Commissioning Outcomes Framework Advisory Committee Minutes of the meeting held on Monday 21 st May 2012 Meeting held at NICE Office in Manchester Attendees Committee Members: Sarah Baker (SB), Nigel Beasley (NB), Derek Chase (DC), Andy Cotgrove (AC), Mark Davis (MD), Sarah Dougan (SD), Richard Garlick (RG), Niru Goenka (NG), Simon Hairsnape (SH), Danny Keenan [Chair] (DK), Gillian Laurence (GL), Colette Marshall (CM), Richard Mindham (RM), Jane Mulholland (JM), Raj Nagaraj (RN), Guy Pilkington (GP), Frances Reid (FR) and Sarah Scobie (SS). NICE Attendees: Nick Baillie (NB), Nicola Bent (NBt), Gavin Flatt (GF), Terence Lacey (TL), Gillian Leng (GL), Liane Marsh (LM), Rachel Neary (RNy), Beth Shaw (BS), Tony Smith (TSm), Tim Stokes (TS), Daniel Sutcliffe (DS), and Andrew Wragg (AW). Health and Social Care Information Centre: Azim Lakhani (AL) and Alison Roe (AR). NHS Commissioning Board Authority: Kathy Maclean (KM). Observers: Kalipso Chalkidou (KC), Francoise Cluzeau (FC) and Tonya Gillis (TG). Apologies Sharon Tuppeny (ST) and Lynn Woods (LW). Authors Liane Marsh (LM) and Rachel Neary (RN). Commissioning Outcomes Framework Advisory Committee minutes 210512 1 of 18
1. Welcome, outline of committee meeting and apologies The Chair DK, welcomed everyone to the meeting, and all attendees introduced themselves. The Chair noted apologies. 2. Introduction to the meeting and Code of Conduct for members of the public attending the meeting. DK briefed the Committee and the public observers on NICE s code of conduct for meetings held in public. Commissioning Outcomes Framework Advisory Committee minutes 210512 2 of 18
3. COF policy update KM updated the Committee on changes in COF policy since the last meeting. The committee queried whether the NHS Commissioning Board (NCB) would be able to select indicators from outside NICE s process for inclusion within the COF and KM confirmed that this would be the case. The chair questioned whether the size of the COF had been agreed and KM advised that this was still a matter for discussion. The committee asked whether there would be an evaluation of the indicators selected for inclusion within the COF to ensure that they are appropriate. KM confirmed that the NCB would need a process for reviewing indicators in the COF on an ongoing basis. She advised however that the focus is currently on establishing the COF but agreed to take the point away for consideration. Commissioning Outcomes Framework Advisory Committee minutes 210512 3 of 18
4. Update on COF process and the role of NICE GL updated the Committee on the COF Process and the role of NICE, specifically how things have moved on since the last meeting. GL advised the Committee that since the last meeting the Department of Health (DH), the Health and Social Care Information Centre (HSCIC) and NICE had identified additional potential indicators for the COF which were either derived from the NHS Outcomes Framework or based on existing indicator collections and that the committee would be considering these indicators. AR also outlined the testing work done by the HSCIC. The committee highlighted that most of the quality standards to date had been disease specific and felt that it would be valuable to have indicators on comorbidities within the COF. GL confirmed that a number of the quality standards in the new core library focus on cross cutting topics and service delivery. Commissioning Outcomes Framework Advisory Committee minutes 210512 4 of 18
5. Declarations of interest 6. Minutes of the last meeting held on 30 th September 2011 7. Structured Decision Making 8. Prioritisation criteria DK highlighted NICE s Declaration of Interests policy. Committee members have filled in new Declaration of Interest forms and declared any new interests since the last COF Committee Meeting in September 2011. Members agreed that the minutes taken of the COF Committee Meeting held on 30 th September 2011 were an accurate record of the meeting that took place. DK briefed the Committee on the structured decision making criteria that should inform their decision making. DK briefed the Committee on the prioritisation criteria that should inform their decision making and explained how the criteria had been applied to the indicators for discussion. DS stressed that recommendation of any indicator was down to the judgement of the committee however these criteria were to guide discussion. Commissioning Outcomes Framework Advisory Committee minutes 210512 5 of 18
9. Position statements DK briefed the Committee on position statements. 10. Explanation of committee briefing papers DK outlined the COF Committee briefing papers that had been provided in advance of the meeting. DS presented some slides on recurrent themes which were likely to arise during the meeting. 11. COPD 2.23 People with COPD who are functionally disabled, usually MRC grade 3 and above referred to a pulmonary rehabilitation programme. The Committee agreed that this is a useful indicator in determining the quality of care for people who have COPD. They agreed that the definition of functionally disabled should be clarified using the QOF guidance. 