Smoking: smoking status for people with long-term conditions

Indicators

IND97: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who have a record of smoking status in the preceding 15 months

IND98: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who smoke whose notes contain a record of an offer of support and treatment within the preceding 15 months

Introduction

This report provides a high-level cost impact assessment for two indicators relating to smoking, in the QOF smoking domain for inclusion on the 2012/13 NICE menu of indicators for QOF. It is intended that these indicators will replace the 2011/12 QOF indicators Smoking 3 and Smoking 4 that incentivise recording smoking cessation and smoking cessation advice, or referral to a specialist service, for people who smoke and who have comorbidities. The proposed indicators would replace and extend the remit Smoking 3 and Smoking 4 by including people with peripheral arterial disease on the register. The wording of QOF indicator Smoking 4 would also be changed from ‘...a record that smoking cessation advice or referral to a specialist service where available, has been offered’ to ‘...a record of an offer of support and treatment’.

Cost implication

The 2011/12 QOF indicator Smoking 3 incentivises recording smoking status in all people who have one or more of the following conditions: coronary heart disease, stroke or transient ischaemic attack, hypertension, diabetes, chronic obstructive pulmonary disease, chronic kidney disease, asthma, schizophrenia, bipolar affective disorder or other psychoses. Those recorded as being smokers would then be eligible for smoking cessation advice or referral to a specialist service as incentivised in QOF indicator Smoking 4.

Amending the register to include people with peripheral arterial disease may identify additional people not included in the current QOF indicator Smoking 3, who would then be eligible for the care incentivised in QOF indicator Smoking 4. However, this is not expected to be associated with significant additional costs.

In addition to smoking status being recorded under indicator Smoking 3, the QOF organisational domain indicator Records 23 incentivises recording smoking status in all people over the age of 15. It would therefore be reasonable to assume that smoking status in people with peripheral arterial disease is already recorded by existing QOF indicators.

The provision of smoking cessation advice or referral to a specialist service for smokers with comorbidities is incentivised in the 2011/12 QOF indicator Smoking 4. In addition, the QOF organisational domain indicator Information 5 incentivises practices to support smokers to stop smoking through a strategy which includes providing literature and an offer of appropriate smoking cessation therapy to all people who smoke. Amending QOF indicator smoking 4 to incentivise an ‘offer of support and treatment’ rather than ‘smoking cessation advice or referral to a specialist service’ is not expected to be associated with significant additional costs.

There is good evidence to suggest that offering support and treatment is sufficient to motivate some smokers to attempt to stop, and that these smokers would not have done so if they had only received brief advice to quit (Stead et al. 2008). Nevertheless, referral to a specialist service such as NHS Stop Smoking Services is specified alongside the delivery of advice in the 2011/12 QOF indicator Smoking 4. The new QOF indicator IND98 allows practitioners to decide what type of support and treatment would be appropriate for individual patients. This indicator is not intended or expected to change GP behaviour, and therefore current practice in terms of referral to these services would still be indicated in a proportion of people.

Conclusions

Recording smoking status is currently incentivised in the 2011/12 QOF indicators Smoking 3, and Records 23. Including people with peripheral arterial disease on the register is not expected to incur any additional costs, and smoking status in this group is likely to already be recorded by existing QOF indicators.

Providing advice, literature, and an offer of therapy or referral to specialist services to support smokers to stop smoking is also incentivised in QOF indicators Smoking 4 and Information 5. Amending QOF indicator Smoking 4 to incentivise an ‘offer of support and treatment’ rather than ‘smoking cessation advice or referral to a specialist service’, is not intended to change GP behaviour and therefore is not expected to be associated with significant additional costs. 

Related QOF indicators

National level results for 2009/10 for the current QOF indicators on smoking (NHS Information Centre 2010)

Current QOF indicator	Numerator	Denominator	Underlying achievement
Smoking 3: The percentage of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the previous 15 months	11,113,003	11,676,997	95.2%
Smoking 4: The percentage of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months	1,825,028	1,966,130	92.8%
Asthma 3: The percentage of patients with asthma between the ages of 14 and 19 in whom there is a record of smoking status in the previous 15 months	232,354	260,940	89.0%
Records 23: The percentage of patients aged over 15 years whose notes record smoking status in the past 27 months	38,543,541	45,568,208	89.4%
Information 5: The practice supports smokers in stopping smoking by a strategy which includes providing literature and offering appropriate therapy	-	-	98.6%

References

Stead LF, Perera R, Bullen C et al. (2008) Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews issue 1: CD000146

NHS Information Centre (2010) QOF 2009/10 results: England level QOF tables 2009/10 – clinical tables 2009/10 [online]