city and hackney practice support searches manual...1 city and hackney practice support searches...

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City and Hackney Practice Support Searches Manual

August 2017 Practice Reports (2017-2018)

QOF Support

DES Support

Clinical Tools

Medicines Management

Confederation Searches

Iummunisations

Additional

*CCG Enhanced Services (2017-2018)

*LTC1: LTC Core (2017-2018)

*LTC2: Time to Talk (2017-2018)

*LTC3: Cancer (2017-2018)

A guide to all the

searches you need for

improving income &

quality in 2017-18

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Contents Introduction ................................................................................................................................................................. 4

Practice Reports (2017/18) .......................................................................................................................................... 5

1. QOF Support ............................................................................................................................................. 6

Dementia Patients in IC- QOF review ........................................................................................................... 6

Expiring exceptions for meds or BP in the past ............................................................................................ 6

2. DES Support .................................................................................................................................................. 6

3. Clinical Tools ................................................................................................................................................. 7

4. Confederation Searches ............................................................................................................................. 10

5. Medicines Management ............................................................................................................................ 10

6. Immunisations ............................................................................................................................................ 10

7. Additional ................................................................................................................................................... 11

CCG Enhanced Services (2017-2018) ......................................................................................................................... 12

CCG04: Phlebotomy v6.1 ................................................................................................................................ 13

CCG05: FHV v6.1 ............................................................................................................................................. 13

CCG08: Mental Health Alliance v6.0 .............................................................................................................. 14

CCG09: End of Life........................................................................................................................................... 14

CCG10: Post-Operative wound care v6.3 ....................................................................................................... 16

CCG11: LTBI v6.3 ............................................................................................................................................. 17

CCG12: CCE Ethnicity v6.1 .............................................................................................................................. 18

CCG13: Early Years v6.0 .................................................................................................................................. 18

CCG14: CMC Transfers v6.0 ............................................................................................................................ 21

GPC1 NHS Health Checks v6.2 ........................................................................................................................ 22

{PH2} Sexual Health Screening and LARC v6.2 .............................................................................................. 25

{PH4} Alcohol PHS v6.1 .................................................................................................................................. 27

NHS Health checks LBH (Q) ............................................................................................................................ 28

LTC1: Core (2017-2018) ............................................................................................................................................. 29

00 Indicators [in year] .................................................................................................................................... 31

01 Recall ......................................................................................................................................................... 32

02 Support ..................................................................................................................................................... 32

03 Registers ................................................................................................................................................... 33

04 Prevalence Reports 2017-2018 ................................................................................................................ 34

05 Denominators ........................................................................................................................................... 34

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Update Notes .................................................................................................................................................. 37

LTC2: Time to Talk (2017-2018) ................................................................................................................................. 38

LTC2: Time to Talk ......................................................................................................................................... 39

Denominators [All Patients] ......................................................................................................................... 39

Denominators [Current] ............................................................................................................................... 40

Notes ............................................................................................................................................................... 40

Support Searches ............................................................................................................................................ 41

LTC3: Cancer v6.2 ....................................................................................................................................................... 42

Indicators ...................................................................................................................................................... 43

Denominator Populations ............................................................................................................................ 43

Support Searches .......................................................................................................................................... 43

Updates ......................................................................................................................................................... 44

................................................................................................................................................................................... 45

Appendix A ................................................................................................................................................................. 45

NHS ENGLAND ....................................................................................................................................................... 45

If you require any support please contact Luis Rivas [email protected]

mailto:[email protected]

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Introduction

City and Hackney Practice Support Searches

This document details the list of CEG searches that are available to practices to use to support a number of services. The searches are located in Population Reporting under ‘City and Hackney Clinical Effectiveness’ domain. The names of the searches are listed in the respective appendices and are designed wherever possible to match directly to the name of the submission line in the various invoicing templates you need to complete for payment. Symbols

Indicates a folder

Indicates a SEARCH

Indicates a REPORT Abbreviations CQRS – Calculation Quality Reporting System ES – Enhanced Services EOY – End of year

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Practice Reports (2017/18) The #Practice Reports (2017/18) search folder contains the following folders:

1. QOF Support

2. DES Support

3. Clinical Tools

4. Confederation Searches

5. Medicines Management

6. Immunisations

7. Additional

Note: Generally where there is a search name followed by a [PAYMENT] label, the ‘Patients Excluded’ list is patients missing activity and the list can be used as Recall list as appropriate. Where available the CQRS manual entry field is provided e.g. ALC001, LD001 etc

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1. QOF Support

Dementia Patients in IC- QOF review

Eligible for Integrated Care Level 2 because of Dementia

With Crisis or a person centred care plan

QOF Dementia review code missing

Expiring exceptions for meds or BP in the past

Osteoporosis

2. DES Support Learning Disabilities reviews

Patients on the Learning Disability Register (DES – age 14+)

LD HAP done in the last 12m

LD review done in the last 12m

Expiring exceptions for AF the year before

Expiring exceptions for CHD the year before

Expiring exceptions for Diabetes the year before

Expiring exceptions for HF the year before

Expiring exceptions for Hypertensions the year before

Expiring exceptions for PAD the year before

Expiring exceptions for Stroke-TIA the year before

OST004- Osteoporosis Register (As defined by QOF)

Expiring exceptions for osteoporosis the year before

OST01- Aged 75+, fragility # from 1Apr14, no osteo diagnosis

OST02- Aged 75+, #, but no fragility # from 1Apr14

OST03 – Aged 50-74, fragility # from 1Apr12, osteo diag, NO DEXA

OST04 – Aged 50-74, fragility # from 1Apr12, no osteo diagnosis

OST05 – Aged 50-74, #, but no fragility # from 1Apr12

OST06 – Aged 50-74, on bone meds, with osteoporosis and #, but no fr…

OST07 – Aged 75+, on bone meds, with osteoporosis and #, but no fra…

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3. Clinical Tools

Atrial Fibrillation APEL (PID)

This search is for the CEG APEL (clinical) tool it collates aspects of the medical record for patients with AF to establish CHADsVASC score, risk of bleeding etc.

Currently Registered patients with AF – APL2017

APL Tool report release 4-1 [PID]

CEG facilitators will install the tool and populate it with the search results from Emis Web ready for use.

CKD Community Clinics CKD

Falling eGFR

Falling eGFR (2)

Heart Failure Tool CEG facilitators will install the tool and populate it with the search results from Emis Web ready

for use.

Prevalence Improvement (QOF v35) v2 W/AUDIT These searches identify lists of patients who may be eligible for inclusion on QOF registers. Note: Use the ‘Check Patient’ option to view details of the search. In City and Hackney includes searches for At High Risk of CVD/Diabetes.

Asthma

A01 – On preventer inhalers (repeat Rx), no asthma or COPD code, age…

A02 – On preventer inhalers (repeat Rx), no COPD code, coded asthma r…

Atrial Fibrillation

AF01 – ECG shows AF or H/O code but not on AF register

AF02 – Irregular pulse

AF03 – On Warfarin but not on AF register

AF04 – On NOAC but not on AF register

AF05 – Monitoring code but not on AF register

Heart failure Report for Tool

Heart failure report v1-1

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Cancer

CA01 – Non QOF cancer codes added since 1 Apr 2016

CHD

CH01- On Nitrates but not on CHD register

CH02- Non QOF CHD codes

CH03- H/O codes but not on CHD Register

CKD

CK01- Latest eGFR 1-29 but not on CKD register

CK02- Latest eGFR 30-45 but not on CKD regsiter

CK03- Renal disease code and low eGFR but not on CKD register

eGFR evidence of CKD

CK04 – Not coded as QOF CKD, but evidence of CKD

COPD

CO01- COPD case finding – age over 50 (smokers last 15m)

CO02- COPD case finding – age over 40-50 (smokers last 15m)

CO03- On Tiotropium but not on COPD register

CO04- MRC 4 or 5 but not on COPD/ HF/ Asthma register

CO05- FEV1 under 65 but not on COPD/Asthma register

CO06- Monitoring codes but not on COPD register

Dementia

DEM01- Non QOF codes

DEM02- On Meds, not on register

DEM03- Dementia tests not normal, not in QOF

DEM03.1 exclude those referred on

DEM04- Referral to memory clinic or psychogeriatrician

DEM04.1 - Exclude those with memory found normal/mildly impaired after referral

Depression

DEP01- Non QOF depression codes, on antidepressents, excl SMI & PMS

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Diabetes

D01- On Insulin, no GD, but not on Diabetes register

D02- On Metformin, no PCOS, no GD, but not on Diabetes register

D03- HbA1c => 48, not GD, not on diabetes register

D04- Diabetes but not coded as for QOF register

Epilepsy

EP01- Monitoring codes but not on Epilepsy register

EP02- On meds, plus seizures but not on Epilepsy register

Heart Failure

HF01- Heart failure case finding

HF02- LVSD but not on HF register

HF03- HF with no LVD

HF04- H/O HF code but not on HF register

HF05- Monitoring code but not on HF register

Hypertension

HY01 - Last 3 BPs >=160/100 but not on Hypertension register

HY02 - Last 3 BPs 140-159/90-99 plus comorbidity but not on Hypertension register

