date (ACHV_DAT) The period during which a GP Practice provides the Quality Service specified in this document. The frequency of data extracts associated with the Quality Service The frequency of payments associated with the Quality Service. In any given Quality Service Period there may be one, multiple or no payment periods. The first day of each period for which payments are made for the Quality Service. (i.e. for monthly payment periods, the PPSD will be the 1 st of the month in question). Where there are no payment periods (e.g. where payments are made as part of core contract) the PPSD denotes the first day of the extract period in question. The last day of each period for which payments are made for the Quality Service. (i.e. for monthly payment periods, the PPED will be the last day of the month in question). Where there are no payment periods (e.g. where payments are made as part of core contract) the PPED denotes the last day of the extract period in question. The date up to which pertinent patient information is considered when determining the output for each extraction. This is usually the same as the RPED; however, where interim extracts are made the achievement date will vary for each extraction. The time period between the QSSD and the QSED Monthly Annual Date not used int this ruleset. 31/03/2018 The last day of each month. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 10 of 22

11 Term Definition Timeframe for this Service Reporting Period Reporting Period Start Date (RPSD) Reporting Period End Date (RPED) The full period which data is being extracted for. The date from which pertinent patient information is considered for the reporting period in question For non-cumulative* data extracts this relates to the extract frequency (e.g. for a monthly data extract the RPSD will be the 1 st of the month in question). For cumulative* data extracts the time period will usually equal the QSSD or PPSD (e.g. for a within quarter cumulative count the RPSD is the first day of the quarter, for an annual cumulative count the RPSD is the QSSD) The last date of the period the extract relates to (usually the last day of a month e.g. 30 th April, 31 st May, etc.). The time period between the RPSD and the ACHV_DAT Date not used in this ruleset. Date not used in this ruleset. * For the purposes of the business rules Cumulative data collections are extracts which have varying incremental end dates but where groups of extracts or all extracts have a single start date e.g. each extract across the year starts at the QSSD and is taken up the achievement date. Due to the fact that patients may change practice during the year this is not a true cumulative data collection as patients may drop out of counts or enter counts at a later stage; however, this is the terminology used in this document to describe these kinds of counts. Non-cumulative refers to data collections which are discrete extracts between two dates. These non-cumulative data collections do not overlap. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 11 of 22

12 3.2 Patient selection criteria All Populations and Outputs in this Ruleset are to be returned at Practice-level GMS registration status Qualifying criteria Action if true Action if false Non-technical Description (If REG_DAT Null AND If DEREG_DAT = Null) OR (If REG_DAT Null AND If DEREG_DAT > ACHV_DAT) End of rules Select Reject Select patients who meet either of the criteria below registered for GMS prior to or on the achievement date and did not subsequently deregister from GMS (Currently registered for GMS) registered for GMS prior to or on the achievement date and subsequently deregistered from GMS after the achievement date (Previously registered for GMS) (i.e. patients who were registered for GMS on the achievement date) Reject the remaining patients. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 12 of 22

13 3.2.2 Populations Case registers Each patient can only be included once per register. Register Name Description Applied to patients defined in: CAN_REG Cancer register; patients diagnosed with cancer since 1 st April 2003 GMS registration status SDS use only: Version 100 Rule number Rule Action if true Action if false Rule description or comments 1 If CAN_DAT >= 01/04/2003 Select Reject End of rules Select patients from the specified population who had a first or new diagnosis of cancer on or after 1 st April 2003 and up to and including the achievement date. Reject the remaining patients. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 13 of 22

