Taking Part In QOF
To optimise QOF points, all men and women aged 50 and over suffering a fragility fracture from 1 April 2014 must be added to a register (i.e. their fracture must be coded in such a way that they can be identified). Practices may want to use a template to ensure that they capture data using the correct codes. Incorrect codes: no money.
At this stage, it is useful to pilot your system for identifying and coding new fractures (and those prevalent fractures identified opportunistically that will not count for QOF but still should identify people to assess and treat) and begin ensuring that appropriate patients with fractures are initiated on bone-sparing therapy.
A fragility fracture is a fracture occurring in a person over the age of 50 years that results from a fall from standing height or less, or a vertebral fracture caused by minor trauma (e.g. bending to pick up a shopping bag, coughing or turning over in bed).
Primary-care teams must identify these incident (i.e. new) fractures from A&E and fracture clinic letters or orthopaedic ward discharge summaries, unless your CCG has an overarching Fracture Prevention Service (FPS), or Fracture Liaison Service (FLS), that does this for you (e.g. Oxfordshire CCGs). It may not be clear whether a fracture is a fragility fracture or was caused by high-impact trauma (e.g. a motor vehicle accident). It may be necessary to clarify this with a telephone call to the patient before coding. Although you may wish to code the exact fracture, including its site and type, you should also use the N331N fragility fracture code, or another code requested by the QOF rules. This will ensure that every patient is included in the register and will allow you to search for all fragility fractures and ensure that they have been referred for DXA and have received treatment where appropriate.
Some locations will have an FLS in place that may already have referred your patient for a DXA scan. This should be documented in the clinic letter or discharge summary. If it is not clear, and your patient has not been told that they have been referred, you need to make the referral yourself using the preferred referral form. Clearly document the fragility fracture and any other reasons for the scan request.
In patients over age 75, a DXA scan may not be required by the QOF indicators. In many cases, it is clinically appropriate and feasible to send a patient over the age of 75 for a scan, although NICE guidance allows for a diagnosis to be assumed in this age group if a scan is not undertaken. Some patients aged over 75 years, however, really want to know if they have osteoporosis or not before they will accept treatment. Under the change of wording of the 2014 QOF this now allows these people to obtain a DXA, which previously in a lot of localities was not commissioned.
<p[>Referral for DXA should be coded (8HQ8) when the referral is sent, and it is vital that the appropriate DXA result code is added when the result is received:
- Hip DXA osteoporotic: 58EG
- Lumbar spine DXA osteoporotic: 58EM
Code only the site with the lowest score to avoid confusion (i.e. if the lumbar spine is osteopenic and the femoral neck is osteoporotic, code as hip DXA osteoporosis). You may also want to add the T-scores in free text for each site, but this is not required for QOF.
It is good practice to check compliance and tolerability of treatment 2 to 3 months after initiation, and this can be carried out by telephone for some patients. If the patient is intolerant of any bone-sparing medication, add that code to the record when initiating new medication (e.g. intolerant of bisphosphonates). This will prevent accidentally restarting or switching to a treatment to which the patient has already been found to be intolerant. Since more than 50% of patients will stop therapy within 1 year, it will be important to check for compliance and persistence with therapy 1 to 2 months before the end of the QOF year so that those who have defaulted can be encouraged to restart. Those not receiving treatment at the end of the year will not be included in targets.