Learning Disabilities

LD01- Down’s syndrome but not on LD register

LD02- Monitoring or cause code but not on LD register

PAD

PAD01- PAD codes, not in QOF register

Stroke

S01- H/O stroke/TIA code but not on Stroke register

S02- Monitoring code but not on Stroke register

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4. Confederation Searches

Hospital Discharge

All those currently on the DES register

Had hospital discharge on DES register – needs review within 3 days MDT v2

Discussed in meeting – Relative run date = date of discussion plus 1 day Clinical meeting minutes – set the date in each report section

Statins for LTC

Eligible for high dose statin

Currently on 80mg atorva

NOT currently on 80mg atorva

Not on a statin at all

statin contraindicated/adverse reaction/declined etc (2)

statin NOT contraindicated/adverse reaction/declined etc

on a statin but not high enough

had annual review

NOT had annual review Denominators

All Currently Registered Patients

AF001- Patients on AF Register

CHD001- Patients on CHD Register

DM017- Patients on Diabetic Register

PAD001- Patients with Peripheral Arterial Disease

STIA001- Patients on Stroke/TIA Register

5. Medicines Management

Diabetes Analogue Insulin search

Analogue insulin use review May 2016

Analogue insulin review May 2016 Auto Report

6. Immunisations

Wrong Meningitis C vaccination code used? COVER Audit Child Immunisation Recall v7

001 6-12 month olds Cohort 12 month olds Cohort Imms detail

002 12-24 month olds Cohort 24 month olds Cohort Imms detail

003 3y4m to 5 year olds Cohort 5 year olds Cohort Imms detail

004 6-12 month olds Cohort

12 month olds NOT fully immunized (excluding Men B)

12 month olds NOT fully immunized (including Men B)

005 12-24 month olds Cohort

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24 month olds NOT fully immunized

006 3y4m to 5 year olds Cohort

5 year olds NOT fully immunized

PCV monthly count

All patients

(01) Primary course of PCV

(02) HiB/Men C

(03) PCV (Booster)

Pertussis vaccination in pregnancy coding v2

PV01 – Patients who have been pregnant in last 9 months and still pregnant

PV02 – Delivery since 1 Apr 16 (excluding premature)

PV03 – Currently pregnant or delivered after 1 Apr 16

PV04 – Exclude correct payment code added since 1 Apr 16

PV05 – Coding suggests Pertussis vac given [ADD code 6556]

7. Additional

New Cancer Audit

Cancer patients

Cancer Audit [PID]

New cancer patients in last 12m

Cancer Audit [PID]

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CCG Enhanced Services (2017-2018) The CCG Enhanced Services (2017-2018) folder contains as follows: *{LTC1} LTC core v6.0

*{LTC2} Time to Talk (2017 – 2018) v6.2

*{LTC3} Cancer v6.3 CCG04: Phlebotomy v6.1 CCG05: FHV v6.1 CCG08: Mental Health Alliance v6.0 CCG09: End of Life v6.1 CCG10: Post-Operative Wound Care v6.3 CCG11: LTBI v6.3 CCG12: CCE Ethnicity v6.1 CCG13: Early years v6.0 CCG14: CMC Transfers v6.0 GPC1: NHS Health Checks v6.2 PH2: Sexual Health Screening and LARC v6.2 PH4: Alcohol PHS v6.1 NHS Health checks LBH (Q)

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CCG04: Phlebotomy v6.1

Denominator Populations

CCG4-PH01 Phlebotomy 2017-2018

CCG4-PH01a Aged <=30yrs

CCG4-PH01b Aged 31-40yrs

CCG4-PH01c Aged 41-50yrs

CCG4-PH01d Aged 51-60yrs

CCG4-PH01e Aged >60yrs Reports

PH01-L Phlebotomy List Report

PH01-La Phlebotomy List Report

PH01-Lb Phlebotomy List Report

PH01-Lc Phlebotomy List Report

PH01-Ld Phlebotomy List Report

PH01-Le Phlebotomy List Report

CCG05: FHV v6.1

An average of 3.5 home visits per patient are required for payment

FHV-01 Current FHV Reg

FHV-11: estimated FHV 2+ visits + CP Reviews

FHV-71 CMC

FHV-72 CMC declined

FHV-73 Not on CMC

FHV-03: Current housebound register [KPI]

FHV-04: Current AUA Register [KPI]

FHV-41: Current AUA + FHV

FHV-05: Current 75+yrs

FHV-06: Current FHV Register 16/17

FHV-61 CMC

FHV-62 CMC declined

FHV-63 Not on CMC Denominator Populations

[00-00] Current Population

FHVC-01: AUA, Housebound or FHV register

[AA-00] All registered 2017-2018

FHVA-01: All FHV register 2017-2018 Reports

CCG5 FHV Audit

FHVR-02 All FHV 2016-2017

FHVR-03 Current AUA, Housebound & FHV Registers Support Searches

FHVS-00: Pts with FHV visits [in year]

FHVS-08: Pts with FHV visit + NO Care plan review

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FHVS-11: Pts with FHV visit NO Care plan

FHVS-01: FHV 0 visits [in year]

FHVS-02: FHV 1 visits


FHVS-04: FHV 2+ Visits

FHVS-41: estimated FHV 2+ visits + CP reviews


FHV-43: estimated FHV 4-8 visits

FHV-44: estimated FHV 9+ visits

FHVS-05: FHV 0 visits [last 2 years]

FHVS-06: FHV 0 visits [last 3 years]

FHVS-07: FHV no AUA Care plan

FHVS-09: 75+yrs no consultation (2years) NOT FHV

FHVS-10: FHV + Nursing Home [DRAFT]

CCG08: Mental Health Alliance v6.0

Denominators

[00-00] Listsize

{00-01} Current Anti-Depressant Meds

{00-02} Current Anti-Psych Medication

Indicators

1. Reviews (Coming soon)

2. Performance indicators (Coming soon)

Support Searches

MH-S01 eligible for Depression Review [RECALL]

MH-s02 eligible for Anti Psych Meds Review

CCG09: End of Life

Notes for v5.1

Notes for v5.2

Notes for v5.3

Notes for v5.4

Notes for v5.5

Notes for v5.6

Notes for v6.1


[00-00] Listsize

[00-01] ALL

[01-00] Anticipatory Palliative Care Register

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Payment

[01-APCR] Anticipatory Palliative Care Register (Current)

EOL01a: Completed Palliative Care Template Q1 – Q4 [PAYMENT]

Reporting

{EOL01a1} Completed Template - ACP drafted (latest)

{EOL01a2} Completed Template - ACP declined (latest)

{EOL01a3} Completed Template - CMC consented (latest)

{EOL01a4} Completed Template - CMC declined (latest)

{EOL01a5} Completed Template - DNAR discussed

{EOL01a6} Completed Template - Deceased 2017/18

{EOL01a7} Complete template + Deceased - Deceased in Preferred Place of Death

{EOL01a8a} Completed Template + Deceased - Preferred Place of Death Recorded

{EOL01a8} Completed Template - Preferred Place of Death Recorded

{EOL01a9} Completed Template - Preferred place of care recorded

{EOL01b} Current APC Patients missing activity

{EOL02a6} APC Deceased 2017/18

{EOL02a} All Completed Palliative Care Templates (in FY)

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CCG10: Post-Operative wound care v6.3

Denominator

[00-00] Listsize

{00-AA} All Patients

[10-M01] Post-Op Wound care

{00-AA-S}: All Walk-In

{10-M01-S}: Walk-In Post-Op Wound Care

Inter-Practice [Springfield]