2.28 Emergency attendance at A&E: COPD 3.7 People admitted to hospital with an exacerbation of COPD who are under the care of a respiratory consultant within 2 days of admission until discharge 3 This indicator is not feasible for inclusion in the 2013/14 COF as there is not sufficient data available at present. The committee did however request that further work be done on this indicator to see if the data could be collected for future years. They also felt that the indicator should include clinical decision units. 3 The Committee agreed that it is appropriate to assign specialists to people with long-term conditions, however they did not want to dictate a care pathway and identify what type of specialist. They acknowledged that this is the role of Clinical Commissioning Groups (CCG s).it was also felt that this indicator could have unintended consequences as there are often good reasons for patients with COPD not to be seen by a respiratory consultant. For these reasons the indicator was not progressed. Commissioning Outcomes Framework Advisory Committee minutes 210512 6 of 18
3.8 Emergency readmissions: people who have been admitted following an exacerbation of COPD 3.10 Emergency readmissions: COPD 3 The Committee agreed that this could be a useful indicator in determining the quality of care for people with COPD. However it was felt that there were a number of coding issues that could limit the value of the indicator. The indicator should therefore not be progressed. The Committee agreed that this could be a useful indicator in determining the quality of care for people with COPD. The indicator does not include co-morbidity readmissions but the indicator can be readjusted if this is a problem. 3.11 Emergency readmissions: oxygen toxicity 12. Asthma 2.10 Emergency attendance at A&E: asthma 3 It is unlikely that this indicator is going to be feasible for inclusion in the 2013/14 COF. This indicator is most likely only going to be applicable to a small number of patients. 3 There may be issues with the quality of clinical coding for this indicator because it is early in the care process when a firm diagnosis may not be made. There is currently no coding specifically for Asthma in A&E. Members noted that there is currently a Quality Standard for Asthma in development and therefore agreed to revisit this topic in future. 13. Stroke 1.34 Mortality within 30 days of hospital admission for stroke 2.85 People who have had a stroke who have been free from vascular events for 6 months following initial (index) admission for stroke (case-mix adjusted) 2.87 Joint health and social care plans on discharge of patients with stroke from hospital The Committee agreed that this is a useful indicator in determining the quality of care for people who have had a stroke. 3 This indicator is not feasible for inclusion in the 2013/14 COF due to a lack of data. The Committee agreed that this is a useful indicator in determining the quality of care for people who have had a stroke. Commissioning Outcomes Framework Advisory Committee minutes 210512 7 of 18
2.88 Psychological support for mood, behaviour and cognitive disturbance by 6 months after stroke 2.89 People with stroke reviewed 6 months after leaving hospital 2.90 People with stroke supported by a stroke skilled early supported discharge (ESD) team 3.31 For those people assessed as having a stroke and seen by ambulance services, the proportion who are taken to a hospital with a acute stroke unit within 1 hour of arrival at the emergency 3.32 People who have had an acute stroke who have brain imaging within one hour of arrival at the hospital 3.33 People who have had an acute stroke who receive thrombolysis 1b 1b The Committee agreed that this is a useful indicator in determining the quality of care for people who have had a stroke. However, they suggested the indicator should be reworded slightly to align directly with the National Sentinel Stroke Audit. The suggested re-wording was: People who have received psychological support for mood behaviour and cognitive disturbance by 6 months after stroke. The Committee agreed that this is a useful indicator in determining the quality of care for people who have had a stroke. However, they would like to specify that people with stroke should be reviewed by somebody who is a specialist in this area. The Committee agreed that this is a useful indicator in determining the quality of care for people who have had a stroke. Members suggested that this is a key indicator which potentially covers several of the other stroke indicators. The committee also agreed that the skill set required could be defined using the Stroke audit. 3 This indicator is not feasible for inclusion in the 2013/14 COF due to a lack of data. quality issues. The Committee noted that this indicator is subsumed into indicator 3.33. The Committee agreed that this is a useful indicator in determining the quality of care for people who have had a stroke and could be measured using HES data. However, they highlighted the risk that patients who are eligible for thrombolysis could be prioritised inappropriately against those who are not. This would be an unintended consequence and should be monitored. Commissioning Outcomes Framework Advisory Committee minutes 210512 8 of 18
