- The available number of points in the hypertension domain has been reduced slightly, but is still considerable
- The QOF recommends a proactive approach in the diagnosis and management of hypertension
- An accurate of register of patients with hypertension is essential
- Recording blood pressure may require a flexible system that incorporates readings from several sources (e.g. face-to-face consultations, corrected home readings)
- The blood-pressure targets specified in the QOF represent a minimum standard of care
- Control of blood pressure features in the new domain of peripheral arterial disease.
The quality and outcomes framework (QOF) was introduced as part of the new general medical services (GMS) contract in 2004.1 It helps to standardise improvements in the delivery of care, as well as offering a means by which practices are rewarded for providing quality healthcare.1 The importance of diagnosis and treatment of hypertension is highlighted in the QOF as both a separate domain and within indicators in other clinical areas, such as diabetes and coronary heart disease. Hypertension accounts for 163/666 (24%) points of the clinical indicators and 15/82 (18%) of the organisational indicators.2 The revisions to QOF 2012/13 have resulted in a slight reduction in the points relating to hypertension compared with previous years, but the current content is still considerable.
The importance of managing hypertension in the primary and secondary prevention of cardiovascular disease is underlined by its well-established links with increased morbidity and mortality. Hypertension is a major risk factor for stroke, myocardial infarction, heart failure, aneurysms of the arteries, and peripheral arterial disease, and is also a cause of chronic kidney disease.3 Increased arterial blood pressure, even below the hypertensive range, is associated with shortened life expectancy, which indicates a continuum of risk with higher blood pressures in the normal range.4
The latest QOF targets include changes to the hypertension indicators in terms of a reduction in points generated in some fields, increases in payment thresholds, and the introduction of a new domain—peripheral arterial disease (see Table 1).5 For example:2
- the points available within the hypertension domain have been reduced from 79 to 69
- the points for recording blood pressure in people with chronic kidney disease (CKD) have been reduced from 6 to 4 (CKD2)
- 2 points have been generated in the new domain of peripheral arterial disease
- the payment thresholds for BP4 and BP5 have increased.
Although the number of points associated with hypertension are fewer, the QOF considers more clinical areas, and the payment thresholds have changed. It is therefore more important to ensure that data are collected as efficiently as possible and that the register is accurate. This is complicated by the fact that most patients with hypertension are asymptomatic and doctors are labelling patients who feel well with an 'illness' and encouraging them to take medications.6 The QOF encourages a proactive approach to increasing the diagnosis and treatment of hypertension and recording of blood pressure by including 15 points in the organisational indicators.2
|Table 1: Quality and outcomes framework indicators for hypertension 2012/132|
|BP1||The practice can produce a register of patients with established hypertension||6||-|
|BP4||The percentage of patients with hypertension in whom there is a record of the blood pressure in the preceding 9 months||8||50-90%|
|BP5||The percentage of patients with hypertension in whom the last blood pressure (measured in the preceding 9 months) is ?150/90 mmHg||55||45-80%|
|DM30||The percentage of patients with diabetes in whom the last blood pressure is ?150/90 mmHg in the preceding 15 months||8||45-71%|
|DM31||The percentage of patients with diabetes in whom the last blood pressure is ?140/80 mmHg in the preceding 15 months||10||40-65%|
|Chronic kidney disease|
|CKD2||The percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months||4||50-90%|
|CKD3||The percentage of patients on the CKD register in whom the last blood pressure reading (measured in the preceding 15 months) is ?140/85 mmHg||11||45-80%|
|CKD5||The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an ACE inhibitor or ARB||9||45-80%|
|Cardiovascular disease—primary prevention|
|PP1||In those patients with a new diagnosis of hypertension (excluding those with pre-existing CHD, diabetes, stroke and/or TIA) recorded between the preceding 1 April to 31 March: the percentage of patients aged 30 to 74 years who have had a face-to-face cardiovascular risk assessment at the outset of diagnosis (within 3 months of the initial diagnosis) using an agreed risk-assessment tool||8||40-75%|
|PP2||The percentage of people with hypertension (diagnosed after 1 April 2009) who are given lifestyle advice in the last 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption, and healthy diet||5||40-75%|
|Peripheral arterial disease|
|PAD3||The percentage of patients with peripheral arterial disease in whom the last blood pressure reading (measured in the preceding 15 months) is ?150/90 mmHg||2||40-90%|
|Coronary heart disease|
|CHD6||The percentage of patients with CHD in whom the last blood pressure reading (measured in the previous 15 months) is ?150/90 mmHg||17||40-75%|
|STROKE 6||The percentage of patients with a history of stroke or TIA in whom the last blood pressure reading (measured in the previous 15 months) is ?150/90 mmHg||5||40-75%|
|RECORDS 11||The blood pressure of patients aged 45 years and over is recorded in the preceding 5 years for at least 65% of patients||10||65%|
|RECORDS 17||The blood pressure of patients aged 45 years and over is recorded in the preceding 5 years for at least 80% of patients||5||80%|
|CKD=chronic kidney disease; ACE= angiotensin-converting enzyme; ARB=angiotensin-receptor blocker; CHD=coronary heart disease; TIA=transient ischemic attack|
The register—BP 1
For most practices, the decision to include patients on the hypertension register relates to confirmed, persistent, high blood pressure ?140/90 mmHg.7 An accurate register is essential, and after several years of QOF, registers should already be up to date, with the appropriate Read codes used. Furthermore, it is important that hypertension is recognised and treated as a separate entity when recording patients with dual problems, such as diabetes and coronary heart disease.8
However, the decision on whether to start therapeutic management depends on:9
- the overall cardiovascular (CV) risk
- evidence of end-organ damage
- the presence of co-morbidities.