POW-M01L: Post-op Wound care information

POWS-R01: Infection

POWS-R02: Trauma

POWS-R03: Perianal Abscess

POWS-R04: Pilonidal Sinus

POWS-R05: Referral to tissue viability

POWS-R07: Wound Healed

POWS-R08: Suture Removal

POWS-R09: Clip removal

POWS-R10: Removal of other materials

Reporting

POW-M01L: Post-op Wound care information

POW-R01: Infection

POW-R02: Trauma

POW-R03: Perianal Abscess

POW-R04: Pilonidal Sinus

POW-R05: Referral to tissue viability

POW-R07: Wound Healed

POW-R08: Suture Removal

POW-R09: Clip removal

POW-R10: Removal of other materials

Support Search

{POW-S01} Activity missing Post-Op Wound Care code

{POW-S02} Post-Op Wound Care missing Appts Count

{POW-S03} Inter-Practice - Activity missing Post-Op Wound Care code

{POW-S04} InterPractice - Post-Op Wound Care missing Appts Count

{POW-S05} POWC - Double Appts [CHECK]

{POW-S06} Minor Surgery 2017-2018

{POW-S07} POWC 2017-2018 [CHECK]

{POW-S08} InterPrac POWC - Double Appts [CHECK]

{POW-S09} InterPrac Minor Surgery 2017-2018

{POW-S10} InterPrac POWC 2017-2018 [CHECK]

{POW-S11} Post-Op Wound Care Weekend Appts Count

{POW-S12} InterPractice - Post-Op Wound Care Weekend Appts Count

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Update notes

Notes for v5.1

Notes for v5.2

Notes for v5.3

Notes for v5.4

Notes for v5.5

Notes for v5.6

Notes for v5.7

Notes for v5.8

Notes for v6.1

Notes for v6.2

Notes for v6.3

CCG11: LTBI v6.3


{00-00} Current Population

{00-TB} All Pts 2017-2018

Indicators

{LTB-00} dx LTB/TB 2017-2018

{LTB-01Y} PC dx Latent TB 2017-2018 [PAYMENT £20]

{LTB-01Q1} PC dx Latent TB




{LTB-02Y} PC dx Active TB 2017-2018 [PAYMENT £100]

{LTB-02Q1} PC dx Active TB




{LTB-06Y} SC dx Latent TB 2017-2018

{LTB-06Q1} SC dx Latent TB




{LTB-07Y} SC dx Active TB 2017-2018

{LTB-07Q1} SC dx Active TB




{LTB-03Y} 1st IGRA Test 2017-2018 [PAYMENT £5]

{LTB-03Q1} 1st IGRA Test




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{LTB-031} Criteria 1 (High Incidence TB Risk)

{LTB-032} Criteria 2 (Social Risk factors)

{LTB-033} No Criteria met

{LTB-034} Positive IGRA

{LTB-04Y} 1st Mantoux Test 2017-2018 [PAYMENT £5]

{LTB-04Q1} 1st Mantoux Test




{LTB-041} Criteria 1 (High Incidence TB Risk)

{LTB-042} Criteria 2 (Social Risk factors)

{LTB-043} No Criteria met

{LTB-044} Positive Mantoux 2016-2017

{LTB-08} Current Criteria 1 (High Incidence TB Risk)

{LTB-09} Current Criteria 2 (Social Risk factors)

Support

{LTB-S01} Current Eligible Criteria 1 (High Incidence TB Risk)

{LTB-S02} Current Eligible Criteria 2 (Social Risk factors)

Update notes

Notes v6.1

Notes v6.2

Notes v6.3

CCG12: CCE Ethnicity v6.1


CCG3-00: Current Listsize

CCG3-ETH01: Interpreter Use 2017-2018

EOY Reporting

ETH01-L Interpreter use list report

Update Notes

Notes v6.1

CCG13: Early Years v6.0

1. LTC Pre-Conception Advice

{MAT03a-Q1} LTC Pre-conception Advice [PAYMENT]




{MAT03-EOY} Pre-conception Advice Q1-Q4

{MAT03a-EOY} LTC Pre-conception Advice Q1-Q4

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{MAT03-Q1} Pre-conception Advice




2. Maternity

{MAT01a-01} First Contact Ref to Antenatal Clinic

{MAT01a-Q1} First contact WITH Validation [PAYMENT]




{MAT01-EOY} First contact Q1-Q4

{MAT01a-EOY} First contact WITH Validation Q1-Q4

{MAT01-Q1} First contact




{MAT02a-Q1} 16w Exam WITH Validation [PAYMENT]




{MAT02-EOY} 16w Exam Q1-Q4

{MAT02a-EOY} 16w Exam WITH Validation (same day) Q1-Q4

{MAT02-Q1} 16w Exam

{MAT02-Q2} 16w Exam

{MAT02-Q3} 16w Exam

{MAT02-Q4} 16w Exam

{MAT04a-Q1} Post-Natal Exam WITH Validation [PAYMENT]




{MAT04-EOY} Post-Natal Exam Q1-Q4

{MAT04a-EOY} Post-Natal Exam WITH Validation Q1-Q4

{MAT04-Q1} Post-Natal Exam




3. UPP

{VUL01a-EOY} No previous AP + New AP Q1-Q4

{VUL01a-Q1} No previous AP + New AP 2017-2018[PAYMENT]




{VUL01b-EOY} Previous AP + Review Q1-Q4

{VUL01b-Q1} Previous AP + Review 2017-2018[PAYMENT]

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{VUL01d-EOY} No Previous AP + Review Q1-Q4

4. Health checks

{VUL02a-EOY} New Child Reg WITH New Patient Health Check

{VUL02a-Q1} New Child Reg WITH New Patient Health Check [PAYMENT]




{VUL-303} 16th Birthday Check (invitation or done) Q1-Q4 [PAYMENT]

Denominators

{00-00} Listsize

{00-AB1} 0-4 Years

{00-AB2} 0-17 Years

{00-AB3} 5-17 Years

{CCG102-MAT01} First Contact Q1-Q4

{00-AA} All Patients L/D

{00-303} Turning 16 within Q1-Q4

{00-304} Women 20-45yrs LTC 2017-2018

{CCG1-MAT03} Eligible for Pre-Conception Advice

{MAT03-CHECK} Pre-conception Advice Q1-Q4 +10

{CCG1-MAT01} First contact 2017-2018

{MAT01-CHECK} First contact Q2-Q4 +6

{CCG1-MAT02} 16w Exam 2016-2017

{CCG1-MAT04} Post-Natal Exam 2016-2017

{MAT04-CHECK} Post-Natal Exam Q1-Q4 +4

{CCG1-VUL01} Universal Partnership Plus

{CCG1-VUL02} New Reg 5-17yrs

{CCG1-VUL04} 5-17yrs Carers Q1-Q4

{MATS01L} Missing Maternity Activity Q1-Q4


KPI’s

{EYKPI-01b} First Contact + Latest BMI>30 (Q1-Q4)

{EYKPI-02b} First Contact + Flu Vaccination (Q1-Q4)

{EYKPI-03b} First Contact + Pertussis Vaccination (Q1-Q4)

{EYKPI-04b} First Contact + Gestation <=10 weeks (Q1-Q4)

{EYKPI-05b} First Contact + Referred to FNP (Q1-Q4)

{EYKPI-06b} First Contact + Smokers Referred to Smoking Cessation (Q1-Q4)

{EYKPI-07b} First Contact + Healthy Start Programme (Q1-Q4)

{EYKPI-08b} 5yr-17yr Carer + Referred to Needs Assessment (Q1-Q4)

Support

{EY01} Current eligible for Preconception Appt

{EY02} Current Reg with UPP coded

{EY02a} 1st Action Plan 2017-2018 Q1-Q4

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{EY02aa} 1st Action Plan before 1stApril2017

{EY02b} Action Plan Reviewed

{EY02c} Action Plan + No Review [RECALL]

{EY02bb} No Action Plan [RECALL]

{EY02d} No Action Plan + Review [ACTION REQUIRED]

{EY-VUL02} Current New Reg 5-17yrs

{VUL02-C} Current New Reg 5-17yrs WITH New Patient Health Check

{MATS01} First Contact Missing Activity


{MATS04} PN Exam Missing Activity


{MATS05} 1+ 16w Exam coded 2016-2017

{MATS06} 1+ Post-Natal Exam coded 2016-2017

{VUL01S02} Current Universal Partnership Plus

{VULS03} UPP recorded as a past problem

{VULS01} Age over 6 yrs still on UPP

Updates

Notes v6.0

CCG14: CMC Transfers v6.0

00 AUA-CMC Transfer

{CMC-00} Current AUA register

{CMC-01} AUA Reg (excl FHV + EoLC)

