Section 2: clinical indicators
2. Exception reporting
The Quality and Outcomes Framework includes the concept of exception reporting. This has 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 twelve months
B) patients for whom it is not appropriate to review the chronic disease parameters due to particular circumstances eg terminal illness, extreme frailty
C) patients newly diagnosed within the practice or who have recently registered with the practice, who should have measurements made within three months and delivery of clinical standards within nine months eg blood pressure or cholesterol measurements within target levels
D) patients who are on maximum tolerated doses of medication whose levels remain sub-optimal
E) patients for whom prescribing a medication is not clinically appropriate eg those who have an allergy, another 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
H) where the patient has a supervening condition which makes treatment of their condition inappropriate eg 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. For example, in a practice with 100 patients on the CHD disease register, in which four patients have been recalled for follow-up on two 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. 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 left ventricular dysfunction (LVD) but who is intolerant of ACE inhibitors could be exception-reported. This would again be done by removing the patient from the denominator.
In some instances, a patient may have been referred to a specialist with the expectation that a test or investigation would be carried out. Where this has not been done (eg a specialist has ordered an alternative test to an echocardiogram for a patient with heart failure), than that patient would be exception-reported (as in I above). In other cases, eg a diabetic with a hospital summary of an annual review which had no record of fundoscopy, it would be the GP’s overall responsibility to ensure that appropriate care had been given.
Practices should report the number of exceptions for each indicator set and individual indicator. Exception codes have been added to systems by supliers. Practices will not be expected to report why individual patients were exception-reported. So, for example, a single new Read code is likely to be developed for exception reporting, rather than one for each of the categories above. However, practices may be called on to justify why they have excepted patients from the quality framework and this should be identifiable in the clinical record.