14 Cohorts N/A - there are no cohorts for this service. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 14 of 22

15 3.2.3 Clinical Code Clusters The dataset may include dates and values associated with the presence of clinical codes in a patient s record. All clinical code clusters referred to in the clinical data extraction criteria are detailed below. The expanded cluster lists for each cluster can be found on the NHS Digital website (see section 2.3). Cluster Name Description Read V2 CTV3 Cluster Version CANEXC_COD Cancer exception reporting codes 9h8..% XaJ4U% 100 CAN_COD Codes for relevant malignancies B0...-B32z., B34..-B6z0. (excluding B677.), Byu..- Byu41, Byu5.-ByuE0, K1323, K01w1, 68W24, C184. XaabR%, B62y.%, X78ef% (excluding B937W%, Byu5A%, Byu43%, Byu4.%, ByuHD%, Byu42%, B5820%, B582z%, B5826%, B5821%, B5825%, B5822%, B5823%, B5824%, Xa0Sh%, XaB49%, X00Z9%, XE1yx%, Xa3eJ%, X78hl%, XM1ML%, X20FX%, X00ZC%, XaFrS%, X78h0%, B331.%, B332z%, B33y.%, B333.%, B334.%, B3320%, B3321%, B3330%, B332.%, B337.%, B330.%, B335.%, B336.%, X78RP%, XaEGW%, XaEGV%, XaCKx%, B33z.%, B33..%, Xa0KC%, X78hS%, X00Z6, X78gs, Xa3BF%, Xa0SJ%, XaB46%, XaYiK%, Xa0SY, D41y1%, XE1vh%, C332.%, Xa0l6%, B934.%, Xa0Se%, Xa0Sg%, Xa0Sf%, XaYv2%, X00ZA%, X00Z8%, C3330%, X78ha, X78hm, X78hn, Xa0EY, Xa34C, Xa34D) 102 The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 15 of 22

16 Cluster Name Description Read V2 CTV3 Cluster Version MDRV_COD Code for cancer care review 8BAV. XaIyc 100 End of clusters The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 16 of 22

17 3.2.4 Clinical Data Extraction Criteria Field number Field name Code cluster (if applicable) Qualifying criteria 1 PAT_ID n/a Unconditional 2 REG_DAT n/a Latest <= ACHV_DAT 3 DEREG_DAT n/a Earliest > REG_DAT 4 CANEXC_DAT CANEXC_COD Latest <= ACHV_DAT 5 CAN_DAT CAN_COD 6 MDRV_DAT MDRV_COD End of fields Latest first or new episode <= ACHV_DAT Earliest (<= ACHV_DAT AND >= CAN_DAT) Non-technical Description The patients unique ID number for the practice in question The most recent date that the patient registered for GMS, where this registration occurred on or before the achievement date The first occurrence of the patient deregistering from GMS following the latest GMS registration Date of the most recent cancer exception reporting code in the patient record up to and including the achievement date. Date of the most recent new episode or first episode of cancer diagnosis up to and including the achievement date. Date of the first cancer care review undertaken after the latest cancer diagnosis and up to and including the achievement date. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 17 of 22

18 4. Outputs 4.1. Indicator(s) Additional supporting information is displayed below each set of indicator tables if required. Indicator ID Description Applied to population: CAN001 The contractor establishes and maintains a register of all cancer patients defined as a register of patients with a diagnosis of cancer excluding non-melanotic skin cancers diagnosed on or after 1 April CAN_REG SDS use only: Version 100 The terms of this indicator will be satisfied if the practice is able to produce a data extraction according to the rules for the population specified above. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 18 of 22