{CMC-11} AUA Reg with Care Plan <01/01/2017

{CMC-12} Transfered to CMC

{CMC-13} CMC declined

00 FHV-CMC Transfer

{CMC-02} Current FHV Register @31/03/2016

{CMC-21} Payable FHV Reg @31/03/2016

{CMC-22} Transfered to CMC

{CMC-221} Transfered to CMC 2015-2016



{CMC-23} CMC declined

{CMC-231} CMC declined 2015-2016



{CMC-24} No CMC

{CMC-241} No CMC - Current Reg [RECALL]

{CMC-25} On FHV Register 2017-2018

01 Denominators

{00-00} Listsize

22

{01-AA} All Registered Patients @31/03/2016

Update Notes

Update v6.0

GPC1 NHS Health Checks v6.2


{PH5-01} NHS Health Checks completed 2017-2018

{PH5-HC01} eligible for NHS Health Checks (LES)

{PH5-02} NHS Health Checks offered 2017-2018

{PH5-03} eligible for NHS Health Check (LES)

{PH5-04} Current Listsize

{PH5-05} Current NHS Health Check eligible population

{PH5-07} Excluding At Risk

{PH5-08} Current NHS Health Checks completed ever

{PH5-09} eligible for NHS Health Checks (LES)

EOY Reporting

{HC01-EOY} Health Check (with applied exclusions)

{HC01a-EOY} QRISK <10% prior to or at Health Check [PAYMENT]

{HC01b-EOY} QRISK >=10% & <20% prior to or at Health Check [PAYMENT]

{HC01c-EOY} QRISK >=20% prior to or at Health Check [PAYMENT]

{HC01d-EOY} No QRISK prior to or at Health Check

Indicators

{HC01-Q1} Health Check (with applied exclusions)

{HC01a-Q1} QRISK <10% prior to or at Health Check [PAYMENT]

{HC01b-Q1} QRISK >=10% & <20% prior to or at Health Check [PAYMENT]

{HC01c-Q1} QRISK >=20% prior to or at Health Check [PAYMENT]

{HC01d-Q1} No QRISK prior to or at Health Check


{HC01a-Q2} QRISK <10% prior to Health Check

{HC01b-Q2} QRISK >=10% & <20% prior to Health Check

{HC01c-Q2} QRISK >=20% prior to Health Check












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KPI + Info

{HCK01-Q1} NHS Health Checks offered [KPI 01]




{HCK02-Q1} NHS Health Checks Carried Out

{HCK21-Q1} QRISK >=20% [2.5%]

{HCK22-Q1} Black African or South Asian

{HCK23-Q1} Male

{HCK24-Q1} under 50yrs

{HCK25-Q1} QRISK >=10%

{HCK26-Q1} Referred to Lifestyle support services

{HCK27-Q1} Declined Lifestyle support services


{HCK21-Q2} QRISK >=20% [2.5%]


{HCK23-Q2} Male






{HCK21-Q3} QRISK >=20% [2.5%]


{HCK23-Q3} Male






{HCK21-Q4} QRISK >=20% [2.5%]


{HCK23-Q4} Male





{HCK02-Y} NHS Health Checks Carried Out

{HCK21-Y} QRISK >=20% [2.5%]

{HCK22-Y} Black African or South Asian

{HCK23-Y} Male

{HCK24-Y} under 50yrs

{HCK25-Y} QRISK >=10%

{HCK26-Y} Referred to Lifestyle support services

24

{HCK27-Y} Declined Lifestyle support services

{HCK03} Current NHS Health Checks eligible (LES)

Notes

Notes v5.2

Notes v5.3

Notes v5.4

Notes v5.5

Notes v5.6

Notes v6.1

Notes v6.2

Quality

{HCQ01} NHS Health Checks Carried Out

{HCQ02} BMI >=30 (or 27.5 if BME)

{HCQ03} Family History - yes/no

{HCQ04} High Blood Pressure >= 140/90 mmHg

{HCQ05} High Cholesterol 7.5 - 9 mmol/L

{HCQ06} High Diabetes Risk

{HCQ07} Aged 65+ on Day of NHS HC

{HCQ08} Given Dementia/Memory Clinics Awareness

{HCQ09} Current Smokers

{HCQ10} Smoking Cessation Advice

{HCQ11} Alcohol Consumption >=1 Unit

{HCQ12} Alcohol Advice

{HCQ13} Diet Advice

{HCQ14} Brief Intervention for Physical Activity

{HCQ15} Exercise on Prescription

{HCQ16} No Blood Pressure Taken (last 5 years)

{HCQ17} Newly Registered (last 6 months)

Supplementary Searches

{HCS01} NHS Health Checks not eligible for payment 2017-2018

{HCS02} Current Eligible WITHOUT Health Check [RECALL]

{HCS02a} QRISK <10%

{HCS02b} QRISK >=10% & <20%

{HCS02c} QRISK >=20%

{HCS02d} No QRISK

{HCS02e} Black African/Caribbean and South Asian

{HCS02f} Male

{HCS02g} Age <50

{HCS03} Current Eligible WITHOUT Health Check offer

{HCS04} Current NHS Health Check coverage

{HCS05} Current NHS Health Check with NO QRISK

25

{PH2} Sexual Health Screening and LARC v6.2


{00-00} Listsize

{PH2-01} HIV Diagnosis 2017-2018

{PH2-STI01} Notification discussed & ES Recorded

{PH2-02} Acute STI 2017-2018

{PH2-03} ES Recorded

{PH2-STI02} Notification discussed

{PH2-STI03} 15-24years registered 2017-2018

{PH2-STI05} 15-59years registered 2017-2018

{PH2-STIR03} Current 15-24years

{PH2-STIR05} Current 15-59years registered 2017-2018

{PH3-01} LARC Activity 2017-2018

{PH3-SHC03} Contraceptive Advice

EOY Reporting

{SHC01-EOY} IUCD fitted

{SHC02-EOY} IUCD removed

{SHC03-EOY} Implant fitted

{SHC04-EOY} Implant removed

{SHCR01-EOY} LARC Report 2016-2017 [RECONCILIATION]

{STI01-EOY} HIV Diagnosis [EOY RECONCILIATION]

{STI02-EOY} 1st Acute STI Diagnosis/Episode [RECONCILATION]

{STI02a-EOY} STI Treatment (within 6w of diagnosis)

{STI02x-EOY} 2nd Acute STI Diagnosis/Episode [EOY RECONCILIATION]

{STI02xa-EOY} STI Treatment (within 6w of diagnosis)

{STI03-EOY} 15-24yrs with Chlamydia Test

{STI03L} Chlamydia Screening

{STI05-EOY} HIV Screening [EOY RECONCILIATION]

{STI05L} HIV Screening

{STIR03} Current 15-24yrs with Chlamydia Test [30% ACHIEVEMENT]

{STIR05} 15-59yrs New Reg HIV Screened [5% ACHIEVEMENT]

{STIR06} 15-59yrs New Reg Offered HIV Screening [90% ACHIEVEMENT]

Indicators - LARC

{SHC01-Q1} IUCD fitted [Q1 PAYMENT]




{SHC02-Q1} IUCD removed [Q1 PAYMENT]




{SHC03-Q1} Implant fitted [Q1 PAYMENT]

26




{SHC04-Q1} Implant removed [Q1 PAYMENT]




Indicators – Sexual Health Screening

{STI01-Q1} HIV Diagnosis [PAYMENT]




{STI02-Q1} Acute STI Diagnosis/Episode [PAYMENT]




{STI03-Q1} Chlamydia Test 15-24yrs [PAYMENT]




{STI05-Q1} HIV Screening [PAYMENT]




Interpractice Report - LARC

{PH3-01I} INTERPRACTICE LARC Activity 2017-2018

{PH3-SHC03I} INTERPRACTICE Contraceptive Advice

{SHCR01I-EOY} INTERPRACTICE LARC Report 2016-2017 [RECONCILIATION]

KPI & Info

{SHCK01} 16-49years registered 2017-2018

{SHCK02} Current 16-49years

{STIK01-Q1} Acute STI Diagnosis/Episode

{STIK01a-Q1} STI Treatment (within 6w of diagnosis)







