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The QOF includes the concept of exception reporting. This was been introduced to allow practices to pursue the quality improvement agenda and not be penalised, where, for example, patients do not attend for review, or where a medication cannot be prescribed due to a contraindication or side effect.
The following criteria have been agreed for exception reporting:
A. patients who have been recorded as refusing to attend review who have been invited on at least three occasions during the preceding 12 months
B. patients for whom it is not appropriate to review the chronic disease parameters due to particular circumstances e.g. terminal illness, extreme frailty
C. patients newly diagnosed or who have recently registered with the practice who should have measurements made within three months and delivery of clinical standards within nine months e.g. blood pressure or cholesterol measurements within target levels
D. patients who are on maximum tolerated doses of medication whose levels remain suboptimal
E. patients for whom prescribing a medication is not clinically appropriate e.g. those who have an allergy, contraindication or have experienced an adverse reaction
F. where a patient has not tolerated medication
G. where a patient does not agree to investigation or treatment (informed dissent) and this has been recorded in their medical records following a discussion between with the patient
H. where the patient has a supervening condition which makes treatment of their condition inappropriate e.g. cholesterol reduction where the patient has liver disease
I. where an investigative service or secondary care service is unavailable.
In the case of exception reporting on criteria A and B this would apply to the disease register and these patients would be subtracted from the denominator for all other indicators in that disease area. For example, in a practice with 100 patients on the CHD disease register, in which four patients have been recalled for follow-up on three occasions but have not attended and one patient has become terminally ill with metastatic breast carcinoma during the year, the denominator for reporting would be 95. However, all 100 patients with CHD would be included in the calculation of practice prevalence. This would apply to all relevant indicators in the CHD set.
In addition, practices may exception-report patients relating to single indicators, for example a patient who has heart failure due to Left Ventricular Dysfunction (LVD) but who is intolerant of ACE inhibitors (ACE-I) could be exception reported. This would again be done by removing the patient from the denominator.
Practices should report the number of exceptions for each indicator set and individual indicator. Practices will not be expected to report why individual patients were exception reported. However, practices may be called on to justify why they have ‘excepted’ patients from an indicator during verification and this should be identifiable in the clinical record.
Exception reporting guidance can be found at the following location: www.pcc.nhs.uk/uploads/QOF/october_06/qof212_exception_reporting_guidance_final.pdf
Prepared By Jean Keenan