14. Coronary Heart Disease 3.34 Patients with stroke admitted to an acute stroke unit within 4 hours of arrival to hospital 3.35 People who have had an acute stroke whose swallowing is screened by a specially trained healthcare professional within 4 hours of admission to hospital 1.16 Timely intervention: ambulance response times following suspected myocardial infarction The Committee agreed that this is a useful indicator in determining the quality of care for people who have had a stroke. However, they highlighted concerns regarding patients with comorbidities. The Committee agreed that this is a useful indicator in determining the quality of care for people who have had a stroke. Members queried whether this indicator is subsumed within indicator 3.34, however it was agreed to progress this indicator for decision by the NCB. 3 The Committee agreed that this is not useful indicator in determining the quality of care for people who have coronary heart disease because it is an area which is difficult for CCGs to influence. Also, this indicator is not feasible for inclusion in the 2013/14 COF due to data issues. It is not possible to capture the data for this indicator in its current wording. 1.17 Timely intervention: thrombolysis following suspected myocardial infarction 3 This indicator was excluded from the 2013/14 COF as it is not supported by evidence. Thrombolysis has been replaced by angioplasty as best practice for this patient group. Commissioning Outcomes Framework Advisory Committee minutes 210512 9 of 18
2.42 Cardiac rehabilitation 2b The Committee agreed that cardiac rehabilitation is important for people who have coronary heart disease, however, they felt that this definition is very poor. The Committee stated that this indicator may reflect practice that is no longer current and may not be attributable to CCGs. There was some discussion that this may be a good indicator if it specified that patients should complete a programme of cardiac rehabilitation. However, people may not complete the programme for appropriate reasons so simple completion is not helpful. The Committee highlighted that there is a lot of variation in the quality of cardiac rehabilitation. This indicator is about being referred or offered rehabilitation. Patients could be referred to poor quality cardiac rehabilitation which would mean this indicator would be of limited use in assessing commissioning quality. ACTION The Committee asked if cardiac rehabilitation and how it improves quality of life could be considered during the development of the secondary prevention of MI and cardiac rehabilitation quality standard. 3.14 Hospital procedures: repeat percutaneous transluminal coronary angioplasty (PTCA) 3.15 Hospital procedures: repeat coronary artery bypass graft (CABG) 3 This indicator was not recommended for inclusion in the 2013/14 COF because of data quality concerns due to the small numbers of patients that this may be applicable to. Members also discussed the limited influence that CCG s have on the quality of individual interventionistssurgeons and felt that this indicator could actually punish people for doing the right thing. The committee felt that mortality at 1 year would be a better indicator. 3 This indicator was not recommended for inclusion in the 2012/14 COF because of data quality concerns due to the small numbers of patients that this is applicable to. The numbers are so small that even when they are aggregated over a period of three years they are still unworkable. Members felt that an alternative possible measure would be unplanned readmission within 30 days of index procedure Commissioning Outcomes Framework Advisory Committee minutes 210512 10 of 18
14. NHS Outcomes Framework General comments: 1b Life expectancy at 75: i males ii females 1.1 Under 75 mortality rate from cardiovascular disease 1.2 Under 75 mortality rate from respiratory disease Committee members suggested that an indicator that measured mortality after a year might be useful in assessing the quality of commissioning in this area. Members also suggested that an indicator under Timely intervention such as call to balloon/thrombolysis time might be appropriate. 3 This indicator is not feasible for inclusion in the 2013/14 COF as data cannot be collected at CCG level. The committee however felt that this was an excellent marker of quality and may be feasible in the future. The Committee agreed that this is a useful indicator in assessing the quality of commissioning. Although this specific data is not yet available, a reasonable estimate can be produced using the Primary Care Mortality Database. The Committee agreed that this is a useful indicator in assessing the quality of commissioning and felt that data was available currently. 1.3 Under 75 mortality rate from liver disease 1.4i one-year survival from colorectal cancer 3 This indicator was not recommended for inclusion in the 2013/14 COF because of data quality concerns due to the small numbers of patients that this may be applicable to. 3 This indicator is not feasible for inclusion in the 2013/14 COF. The HSCIC is working with the London School of Hygiene and Tropical Medicine to develop the indicator but they do not expect it to be ready by April 2013. The HSCIC also highlighted potential problems attributing the indicator to CCGs and problems with small numbers. It was also felt that cancer survival rates were dependent on the socio-economic status of an area. The Committee noted survival rates at one year were not a good measure of high quality cancer care. Commissioning Outcomes Framework Advisory Committee minutes 210512 11 of 18
