Dr Alan Begg discusses the revised quality and outcomes framework indicators for coronary heart disease and how national guidance relates to these targets

Practices are continuing to perform well in the quality and outcomes framework (QOF), with a high percentage of points being achieved in the coronary heart disease (CHD) and heart failure (HF) categories. A significant amount of information on how well individual practices in England are achieving in the QOF, with local and national comparisons, can be found on the NHS Information Centre website (www.qof.ic.nhs.uk).1 In 2010/11, practices achieved 99.1% and 98.0% for CHD and HF, respectively—a rise of 0.3% and 0.7% from the previous year.2 Links to data from other devolved nations and 2010/11 data for Wales are also available.3

QOF updates

In the original QOF guidance published in May 2003, there were 12 indicators relating to secondary prevention of CHD, but these have now been reduced to eight in the 2011/12 revision of the GMS contract (see Table 1, below).4,5 Two indicators have been retired (CHD5 and CHD7) resulting in practices no longer being rewarded for recording blood pressure or cholesterol levels in patients with CHD.5

There were no changes to the heart failure indicators in the 2011/12 QOF revision. The original three indicators in 2003 referred only to left ventricular dysfunction (LVD) but these were subsequently renamed ‘heart failure’ to include patients with all causes of this condition. The two indicators on treatment of heart failure (HF3 and HF4) only refer to patients with LVD.5

The main evidence base for the development of the original indicators were guidelines from the Scottish Intercollegiate Guidelines Network (SIGN), with only one reference being made to a NICE guideline (Technology Appraisal 39 on nicotine replacement therapy6). In recent years, NICE has published its own guidelines on CHD and HF, which now have a significant influence on the way patients from these clinical areas are managed across England and Wales (see Table 2).

Table 1: QOF indicators relating to secondary prevention of coronary heart disease5
No. Indicator Amendments Points Payment stages
CHD1 The practice can produce a register of patients with CHD 4  
CHD13 For patients with newly diagnosed angina (diagnosed after 1 April 2011), the percentage who are referred for specialist assessment CHD13 replaces CHD2 7 40–90%
CHD6 The percentage of patients with CHD in whom the last blood pressure reading (measured in the previous 15 months) is ?150/90 mmHg Increased threshold 17 40–71%
CHD8 The percentage of patients with CHD whose last measured total cholesterol (measured in the previous 15 months) is ?5 mmol/l 17 40–70%
CHD9 The percentage of patients with CHD with a record in the preceding 15 months that aspirin, an alternative antiplatelet therapy, or an anticoagulant is being taken (unless a contraindication or side-effects are recorded) 7 40–90%
CHD10 The percentage of patients with CHD who are currently treated with a beta blocker (unless a contraindication or side-effects are recorded) 7 40–60%
CHD14 The percentage of patients with a history of myocardial infarction (from 1 April 2011) currently treated with an ACE inhibitor (or ARB if ACE intolerant), aspirin or an alternative antiplatelet therapy, beta blocker, and statin (unless a contraindication or side-effects are recorded) CHD14 replaces
CHD11
10 40–80%
CHD12 The percentage of patients with CHD who have a record of influenza immunisation in the preceding 1 September to 31 March 7 40–90%
    Total 76  
CHD=coronary heart disease; ACE=angiotensin-converting enzyme; ARB=angiotensin-receptor blocker

Register—CHD 1

Identifying patients with CHD is essential in order to provide effective secondary preventive care. An accurate diagnosis is therefore vital. The register needs to include all patients within the category of acute coronary syndrome (ACS) including those who have had:

  • ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI)
  • unstable angina
  • stable angina due to obstructive CHD.

Patients with ACS are invariably admitted to hospital and have diagnosis confirmed through a combination of clinical history, electrocardiographic changes, and biochemical markers (although there may be diagnostic uncertainty in those with unstable angina). In due course it may be possible to identify patients who have ACS but are troponin negative through the use of newer biochemical markers for ischaemia, such as heart-type fatty acid-binding protein.7 However, at present NICE Clinical Guideline (CG) 95 on chest pain of recent onset advises against using biochemical markers of myocardial ischaemia as opposed to markers of necrosis when assessing patients with acute chest pain.8

Diagnosis and initial management—CHD13 (previously CHD2)