{STIK02-Q1} Gonorrhoea Diagnosis

{STIK02a-Q1} Partner Notification


27






{STIK03-Q1} Chlamydia Diagnosis








{STIK04} Current 15-24years

{STIK05} 15-24years 2015-2016

{STIK06-L} Sexual Health KPIs

Supplementary Searches

{SHCS01} IUCD or Implant WITHOUT LES or Contraceptive Advice code

{STIS02} STI WITHOUT Notification discussed or ES recorded

{STIS03} HIV WITHOUT Notification discussed & ES Recorded

{PH4} Alcohol PHS v6.1

{ALC01-Q1} Audit-C or FAST




{ALC02-Q1} Full Audit Screening





{00-00} Current Listsize

{PH4-01} 16+yrs Long Term Conditions 2017-2018

{PH4-ALC01} EXCLUDE 16+yrs Registered in 2017-2018

{PH4-ALC02} Positive Audit-C/FAST or Full Audit 2017-2018

EOY Reporting

{ALC01-EOY} Audit-C or FAST

{ALC02-EOY} Full Audit Screening

{ALCR05} Full Audit 8-19

{ALCR07} Brief intervention

{ALCR08} Extended Intervention

28

{ALCR06} Full Audit 20+

{ALCR09} Referral to Specialist Alcohol Service

KPI + Info

{ALCK01} Current 16+yrs Long Term Conditions

{ALCK04} EXCLUDE 16+yrs Registered in 2017-2018

{ALCK02} 16+yrs Reg 2017-2018

{ALCK03} EXCLUDE Long Term Conditions 2017-2018

Notes

Notes v6.1

NHS Health checks LBH (Q)

{00-00} Listsize

{SDLR01} NHS Health Checks offered 2017-2018

{SDLR01a} Excluding ineligible for NHS Health Check (SDLR)

{SDLR01-Q1} NHS Health Checks offered




{SDLR02} NHS Health Checks done 2017-2018

{SDLR02a} Excluding ineligible for NHS Health Check (SDLR)

{SDLR02-Q1} NHS Health Checks done




{SDLR03} Current Aged 40-74yrs

{SDLR03a} Excl DM, IHD, Stroke/TIA, HyperT, PAD, FH, CKD, AF, Statins

{SDLR03TEP} current eligible TEP

29

LTC1: Core (2017-2018)

Indicators [in last 12m] Indicators [in year] Recall Support Registers Prevalence Denominators Updates

30

LTC Core v6.0

LTC1AR1 Indicators [Last 12m] + Listsize

LTC1AR2 Indicators [In year]

LTC1AR3 Denominators

LTC1AR4 Registers

00 Indicators [in last 12m]

{LTC1-A04} Aged 65+yrs LTC with Pulse Rhythm (12m)

{LTC1-A05} Aged 65+yrs non-LTC with Pulse Rhythm (48m)

{LTC1-A07} Evidence of CKD coded CKD

{LTC1-A08} Evidence of CKD with Diabetes coded CKD

{LTC1-B01} Diabetes / COPD dxFY with Extended Consultation

{LTC1-C01-0} Incomplete At Risk Diabetes Annual Review [INFO ONLY]

{LTC1-C01} At Risk Diabetes FULL Annual Review

{LTC1-C02} NDPP Referrals w/ HbA1c [660]

{LTC1-C03-0} Incomplete At Risk CVD Annual Review [INFO ONLY]

{LTC1-C03} At Risk CVD FULL Annual Review [NT]

{LTC1-C04-0} Incomplete Diabetes with Annual Review [INFO ONLY]

{LTC1-C04} Diabetes with FULL Annual Review [NT]

{LTC1-D01} Diabetes with Care Plan

{LTC1-D02} COPD with Care Plan

{LTC1-D03} Asthma II+ with Action Plan

{LTC1-E01} Hypertension with BP <=140/90

{LTC1-F01} Under 75 + Simvastatin/Atrovastatin 80mg (6m)

{LTC1-F02} Under 75 + Simvastatin 40mg /Atrovastatin 40mg (6m)

{LTC1-F03} Aged 75+ with Atorvastatin 40mg/80mg (6m)

{LTC1-F04} At Risk CVD prescribed Statins

{LTC1-G02} Diabetes with BP <=140/80

{LTC1-H01} AF CHADSVASC 2+ with Oral Anticoagulation

{LTC1-I01} CKD & Hypertension + Proteinuria with ACE-I or ARB

{LTC1-I02} CKD with ACR/PCR

{LTC1-I05} Evidence of CKD with diabetes and BP <= 130/80

{LTC1-J01} COPD MRC 3+ referred to Pulmonary Rehab

{LTC1-K01} LTC (Chronic Conditions) with Smoking Advice

{LTC1-K02} LTC consent for Specialist Smokng Cessation Service

{LTC1-L02} LTC with Audit-C [NT]

{LTC1-L03} Patients 45yrs or over with BP Check

{LTC1-L04a} LVSD Heart Failure coded

{LTC1-L04b} LVD patients on max tolerated ACE-I/ARB

31

{LTC1-L04c} LVD patients on max tolerated Beta Blockers

{LTC1-L04d} LVD on max tolerated ACE-I/ARB & Beta Blockers

{LTC1-L05} Hepatitis B annual Review

{LTC1-L06} LD with a health action plan

{LTC1-L10} Diabetes and Structured Education Programme

{LTC1-L12} Triple NDA Targets [43%]

00 Indicators [in year]

{LTC1-A04Y} Aged 65+yrs LTC with Pulse Rhythm (12m)

{LTC1-A05Y} Aged 65+yrs non-LTC with Pulse Rhythm (48m)

{LTC1-A07Y} Evidence of CKD coded CKD

{LTC1-A08Y} Evidence of CKD with Diabetes coded CKD

{LTC1-B01Y} Diabetes / COPD dxFY with Extended Consultation

{LTC1-C01-0Y} Incomplete At Risk Diabetes Annual Review [INFO ONLY]

{LTC1-C01Y} At Risk Diabetes FULL Annual Review

{LTC1-C02Y} NDPP Referrals w/HbA1c [660]

{LTC1-C03-0Y} Incomplete At Risk CVD Annual Review [INFO ONLY]

{LTC1-C03Y} At Risk CVD FULL Annual Review [NT]

{LTC1-C04-0Y} Incomplete Diabetes with Annual Review [INFO ONLY]

{LTC1-C04Y} Diabetes with FULL Annual Review [NT]

{LTC1-D01Y} Diabetes with Care Plan

{LTC1-D02Y} COPD with Care Plan

{LTC1-D03Y} Asthma II+ with Action Plan

{LTC1-E01Y} Hypertension with BP <=140/90

{LTC1-F01Y} Under 75 + Simvastatin/Atrovastatin 80mg (6m)

{LTC1-F02Y} Under 75 + Simvastatin 40mg /Atrovastatin 80mg (6m)

{LTC1-F03Y} Aged 75+ with Atorvastatin 40mg/80mg (6m)

{LTC1-F04Y} At Risk CVD prescribed Statins

{LTC1-G02Y} Diabetes with BP <=140/80

{LTC1-H01Y} AF CHADSVASC 2+ with Oral Anticoagulation

{LTC1-I01Y} CKD & Hypertension + Proteinuria with ACE-I or ARB

{LTC1-I02Y} CKD with ACR/PCR

{LTC1-I05Y} Evidence of CKD with diabetes and BP <= 130/80

{LTC1-J01Y} COPD MRC 3+ referred to Pulmonary Rehab

{LTC1-K01Y} LTC (Chronic Conditions) with Smoking Advice

{LTC1-K02Y} LTC consent for Specialist Smokng Cessation Service

{LTC1-L02Y} LTC with Audit-C [NT]

{LTC1-L03Y} Patients 45yrs or over with BP Check

{LTC1-L04aY} LVSD Heart Failure coded

{LTC1-L04bY} LVD patients on max tolerated ACE-I/ARB

{LTC1-L04cY} LVD patients on max tolerated Beta blockers

{LTC1-L04dY} LVD on max tolerated ACE-I/ARB & Beta Blockers

{LTC1-L05Y} Hepatitis B annual Review

{LTC1-L06Y} LD with a health action plan

32

{LTC1-L10Y} Diabetes and Structured Education Programme

{LTC1-L12Y} Triple NDA Target [43%]

01 Recall

{00-00} Current Listsize

{LTC1-R02} eligible for NDPP (Appropriate HbA1c in 12m)

{LTC1-R021} Appropriate HbA1c in 3m [CH Target group]

{LTC1-RC01} At Risk Diabetes Review [RECALL]

{LTC1-RC03} At Risk CVD Review [RECALL]

{LTC1-RC04} Diabetes Review [RECALL]

{LTC1-RC11} LTC (as detailed) Missing BP last12m [RECALL]

{LTC1-RC12} LTC (as detailed) Missing BP in FY [RECALL]

{LTC1-RC20} Missing NDA Target(s)