1.4ii five-year survival from colorectal cancer 1.4iii one-year survival from breast cancer 3 This indicator is not feasible for inclusion in the 2013/14 COF. The HSCIC is working with the London School of Hygiene and Tropical Medicine to develop the indicator but they do not expect it to be ready by April 2013. The HSCIC also highlighted potential problems attributing the indicator to CCGs and problems with small numbers. It was also felt that cancer survival rates were dependent on the socio-economic status of an area. 3 See1.4i. 1.4 iv five-year survival from breast cancer 1.4v one year survival from lung cancer 1.4 vi five-year survival from lung cancer 3 See 1.4ii. See1.4i. 3 See 1.4ii. 1.4 vii under 75 mortality rate from cancer General comments on indicator 1.4 The Committee agreed that this is a useful indicator in assessing the quality of commissioning and noted it is easier to measure mortality than survival rates. The data for this indicator is available and the indicator is being considered for the Public Health Outcomes Framework. The Committee commented generally on indicator 1.4 that survival rates are generally more useful than mortality rates in assessing quality commissioning however survival rate data is currently not available. 1.6 i Infant mortality issues. This specific data won t be available until 2015. 1.6 ii Neonatal mortality and stillbirths issues. This specific data won t be available until 2015. Commissioning Outcomes Framework Advisory Committee minutes 210512 12 of 18
2 Health-related quality of life for people with long-term conditions 2.1 Proportion of people feeling supported to manage their condition 2.2 Employment of people with long-term conditions 2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive conditions ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s 2.5 Employment of people with mental illness 3a Emergency admissions for acute conditions that should not usually require hospital admission 3b Emergency readmissions within 30 days of discharge from hospital The Committee discussed whether this is a useful indicator in assessing the quality of commissioning and agreed that CCGs should be responsible for health related quality of life. The data for this indicator could come from the GP Patient Survey. The Committee agreed that this is a useful indicator in assessing the quality of commissioning. The data for this indicator might be made available using GP Patient Surveys. issues. Data is not currently available to match employment to health. 3 See 2.2. See 3a. The Committee agreed that this is a useful indicator in assessing the quality of commissioning. The Committee agreed that this is a useful indicator in assessing the quality of commissioning. The data for this indicator is readily available as it is already being measured. The Committee discussed that there is a high level of variation within this area and so there are likely to be coding issues however they felt that this can be addressed. Commissioning Outcomes Framework Advisory Committee minutes 210512 13 of 18
3.1 Patient Reported Outcomes Measures (PROMs) for elective procedures i Hip replacement ii Knee replacement iii Groin hernia iv Varicose Veins 3.2 Emergency admissions for children with LRTI 4a Patient experience of ii GP Out of Hours services 4b Patient experience of hospital care 4.1 Patient experience of outpatient services 4.2 Responsiveness to inpatients personal needs 4.3 Patient experience of A&E services 4.5 Women s experience of maternity services See 3a and 3b. The Committee agreed that these are useful indicators in assessing the quality of commissioning. Members agreed that the hip replacement and knee replacement indicators were important as these procedures are associated with good outcomes and with an improved quality of life. However, members queried whether to include the indicator on varicose veins and groin hernia. These indicators were however recommended for inclusion in the COF. It was noted untreated varicose veins can result in serious health concerns such as skin ulcers, and data relating to varicose vein surgery is collected already. The Committee agreed that this is a useful indicator in assessing the quality of commissioning and can be measured using the GP patient survey. The Committee clarified that this indicator did not include dental services. issues. It was felt to be too difficult to apportion to CCGs. Data is based on trust surveys and cannot be mapped to CCGs issues. Data is based on trust survey surveys and cannot be mapped to CCGs issues. Data is based on trust surveys and cannot be mapped to CCGs issues. Data is based on trust surveys and cannot be mapped to CCGs issues. Data is based on trust surveys and cannot be mapped to CCGs Commissioning Outcomes Framework Advisory Committee minutes 210512 14 of 18