Confusion has arisen in the assessment of patients with stable angina as a result of indicator CHD13. NICE recommends that the diagnosis of stable angina should be based on either clinical assessment alone or clinical assessment plus the use of diagnostic testing.8 This consists of an estimate of the likelihood of obstructive CHD and subsequent modern imaging techniques such an invasive coronary angiography or functional imaging using computed tomography (CT) scanning. The NICE guideline states clearly that exercise electrocardiogram testing should not be used to diagnose or exclude stable angina.8

The new clinical indicator, CHD13, has, as a result, dropped the requirement to confirm diagnosis of angina using exercise testing. If the diagnosis is made on clinical assessment alone—as it should be for individuals with a greater than 90% likelihood of CHD—patients should be exception reported, as the indicator now only applies to those who are referred for specialist opinion;5 an explanation should be included in the patient’s notes as to how the diagnosis has been made.5 This confusion concerning diagnosis is exacerbated with regard to the validity of the risk assessment, which can result in uncertainty and possible misdiagnosis particularly in individuals deemed to be at low risk of CHD.

A survey of GPs who had recently referred patients with suspected angina to a rapid access chest pain clinic, showed that 82% would continue to refer to the clinic to confirm a diagnosis.9 Before NICE guidance can be fully implemented, there is a need to increase access to functional imaging and also to introduce CT calcium scoring, which is only available in a few NHS hospitals.

General practitioners may subsequently be reluctant, based solely on a clinical assessment, to provide the whole range of pharmacological therapies for angina to meet the QOF regulations.

Antithrombotic therapy—CHD9

Indicator CHD9, which applies to antithrombotic therapy, only covers antiplatelet monotherapy, and this is perhaps one area where QOF could be improved, particularly, by the introduction of CHD14 (treatment of myocardial infarction [MI]). NICE CG94 on the early management of unstable angina and NSTEMI recommends the indefinite use of aspirin. Clopidogrel therapy should be used if aspirin hypersensitivity is an issue. Clopidogrel plus low-dose aspirin should be continued for a period of 12 months after the most recent episode of non-ST-segment-elevation ACS.10 However, alternative newer antiplatelet therapies may be used in certain intervention centres, as may a variety of different treatment regimens depending on the clinical situation.

Recent research has shown that stopping clopidogrel antiplatelet therapy prematurely can lead to adverse outcomes.11 Primary care teams need to be clear on their approach to such patients and not rely on achieving the QOF target to provide good-quality care. There is a NICE guideline covering NSTEMI,10 and the NICE guidance on MI with ST-segment elevation is currently in development, but will not follow the standard clinical guideline process. An interim pilot process and methodology is being used to develop this guidance along with a quality standard on the management of ACS including MI (www.nice.org.uk/guidance/CG/Wave25/8).

Table 2: NICE guidelines relevant to QOF indicators in coronary heart disease and heart failure
Guideline number Title Date issued
In progress Myocardial infarction with ST-segment elevation: the acute management of MI with ST-segment elevation. Available at: www.nice.org.uk/guidance/CG/Wave25/8 To be confirmed
127 Hypertension: clinical management of primary hypertension in adults. Available at: www.nice.org.uk/guidance/CG127 August 2011
126 Management of stable angina. Available at: www.nice.org.uk/guidance/CG126 July 2011
95 Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Available at: www.nice.org.uk/guidance/CG95 March 2010
94 Unstable angina and NSTEMI: the early management of unstable angina and non-ST-segment-elevation myocardial infarction. Available at: www.nice.org.uk/guidance/CG94 March 2010
108 Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. Available at: www.nice.org.uk/guidance/CG108 August 2010
71 Identification and management of familial hypercholesterolaemia. Available at: www.nice.org.uk/guidance/CG71 August 2008
67 Lipid modification—cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Available at: www.nice.org.uk/guidance/CG67 May 2008
48 MI: secondary prevention—secondary prevention in primary and secondary care for patients following a myocardial infarction. Available at: www.nice.org.uk/guidance/CG48 May 2007
MI=myocardial infarction; NSTEMI=non-ST-segment-elevation myocardial infarction

Hypertension—CHD6

Patients with confirmed CHD have, in effect, evidence of organ damage, which may be associated with high blood pressure so any increase in levels needs to be treated in this patient group. However, there have been no clinical trials to indicate the optimum target for blood pressure, and the level set in indicator CHD6 of ?150/90 mmHg is based on the pragmatic audit standard in the 2004 guidance from the British Hypertension Society.12