19 Indicator ID Description Applied to population: CAN003 The percentage of patients with cancer, diagnosed within the preceding 15 months, who have a patient review recorded as occurring within 6 months of the date of diagnosis. CAN_REG SDS use only: Version 100 The numerator is applied to the patients selected into the denominator for this indicator. Denominator Rule number Rule Action if true Action if false Rule description or comments 1 If CAN_DAT <= (PPED 18 months) Reject Next rule 2 If MDRV_DAT <= (PPED 12 months) Reject Next rule 3 If MDRV_DAT <= (CAN_DAT days) Select Next rule 4 If CAN_DAT > (PPED 6 months) AND If MDRV_DAT = Null Reject Next rule 5 If REG_DAT > (PPED 3 months) Reject Next rule 6 If CANEXC_DAT > (PPED 12 months) Reject Next rule Reject patients from the specified population whose most recent episode of cancer was at least 18 months before the payment period end date. Pass all remaining patients to the next rule. Reject patients passed to this rule whose cancer care review was at least 12 months before the payment period end date. Pass all remaining patients to the next rule. Select patients passed to this rule whose cancer care review was within 6 months of their diagnosis. (NOTE: for the purposes of the business rules 6 months is treated as 186 days). Pass all remaining patients to the next rule. Reject patients passed to this rule who meet both of the criteria below: Most recent episode of cancer was within the 6 months leading up to and including the payment period end date. Did not receive a cancer care review between the date of diagnosis and the payment period end date. Pass all remaining patients to the next rule. Reject patients passed to this rule who registered with the GP practice within the 3 months leading up to and including the payment period end date. Pass all remaining patients to the next rule. Reject patients passed to this rule who had a cancer exception reporting code in the 12 months leading up to and including the payment period end date. Pass all The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 19 of 22

20 remaining patients to the next rule. 7 If CAN_DAT > (PPED 3 months) Reject Select End of denominator rules Reject patients passed to this rule whose most recent episode of cancer was within the 3 months leading up to and including the payment period end date. Select the remaining patients. Numerator Rule number Rule Action if true Action if false Rule description or comments 1 If MDRV_DAT <= (CAN_DAT days) Select Reject End of numerator rules Select patients passed to this rule whose cancer care review was within 6 months of their diagnosis. (NOTE: for the purposes of the business rules 6 months is treated as 186 days). Reject the remaining patients. Indicator-specific Supporting Information Overview This indicator has been developed to measure the effectiveness of the provision of a clinical care component for patients on the Cancer register. The aspect that is being measured is that of the provision of a clinical care component for patients with cancer. The aspect being measured is that relating to a review being recorded. Disease register The disease register is made up of patients who are eligible to receive the required care component. In this case;- Patients who have a diagnosis of cancer (i.e. there is evidence within the patient s electronic health record of a cancer diagnosis code occurring after 1 April 2003) The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 20 of 22

21 Numerator and Denominator The success criteria for this indicator (numerator) is where those patients in the denominator have had a review recorded within 186 days of the date of diagnosis. The patients that make up the denominator for this indicator are those patients where it is appropriate for the cancer management to be carried out. This is the relevant disease register adjusted for exclusions and exceptions. Exclusions For this indicator there are two exclusions: If the patient s latest first or new episode of cancer is recorded outside the preceding 18 months then they will be excluded If the patient s earliest cancer care review (after their latest first or new episode of cancer) was outside the preceding 12 months then they will be excluded. Exceptions Patients that don t achieve the success criteria of the indicator are checked for valid exceptions. For this indicator the exceptions are any patient that has been diagnosed with cancer within the last 6 months of the year and hasn t had a review recorded within this period. If the patient has not received a review then it would be unreasonable for the patient to be considered unsuccessful until the full 6 month period has elapsed, which can only be done in the next QOF period. Such patients are excepted for this year. any patient who has been registered within the last 3 months of the qualifying year (new patient). New patients may be regarded as exceptions if they fulfil the criteria of the indicator but have not yet had a review - maybe because there hasn t been an opportunity in the qualifying year to arrange it. any patient that has a valid cancer exception code recorded within the preceding 12 months. any patient that has been diagnosed with cancer within the last 3 months of the year (new diagnosis of cancer). Newly diagnosed patients may be regarded as exceptions if they fulfil the criteria of the indicator but have not yet had a review - maybe because there hasn t been an opportunity in the qualifying year to arrange it. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 21 of 22

22 4.2. Payment Count(s) N/A - there are no payment counts for this service Management Information Count(s) N/A - there are no management information counts for this service Patient-level Extract(s) N/A - Not applicable for this service. 5. Appendix - Supporting data for NHS Digital SDS Category Database value TRUD version V21_0_0 Document version 36.0 Ruleset Database ID Cancer Database Service ID QOF QSR Reference if applicable n/a The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. Page 22 of 22