4.7 Patient experience of community mental health services 5a Patient safety incidents reported 5b Safety incidents involving severe harm or death issues. Data is based on trust surveys and cannot be mapped to CCGs. 3 This indicator was not recommended for inclusion in the 2013/14 COF due to data concerns and issues of interpretation. This information is already known at an individual patient level, however the attribution of data to CCG level is not robust. Committee members also discussed the varying interpretations of this indicator. Some members thought that a higher number of reported patient safety incidents showed low quality care. However, others argued that a higher number of reported patient safety incidents showed a good reporting culture which is a positive thing. It was therefore agreed that this indicator was unlikely to change commissioning. 3 This indicator was not recommended for inclusion in the COF due to data concerns and issues of interpretation. This information is already known at an individual patient level, however it was felt aaggregation of data to CCG level would be unhelpful. 5.2 Incidence of healthcare associated infection (HCAI): i MRSA ii C. Difficile 5.4 Incidence of medication errors causing serious harm 3 This indicator was not recommended for inclusion in the COF due to data concerns. Health Protection Agency (HPA) data is currently available at Trust level, however members raised concerns about aggregating this data to CCG level due to data differences. 3 This indicator is not feasible for inclusion in the 2013/14 COF as the data is not currently available. Commissioning Outcomes Framework Advisory Committee minutes 210512 15 of 18
5.5 Admission of full-term babies to neonatal care 5.6 Incidence of harm to children due to failure to monitor 15. Cancers 4.10 Deaths at home (all cancers) 16. Out of Hours Care 3.29 Total time: time from the start of the original call or arrival at the urgent care or out-ofhours base until discharge, admission or transfer to another service. 2b 3 See 5.4. Committee members required further information on this indicator definition. There were data concerns associated with this indicator. It is possible to collect data for this indicator at present. However, the Department of Health is reviewing how this is reported which will affect data collection. Committee members also raised issues of interpretation. In some cases it may be a good thing to admit more babies to neonatal care. Further clarification is therefore needed before a decision can be made on whether to recommend this indicator. 3 The Committee suggested that the COF should address all deaths and not just deaths from cancer. They also suggested that an indicator measuring deaths should include the usual place of care rather than just at home. This indicator may be better suited to the End of Life Care topic. Indicators are currently being developed for End of Life Care. It was therefore agreed not to progress this indicator in its current form. 3 This indicator is not feasible for inclusion in the 2013/14 COF as the data is not currently available. The Committee acknowledged that plans for this data collection have recently been postponed by the Department of Health. Commissioning Outcomes Framework Advisory Committee minutes 210512 16 of 18
3.30 Unplanned re-contact rate: 3 See 3.29. a) Re-contact following discharge of care by clinical telephone advice within 7 days of a previous call. b) Unplanned re-contact within 7 days of attendance at an urgent care or out-of-hours base. 17. Urgent Care 3.41 Unplanned re-attendance at A&E within 7 days of original attendance 4.22 Attenders leaving without being seen 4.23 High risk re-attenders reviewed by consultant before being discharged concerns. The Committee were supportive of this indicator. However, data collection may be distorted by people re-attending A&E for different conditions. It was also noted that the data set used in A&E is very broad and therefore the indicator would not currently be feasible even with an amended definition. The Committee asserted that one of the main issues in urgent care is encouraging people with needs more suited to primary care to attend there rather than attending A&E. This indicator does not address this issue. 3 This indicator was not recommended for inclusion in the 2013/ 14 COF as it was not considered a useful indicator in assessing the quality of commissioning. The data collection could be distorted by people attending A&E intoxicated and then going home. The Committee also felt that A&E waiting times are already very strict so this indicator does not add anything to commissioning. 3 The Committee raised issues with the definition of a high-risk attender And noted that data collections would need to be changed in order to measure. Also, the Committee queried why patients had to be reviewed by a Consultant specifically. There may be other specialised health professionals who are able to conduct the review. Commissioning Outcomes Framework Advisory Committee minutes 210512 17 of 18
6. Review of decisions and general discussion General comments: The Committee reviewed decisions made. The Committee queried if there is going to be a Quality Standard for Urgent Care. ACTION AW to check and advise Committee members. * Structured decision making options Recommend to NHS Commissioning Board subject to confirmation of data availability / risk adjustment methods (prior to final sign off by NICE Guidance Executive) 1b Recommend to NHS Commissioning Board subject to confirmation of data availability / risk adjustment methods (prior to final sign off by NICE Guidance Executive) 2a Committee requires further evidence of clinical effectiveness to make a recommendation (for indicators not based on NICE quality standard, guidance or accredited sources) 2b Committee requires further information on indicator definition (for indicators not developed by quality standard review groups) 3 Not recommend to NHS Commissioning Board Commissioning Outcomes Framework Advisory Committee minutes 210512 18 of 18