The recently updated NICE guideline on the clinical management of primary hypertension in adults recommends antihypertensive treatment for patients with established cardiovascular disease and established Stage 1 hypertension (i.e. defined as a clinic blood pressure of 140/90 mmHg or higher and subsequent average ambulatory blood pressure monitoring or home blood pressure monitoring levels higher than 135/85 mmHg).13 These levels are considerably lower than the 150/90 mmHg target that currently needs to be reached under CHD6, although there is scope in later updates to lower this level in line with the NICE guideline.5

Cholesterol lowering—CHD8

Cholesterol lowering remains an important part of secondary prevention of CHD and there is a sizeable evidence base to support the use of a statin for this purpose. A major omission in the present system of the QOF indicators is that the set target of ?5 mmol/l can be achieved in patients with CHD who do not have a history of a MI and without the use of a statin drug—this needs to be rectified. The debate on the cholesterol target, based on the relative and absolute benefit of lowering cholesterol in relation to fewer future cardiovascular events has still not been fully resolved. It is accepted however that intensive statin therapy is indicated for all patients with CHD, although the degree of intensity should be dependent on the level of risk of a future event. This level of risk varies within different categories of ACS and may be lower in those with stable angina, but there is scope to lower the cholesterol target in future QOF updates.

Therapeutic prevention after a myocardial infarction—CHD14 (previously CHD11)

An interesting change to the indicators in the 2011/12 update is the replacement of CHD11 by CHD14. This indicator requires that all patients with a history of MI from 1 April 2011 be treated with the following four main preventive therapies, unless individually contraindicated:5

  • Angiotensin-converting enzyme (ACE) inhibitor
  • Aspirin or an alternative antiplatelet therapy
  • Beta blocker
  • Statin.

The introduction of CHD14 was based on NICE Menu 7, which found that treating post-MI with all four groups of drugs was highly cost effective.14 Although bringing all four therapeutic categories together reflects the evidence, clinical practice may lead to discrepancies in how other patients with CHD are managed within the QOF process and how these drugs are used. This is because CHD 14 only applies to myocardial infarction and not to unstable angina and stable angina.

This multifaceted approach to management of post-MI could be developed further to cover lifestyle interventions. Smoking cessation is covered separately (SMOKING 4), but dietary improvement in terms of intake of omega 3 fatty acids could be included under CHD14 in line with the recommendations from NICE CG48.15

Therapeutic prevention in patients with CHD and left ventricular dysfunction—CHD10

Beta blockers are recommended for patients with both CHD (CHD10) and LVD (HF4), but the choice of drug can however vary between the different categories. The benefit of a beta blocker in patients with stable angina who have not had an MI is believed to be due to heart rate control and is most likely a class effect. For individuals who have had an MI, a cardiospecific beta blocker, such as bisoprolol, is invariably used. In treating LVD, healthcare professionals should only use a drug licensed for use in this condition.

The use of ACE inhibitors is beneficial in all categories of CHD and is recommended for stable angina by SIGN16 and NICE,17 yet the QOF indicators only recommend their use in patients with an MI (CHD14).5 Patients who fall within the unstable angina category of ACS will also be excluded from receiving this pharmacological therapy under QOF guidance. The use of ACE inhibitors should therefore be extended to all patients with CHD, as indicated in the two national clinical guidelines.16,17

Although an angiotensin-receptor blocker is used in most patients who are unable to tolerate an ACE inhibitor (CHD14), there is no clear evidence for their benefit in individuals who have had a MI, but who have no evidence of LVD.

Smoking 3 and 4

The management of patients with CHD also extends into other QOF categories. The smoking indicators (3 and 4) include patients with CHD, who should have their smoking status recorded and who should have received smoking cessation advice or referral to a specialist service in the preceding 15 months. Although a large amount of resources are currently focused on smoking cessation, we do not know how successful we are in reducing the overall level of smoking. The benefits of persuading people with CHD to stop smoking cannot be overemphasised; in the future, an additional QOF indicator could be used to quantify primary care success in this group of patients.

Summary

There has been much debate on how well the QOF indicators have influenced the uptake of secondary prevention of CHD within the UK as much of the published evidence is contradictory. Worldwide, there is a clear gradient between the affluent, middle, and lower income countries in terms of the uptake of preventive medication after a cardiac event.18 I have no doubt that the QOF has been a major driver in increasing the uptake of secondary preventive measures, allowing a very favourable comparison to be made between the UK and other countries. The process of rationalising the indicators has commenced with the 2011/12 update, but the healthcare profession needs to be alert to any future NICE Menus as they are published to ensure that they reflect the evidence and accepted clinical practice.