{LTC1-RC21} Missing 1 or 2 Targets

{LTC1-RC22} Missing 3 Targets

{LTC1-RC29} NDA Missing Targets Detail [PID LIST REPORT]

02 Support

01 At Risk CVD/Diabetes

01-S05: Eligible for at risk annual review detail [PID LIST REPORT]

01-S06: At risk annual review detail [PID LIST REPORT]

01-S11: At risk AR 2017-2018 but NOT coded at high risk

01-S12: Old review code (6A5) use 2017-2018

01-S13: All parameters BUT missing At-Risk CVD review code (12m)

01-S14: All parameters BUT missing At-Risk CVD review code (FY)

01-S15: All parameters BUT missing At-Risk Diabetes review code (12m)

01-S16: All parameters BUT missing At-Risk Diabetes review code (FY)

05 Diabetes

05-S01: Diabetes Annual Review 2017-2018 Detail [PID LIST REPORT]

05-S03: Parameters completed BUT missing Annual Review (in FY)

05-S04: FULL Annual Review EXCEPT Retinal Screen (in FY)

05-S07: Diabetes Dx coded Review or End

05-S08: T1 Diabetes in Hospital Care 2017-2018

05-S09: T2 Diabetes in Hospital Care 2017-2018

05-S10: National Diabetes Prevention Programme

05-S12 Patients without SEP + near end of 9 month window

Heart Failure

{06-S01} HF not coded with Sided Dysfunction Atrial Fibrillation

10-S01 AF without CHADS2VASC

Smoking Cessation

11-S01: Consent for Specialist Smoking Cessation [PID LIST REPORT]

33

NDA

{12-S01} Missing NDA HbA1c Target

{12-S02} Missing NDA HbA1c Target with low risk HbA1c

{12-S03} Missing NDA Cholesterol Target

{12-S05} Missing NDA BPTarget

NDA ACTIVITY - RENAME THIS LIST REPORT

on target for hba1c

Hepatitis

{15-S01} All Hepatitis B codes

{15-S02} Patients without +ve surface antigen code

03 Registers

00 Listsize

[00-00] Current Listsize

[00-01] Long Term Conditions Population

[01-01] Current <75yrs

[01-02] Current 75+yrs

01 At Risk CVD-Diabetes

[01-00] Current Listsize (for At Risk CVD-Diabetes)

[01-03] u75yrs excl current LTC

[01-12ALL] Current At High Risk Diabetes <75yrs

[01-12ALLCVD] Current At High Risk CVD <75yrs

[01-03] u75yrs excl current LTC (except AR 12m)

[01-04] excl LTC prior to Annual Review (12m)

[01-05] At Risk CVD-Diabetes (all codes) recorded ever

[01-12NHS] Current At High Risk CVD or Diabetes <75yrs

[01-07] Current At High Risk CVD <75yrs

[01-08] At Risk Annual Reviews 2017-2018

[01-10] Current At High Risk Diabetes <75yrs

[01-12] Current At High Risk CVD or Diabetes <75yrs

[01-40] Current excl current LTC

03 COPD

[03-00] Current COPD

[03-01] Current Mild & Moderate COPD (predicted FEV1 >=50%)

[03-02] Current Severe & V Severe COPD (predicted FEV1 <50%)

04 Asthma

[04-00] Current Asthma

[04-01] Current Asthma Step I

[04-02] Current Asthma Step II

[04-03] Current Asthma Step III

[04-04] Current Asthma Step IV/V

[04-05] Asthma register who don’t have a resolved code parent

05 Diabetes

[05-00] Current Diabetic Register

[05-01] Current T1 Diabetes

34

[05-02] Current T2 Diabetes

[05-03] Uncoded Diabetes

[05-04] Diabetic Register who don’t have a resolved code parent

{05-05} Current NDA Diabetic

06 Heart Failure

[06-00] Current Heart Failure

{06-01} LVSD Heart Failure

07 Hypertension

{07-00} Current Hypertension

{07-01} Hypertension Register who don't have a resolved code parent

08 CKD3-5

{08-00} Current CKD3-5 Register

{08-01} CKD3-5 <75yrs

{08-02} CKD3-5 >=75yrs

09 Stroke/TIA

{09-00} Current Stroke/TIA

10 Atrial Fibrillation

{10-00} Current Atrial Fibrillation

{10-02} Current Aged 65+yrs

11 PAD

{11-00} Current Peripheral Arterial Disease

12 CHD

{12-00} Current CHD Register

13 Mental health

{13-00} Mental Health Register

{13-01} Psychosis (excl Lithium)

14 Learning Disabilities

{14-00} Learning Disabilities Register

15 Hepatitis

{15-00} Current Hepatitis B Register

CCTLC (Combined conditions)

{CC-01} Diabetes / COPD

{CC-02} CHD / Stroke/TIA / PAD / Diabetes

{CC-04} Long Term Conditions for Smoking Cessation (K01)

{CC-05} Long Term Conditions for Smoking Cessation (K01a)

04 Prevalence Reports 2017-2018

[00-00] Prevalence AGG LTC1-A01 At risk Diabetes u75yrs [PREVALENCE] (no AR) LTC1-A02 At risk CVD [PREVALENCE] (no AR) LTC1-A06 Hypertension [PREVALENCE]

05 Denominators

01 At Risk CVD / Diabetes

{00-AA} L/D Patients 18+

{C02} Referrals to Healthier You – NDPP

{C02Y} Referrals to Healthier You - NDPP

35

[01-03] u75yrs excl current LTC (except AR 12m)

[01-04] exclude LTC prior to Annual Review (12m)


[01-06] At Risk CVD (last coded after 01/04/2012)

[01-09] At Risk Diabetes (all codes) recorded ever

[01-11] At Risk Diabetes (last coded after 01/04/2012)

[01-13] Eligible for At Risk CVD-Diabetes Annual Review

[01-23] u75yrs excl current LTC (except AR in current year)

[01-24] excl LTC prior to Annual Review (FY)


[01-27] At High Risk CVD <75yrs

[C03Y] Eligible for At Risk CVD Annual Review

[01-30] At High Risk Diabetes <75yrs

[C01Y] Eligible for At Risk Diabetes Annual Review

{C01YA} At Risk Diabetes Annual Review Activity

[C01] Eligible for At Risk Diabetes Annual Review

{C01A} At Risk Diabetes Annual Review Activity

[C03] Eligible for At Risk CVD Annual Review

[F04] Eligible for Statins

[F04Y] Eligible for Statins

03 COPD

[D02] Eligible for COPD Care Plan

[D02Y] Eligible for COPD Care Plan

[J01] MRC 3+ Eligible for Pulmonary Rehabilitation

[J01Y] MRC 3+ Eligible for Pulmonary Rehabilitation

04 Asthma

[D03] Eligible for Asthma Action Plan

[D03Y] Eligible for Asthma Action Plan

05 Diabetes

[05-05] Women 16-45yrs

[05-06] Diabetes excluding Hospital Care

[C04] Eligible for Diabetic Annual Review

[D01] Eligible for Diabetic Care Plan

{05-06Y} Diabetes excluding Hospital Care 2016-2017

{C04Y} eligible for Diabetic Annual Review

{05-S01} Excluding those with full annual review

{D01Y} Eligible for Diabetic Care Plan

[05-AA01] Current T1 Diabetes

[05-AA02] Current T2 Diabetes

{G02} Eligible for BP 140/80 Value Checks

{G02Y} Eligible for BP 140/80 Value Checks

{L10} Eligible for Structured Education Programme

{L10Y} Eligible for Structured Education Programme

{L12} Eligible FOR NDA triple target

{L12Y} Eligible for NDA triple target

36

06 Heart Failure

{L04a} Eligible for LVSD coding

{L04aY} Eligible for LVSD coding

{L04b} Eligible for max tolerated ACE-I/ARB

{L04bY} Eligible for max tolerated ACE-I/ARB

{L04c} Eligible for max tolerated Beta Blockers

{L04cY} Eligible for max tolerated Beta Blockers

{L04d} Eligible for max tolerated ACE-I/ARB & Beta Blockers

{L04dY} Eligible for max tolerated ACE-I/ARB & Beta Blockers

07 Hypertension

[E01] Eligible for BP Value Checks

[E01Y] Eligible for BP Value Checks

08 CKD3-5

[A07] Evidence of CKD

{A07Y} Evidence of CKD

[A08] Evidence of CKD with diabetes

{A08Y} Evidence of CKD with diabetes

[I01] Eligible for ACE-I or ARB

[I01Y] Eligible for ACE-I or ARB

[I02] Eligible for ACR/PCR

[I02Y] Eligible for ACR/PCR

[I05] Evidence of CKD with diabetes or uACR >30

[I05Y] Evidence of CKD with diabetes or uACR >30

10 Atrial Fibrillation

[10-01] CHADSVASC 2+

[H01] Eligible for Anticoagulation

[H01Y] Eligible for Anticoagulation

14 Learning Disabilities

{L06} LD Patients eligible for health action plan

{L06Y} LD Patients eligible for health action plan

15 Hepatitis

{L05} eligible for Hepatitis B review

{L05Y} eligible for Hepatitis B review

CCLTC (Combined Conditions)