  • GP commissioners should be aware that the QOF CHD markers do not match NICE and SIGN guidance in all areas
  • The diagnosis and investigation of possible CHD is a key point for agreement of a local care pathway that follows NICE/SIGN guidance and which matches the availability of specialist investigations
  • GP commissioners could work with colleagues in primary care commissioning to agree local-exception reporting to cover CHD13 and CHD8 (if target cholesterol levels cannot be met using NICE-approved lipid-lowering agents)
  • GP commissioners could specify that acute hospital contracts include a requirement for NICE-approved medication and interventions following acute admissions for ACS and angina
  • NICE has released new guidance on the use of ticagrelor in ACS (Technology Appraisal 236), which will need to be funded and built into local antiplatelet protocols for management post-ACS
  • Costs of antiplatelet treatment per month:a
  • Aspirin 75 mg (28) = £0.82
  • Clopidogrel 75 mg (30) = £1.94
  • Ticagrelor 90 mg (56) = £54.60.
  1. The NHS Information Centre. Quality and outcomes framework online GP practice results database. Available at: www.qof.ic.nhs.uk/search/index.asp (accessed 26 September 2011).
  2. The NHS Information Centre. Quality and outcomes framework achievement data 2010/11. The Health and Social Care Information Centre, 2010. Available at: www.ic.nhs.uk/statistics-and-data-collections/supporting-information/audits-and-performance/the-quality-and-outcomes-framework/qof-2010-11/qof-2010-11-bulletin
  3. Information Centre website. QOF related external links. Available at: www.ic.nhs.uk/statistics-and-data-collections/supporting-information/audits-and-performance/the-quality-and-outcomes-framework/qof-2010-11/qof-related-external-links
  4. British Medical Association. Investing in general practice. The new general medical services contract. London: BMA, 2003.
  5. British Medical Association. NHS Employers. Quality and outcomes framework guidance for GMS contract 2011/12. London: BMA, NHS Employers, 2011. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qofguidance2011.jsp
  6. National Institute for Health and Care Excellence. The clinical effectiveness and cost effectiveness of bupropion and nicotine replacement therapy for smoking cessation. London: NICE, 2002.
  7. Pearson I, Hall A, Gale C et al. In acute coronary syndromes, heart-type fatty acid binding protein is a more accurate predictor of long term prognosis than troponin. Circulation 2010; 122 (21): A11374.
  8. National Institute for Health and Care Excellence. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Clinical Guideline 95. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG95
  9. Kelly D, Cole S, Rossiter F. Implementation of the new NICE guidelines for stable chest pain: likely impact on chest pain services in the UK. Br J Cardiol 2011; 18: 185–188.
  10. National Institute for Health and Care Excellence. Unstable angina and NSTEMI: the early management of unstable angina and non-ST-segment-elevation myocardial infarction. Clinical Guideline 94. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG94
  11. Boggon R, van Staa T, Timmis A et al. Clopidogrel discontinuation after acute coronary syndromes: frequency, predictors and associations with death and myocardial infarction—a hospital registry-primary care linked cohort (MINAP-GPRD). Eur Heart J 2011; 32 (19): 2376–2386.
  12. Williams B, Poulter N, Brown M et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004; BHS IV. J Hum Hypertens 2004; 18 (3): 139–185.
  13. National Institute for Health and Care Excellence. Hypertension: clinical management of primary hypertension in adults. Clinical Guideline 127 (partially updates and replaces CG34). London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG127
  14. NICE website. NICE menu of indicators. www.nice.org.uk/aboutnice/qof/indicators_detail.jsp?summary=13071 (accessed 21 October 2011).
  15. National Institute for Health and Care Excellence. MI: secondary prevention. Secondary prevention in primary and secondary care for patients following a myocardial infarction. Clinical Guideline 48. London: NICE, 2007. Available at: www.nice.org.uk/guidance/CG48
  16. Scottish Intercollegiate Guidelines Network. Management of stable angina. SIGN 96. Edinburgh: SIGN, 2007. Available at: www.sign.ac.uk/guidelines/fulltext/93-97/index.html
  17. National Institute for Health and Care Excellence. Management of stable angina. Clinical Guideline 126. London: NICE, 2011. Available at: nice.org.uk/guidance/CG126
  18. Yusuf S, Islam S, Chow C et al; Prospective Urban Rural Epidemiology (PURE) Study Investigators. Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey. Lancet 2011; 378 (9798): 1231–1443.G