[A04] Long term conditions

[A04Y] Long term conditions

[A05] Excluding long term conditions

[A05Y] Excluding long term conditions

[B01] Eligible for Diabetes/COPD Extended consultation

[B01Y] Eligible for Diabetes/COPD Extended consultation

[F01] Under 75 with CVD or Diabetes

[F01Y] Under 75 with CVD or Diabetes

[F02] Under 75 with CVD or Diabetes

[F02Y] Under 75 with CVD or Diabetes

[F03] Aged 75+ with CVD or diabetes

[F03Y] Aged 75+ with CVD or Diabetes

[K01] Chronic Disease Eligible for Smoking Advice

37

Update Notes

Notes for v6.0

[K01Y] Chronic Disease Eligible for Smoking Advice

[K02] Eligible for Specialist Smoking cessation service

[K02Y] Eligible for specialist smoking cessation service

[L02] LTC Eligible for Audit-C

[L02Y] Eligible for Audit-C

{L03} Patients age 45 or above for BP Check

{L03Y} Patients age 45 or above for BP Check

38

LTC2: Time to Talk (2017-2018)

Denominators [All Patients] Denominators [Current] Notes Support Searches

39

LTC2: Time to Talk

[00-00] Listsize

[00-LTC2] Current eligible for T2T extended consultation

{LTC2-01} eligible T2T Extended Consultation Offered

{LTC2-M01} Eligible T2T extended consultation [PAYMENT]

LTC2-M02L Extended consultations X

Denominators [All Patients]

[00-AA] Listsize

{02-01} T2T Extended Consultation Offered 2017-2018

{02-M02} T2T 18+yrs Extended Consultation Offered 2017-2018

{02-M01} T2T Extended Consultation 2017-2018

{02-M01} T2T 18+yrs Extended Consultation 2017-2018

LTC2-AD01: Patients on AF Register

LTC2-AD02: AF only

LTC2-AD03: Patients on Asthma register

LTC2-AD04: Asthma Only

LTC2-AD05: Patients on CHD register

LTC2-AD06: CHD Only

LTC2-AD07: Patients on CKD Register

LTC2-AD08: CKD Only

LTC2-AD09: Patients on COPD register

LTC2-AD10: COPD Only

LTC2-AD11: Patients on Dementia register

LTC2-AD12: Dementia Only

LTC2-AD13: Patients on Diabetic Register

LTC2-AD14: Diabetes only

LTC2-AD15: Patients on Heart Failure register

LTC2-AD16: HF Only

LTC2-AD17: Patients on hypertension register

LTC2-AD18: Hypertension only

LTC2-AD19: Patients on Learning Disabilities register

LTC2-AD20: LD Only

LTC2-AD21: Patients on Mental Health Register

LTC2-AD22: MH Only

LTC2-AD23: Patients on Peripheral Arterial Disease

LTC2-AD24: PAD only

LTC2-AD25: Patients on Stroke/TIA register

LTC2-AD26: Stroke/TIA only

LTC2-AD27: On any of the eligible registers

LTC2-AD29: Patients on a single register only

40

Denominators [Current]

[00-00] Current Listsize

LTC2-CD01: Patients on AF register

LTC2-CD02: AF only

LTC2-CD03: Patients on Asthma Register

LTC2-CD04: Asthma only

LTC2-CD05: Patients on CHD Register

LTC2-CD06: CHD only

LTC2-CD07: Patients on CKD register

LTC2-CD08: CKD only

LTC2-CD09: Patients on COPD Register

LTC2-CD10: COPD only

LTC2-CD11: Patients on Dementia Register

LTC2-CD12: Dementia only

LTC2-CD13: Patients on Diabetic Register

LTC2-CD14: Diabetes only

LTC2-CD15: Patients on Heart Failure Register

LTC2-D16: HF Only

LTC2-D17: Patients on Hypertension register

LTC2-D18: Hypertension only

LTC2-D19: Patients on Learning disabilities register

LTC2-D20: LD Only

LTC2-D21: Patients on Mental Health register

LTC2-D22: MH only

LTC2-D23: Patients with Peripheral Arterial Disease

LTC2-D24: PAD only

LTC2-D25: Patients on stroke/TIA register

LTC2-D26: Stroke/TIA only

LTC2-D27: On any of the eligible registers

LTC2-D29: Patients on a single register only

Notes

Notes v5.5

Notes v5.6

Notes v5.7

Notes v6.1

Notes v6.2

41

Support Searches

LTC2-S01: Eligible for T2T Extended Consultation [RECALL]

LTC2-S03: 30mins+ consultations not coded as T2T

LTC2-S03L: 30mins + consultations [PID REPORT]

LTC2-S04: Coded 2Je (Multiple LTCs)

LTC2-S05: Aged under 18yrs

LTC2-S06: on AUA register

LTC2-S07: with 0 eligible register LTCs

LTC2-S08: with 1 eligible register LTC only

LTC2-S09: with 2+ eligible register LTCs

42

LTC3: Cancer v6.2

Indicators Denominator populations Support Searches Updates

43

Indicators {LTC3A-01A} Telephone Activity [60%] [PAYMENT]

{LTC3A-01A1} Successful Telephone call

{LTC3A-01A2} Unsuccessful Attempt to contact by telephone

{LTC3A-01A2a} Letter to unsuccessful telephone contacts

{LTC3A-01B} Letter to those not called [90%] [PAYMENT]

{LTC3A-01C} Letter not sent to those not called

{LTC3A-02A} Telephone activity [60%] [PAYMENT]

{LTC3A-02A1} Successful Telephone call

{LTC3A-02A2} Unsuccessful Attempt to contact by telephone

{LTC3A-0A2a} Letter to unsuccessful telephone contacts

{LTC3A-02B} Letter to those not called [90%] [PAYMENT]

{LTC3A-02C} Letter not sent to those not called

{LTC3B-02} Offered Extended Consultation (in FY)

{LTC3B-03} Attended Extended Consultation (in FY) [PAYMENT]

{LTC3C-001} DNA fast track clinic (2017-2018)

{LTC3C-001A} DNA followed-up (2017-2018)

{LTC3C-002} Seen in fast track clinic (2017-2018)


[00-00] Listsize

LTC2-S00: Excluding those not eligible

[00-AA] All patients D/D

{LTC3A-01} 60th Birthdays (from April to Current Date)

{LTC3A-010} Patients not called

{LTC3A-0100} Registered patients not called

{LTC3A-02} 61-74yrs No response, Incomplete or Spoilt

{LTC3A-020} Patients not called

{LTC3A-0200} Registered patients not called

{LTC3B-01} Eligible for Time to Talk Cancer

{LTC3C-000} All Fast Track Referrals Made (2017-2018)

Support Searches {LTC3A-01S} Current 60th Birthdays (from April to Current Date)

{LTC3A-S22} Current Unsuccessful attempt to contact by Telephone

{LTC3A-S23} Current Unsuccessful WITHOUT Letter

{LTC3A-02S} Current 61-74yrs No response, Incomplete or Spoilt

{LTC3A-S24} Current Unsuccessful attempt to contact by Telephone

{LTC3A-S25} Current Unsuccessful WITHOUT Letter

LTC3A-S01: Incomplete (1m) [RECALL]

LTC3A-S02: Incomplete (since 1st April) [RECALL]

LTC3A-S03: No Response (1m) [RECALL]

LTC3A-S04: No Response (since 1st April) [RECALL]

LTC3A-S05: Spoilt (1m) [RECALL]

LTC3A-S06: Spoilt (since 1st April) [RECALL]

LTC3A-S07: 60th birthday in the preceding month

44

LTC3A-S08: Currently w/o Bowel Cancer Screening invite (in financial year)

LTC3A-S09: Eligible for Bowel Screening invite April 2017

LTC3A-S10: Eligible for Bowel Screening invite May 2017

LTC3A-S11: Eligible for Bowel Screening invite June 2017

LTC3A-S12: Eligible for Bowel Screening invite July 2017

LTC3A-S13: Eligible for Bowel Screening invite August 2017

LTC3A-S14: Eligible for Bowel Screening invite September 2017

LTC3A-S15: Eligible for Bowel Screening invite October 2017

LTC3A-S16: Eligible for Bowel Screening invite November 2017

LTC3A-S17: Eligible for Bowel Screening invite December 2017

LTC3A-S18: Eligible for Bowel Screening invite January 2018

LTC3A-S19: Eligible for Bowel Screening invite February 2018

LTC3A-S20: Eligible for Bowel Screening invite March 2018

{LTC3A-S21} Current No Response/Spoilt/Incomplete without call or letter (in FY)

{LTC3B-S01} Eligible for T2T Caner (without extended consultations offered)

{LTC3C-S01} DNA Fast Track support search

{LTC3C-S04} Fast track referral - type not specified (2m)

{LTC3C-S05} Fast track referral - suspected cancer (2m)

{LTC3C-S05L} Fast track referral - suspected cancer [DETAIL]

{LTC3C-S07} Not coded as 'Seen' or 'DNA' - require follow-up

{LTC3C-S09} Seen in Fast Track Cancer Clinic After Follow-Up

Updates Notes v6.1 Notes v6.2

45

Appendix A NHS ENGLAND Alcohol CQRS (Annually)

ALC001 (Payment) – Newly registered aged over 16 from 1st Apr’13 to 31st Mar’14 who have received screening using either the FAST or AUDIT- C tool

ALCMI001 –Received a FAST test in the year

ALCMI002 - Received AUDIT C in the year

ALCMI003 – Screened positive (3+ for FAST, 5+ for AUDIT C)

ALCMI004 – Screened positive have received a full AUDIT patients with a

ALCMI005 – Screened positive with a full AUDIT score 0-7



ALCMI008 – Screened positive with a full AUDIT score 20 or over

ALCMI009 – AUDIT score 8-15 who have received brief intervention

ALCMI010 – AUDIT score 16-19 who have received brief intervention

ALCMI011 – AUDIT score 16-19 who have received extended intervention

ALCMI012 – AUDIT score 20 or over who have been referred for specialist advice for dependent drinking All searches are based on newly registered patients aged over 16 from 1st April’13 to 31st March’14 Code Set For Alcohol Searches

Read Code Description

388u 38D4 38D3 9k1A 9k1B 8HKG

Fast alcohol screening test Alcohol use disorder identification test consumption questionnaire Alcohol use disorders identification test Brief intervention for excessive alcohol consumption completed Extended intervention for excessive alcohol consumption completed General surgery D.V. requested

Dementia DES – CQRS (Annually) Exclusion Codes for Dementia Searches

Read Code Description

Eu02 E00 Eu01 E02y1 E012 Eu00 E041 Eu041 F110 F111 F112

[X]Dementia in other diseases classified elsewhere Alcohol use Senile and presenile organic psychotic conditions [X]Vascular dementia Drug-induced dementia Other alcoholic dementia [X]Dementia in Alzheimer's disease Dementia in conditions EC [X]Delirium superimposed on dementia Alzheimer's disease Pick's disease Senile degeneration of brain

46

F116 Lewy body disease

Dementia Assessment Count – recorded from 1st April to 31st March

Hep B (new born babies)

Babies born between 1st Jan ’13 and 31st March ‘15

Hep B vac given [PAYMENT] 65F2. 2nd hepatitis B vaccination 65F3. 3rd hepatitis B vaccination 65F4. Boost hepatitis B vaccination

Learning Disabilities CQRS (Quarterly)

LDMI001 - % of patients who received a learning disability health check

LD001 (Payment) – Number of patients who have received a learning disability health examination –

Learning disabilities – Cohort eligible for DES payment Eu81z [X]Developmental disorder of scholastic skills, unspecified 918e. On learning disability register Eu7.. [X]Mental retardation Eu814 [X]Moderate learning disability Eu815 [X]Severe learning disability Eu816 [X]Mild learning disability Eu817 [X]Profound learning disability E3... Mental retardation

LD001 [PAYMENT] 69DB. Learning disability health examination – recorded in each quarter for claiming on CQRS

Learning disabilities register QOF

MenC freshers CQRs (Monthly)

Eligible Age. Patients born between 02.04.1988 and 31.03.1998

Not had Men C vac since age 10. Exclude patients aged 10 or over if they have any of the below recorded. 657E. First meningitis C vaccination 657F. Second meningitis C vaccination 657G. Third meningitis C vaccination 657H. Meningitis A & C vaccination 657I. Single meningitis C vaccination

47

657J. Meningitis ACW & Y vaccination 657S. Booster meningitis C vaccination 657S0 Booster meningitis C vaccination given by other healthcare provider EMISSI2 65b0. First Haemophilus influenza type B and meningitis C vaccination 65b1. Second Haemophilus influenza type B and meningitis C vaccination

Men C booster to fresher given [PAYMENT] 657E. First meningitis C vaccination 657F. Second meningitis C vaccination 657G. Third meningitis C vaccination 657H. Meningitis A & C vaccination 657I. Single meningitis C vaccination 657J. Meningitis ACW & Y vaccination 657S. Booster meningitis C vaccination 657S0 Booster meningitis C vaccination given by other healthcare provider EMISSI2 65b0. First Haemophilus influenza type B and meningitis C vaccination 65b1. Second Haemophilus influenza type B and meningitis C vaccination 657I. or 657S. Recorded in each month for claiming on CQRS

MMR Catch up CQRS (Monthly)

Patients aged 16 or over born before 31.03.99

Unvaccinated or partially vaccinated. Exclude patients already vaccinated 65M1. Measles/mumps/rubella vaccn. ZV064 [V] Measles-mumps-rubella (MMR) vaccination before 01.04.14 must have. And 65MA. Measles mumps and rubella booster vaccination 65MB. MMR pre-school booster vaccination 65MC. MMR vaccination - 2nd dose 65M1. Measles/mumps/rubella vaccn. ZV064 [V] Measles-mumps-rubella (MMR) vaccination before 01.04.14

MMRCU02 (vacs given) [PAYMENT] Recorded each month for claiming on CQRS 65M1. Measles/mumps/rubella vaccn. 65MA. Measles mumps and rubella booster vaccination 65MB. MMR pre-school booster vaccination 65MC. MMR vaccination - 2nd dose

Patient Access

Patients registered – List Size. All currently registered patients

Patient Access. Patient Access Status is Pending or Active. Annual claim on CQRS

Pertussis IMMFORM (Monthly)

48

Payment

Denominator: Pregnant (28 wks & over) from 1st Apr’13

Numerator: Repevax given to pregnant women in the month

Numerator cumulative: Repevax given to pregnant women since 1st Apr’13

Uptake

Pregnancy not finished (last 9 months)

Denominator: Estimated date of delivery in the month

Numerator: EDD in the month with Repevax given

Pneumococcal CQRS (Monthly)

Age cohort. Patients born before 31.03.50

PNEUM01 [PAYMENT] 65720 Pneumococcal vaccination given, or 6572. Pneumococcal vaccination - Administered in the month of the claim for CQRS

Rotavirus CQRS (Monthly)

ROTA001: Fully vaccinated patients (in the last month) [PAYMENT]. Babies older or equal to 6 weeks with:

65d0. First rotavirus vaccination recorded AND more than or equal to 28 days after 65d1. Second rotavirus vaccination recorded and the baby is younger than 6 months

Shingles Catch Up (aged 79) CQRS (Monthly)

The following relate to patients aged 79 on 1st Sept’13

Patients DOB is after or on 02.09.33 and before or on 01.09.34

SH79CU01 [PAYMENT] Excludes patients with pervious 65FY. Herpes zoster vaccination or 65FY0 Herpes zoster vaccination given by other health care provider Patients with 65FY. Herpes Booster recorded in the month of submission on CQRS

Shingles Routine Immunisations CQRS (Monthly)

The following relate to patients aged 70 on 1st Sept’13 Patients’ DOB is after or on 02.09.42 and before or on 01.09.43

SHROU01 [PAYMENT] Exclude patients with previous 65FY0 Herpes zoster vaccination given by other health care provider. Patients with 65FY. Herpes zoster vaccination recorded in the month of submission on CQRS

50

Visit the CEG Website:

http://blizard.qmul.ac.uk/ceg-home.html

Clinical Effectiveness Group Centre for Primary Care & Public Health Blizard Institute

Queen Mary University of London London

http://blizard.qmul.ac.uk/ceg-home.html

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