Therefore, the threshold to treat will be lower in the above groups. In contrast some patients with stage 1 hypertension may not require medication and will only be advised on lifestyle changes and followed up through annual review.
The NICE and British Hypertension Society (BHS) definitions of hypertension are shown in Table 2.10 A major change is the use of ambulatory blood pressure readings or average home blood pressure readings when the ambulatory monitor is not tolerated. This reflects evidence from studies demonstrating that morbidity and mortality correlate better with ambulatory blood pressure measurements than with clinical face-to-face readings.11 Some authors have suggested that this approach should be introduced into future QOF targets, but the implications for training, resources, and cost in terms of time and money could be considerable.12 However, others have argued that the use of ambulatory blood pressure monitoring has its own pitfalls.13
|Table 2: NICE definitions of hypertension10|
|BP=blood pressure; ABPM=ambulatory blood pressure monitoring; HBPM=home blood pressure monitoring|
The preferred interval for repeat blood pressure readings for QOF is 9 months (BP4 and BP5)—interestingly, however, the NICE guidance suggests an interval of 1 year for patients with stable hypertension,10 and the QOF audit criteria for most other conditions is 15 months.2 In a time when hospitals are being encouraged to reduce follow-up appointments and primary care is taking on greater responsibility, pressure on the system and the need for appointments is increasing. To achieve the targets set for BP4, BP5, and other clinical areas, the recording of blood pressure will ideally require a flexible system that can incorporate readings from several sources such as:
- face-to-face consultations with nurses/doctors
- hospital letters
- freestanding self-monitoring equipment in practice waiting areas
- corrected home readings
- ambulatory recordings.
The definition of hypertension with the new NICE guidance also corrects for the difference in ambulatory, home, and clinic blood pressure readings as outlined in Table 2. Regular calibration and maintenance of equipment are also needed, which may be more haphazard and less consistent with home- and hospital-based outpatient monitors. Unlike the advice for correction of home and ambulatory readings shown in Table 2, no formal advice is available on correction of readings from free-standing monitors in surgeries.
Targets for blood pressure
The blood-pressure targets specified in the QOF must be regarded as an audit standard, representing only a minimum standard of care (e.g. BP5 requires a target blood pressure of ?150/90 mmHg). The over arching aim is to provide best standard practice to achieve the optimum blood pressure readings shown in Table 3. The lower the blood pressure, the lower the cardiovascular risk, and the risk reduction, especially for diastolic blood pressure, remains linear as blood pressure is reduced,18 so the ideal scenario is the lowest blood pressure possible.
Hypertension is one of the many risk factors for cardiovascular disease; it is also a common co-morbidity in conditions, such as diabetes.19 This is reflected by the lower blood pressure targets recommended by national guidance (see Table 3).
Hypertension and age
Recently, NICE recommended tighter target blood pressure control for people younger than 80 years, as better clinical outcomes are consistently associated with blood pressure ?140/90 mmHg.10 The NICE guideline recommends a target blood pressure of 150/90 mmHg (clinic readings) for people aged ?80 years because of results from key studies that generally included older people who were fit and active and had low levels of co-morbidities.10 However, advice for those older than 80 years should be based on the realistic expectation of clinical benefit from treatment in the context of other co-morbidities that might limit life expectancy. The new targets have been put forward for discussion as possible QOF points in 2013/14;20 however, given the very high prevalence of co-morbidities in people younger than 80 years, such aggressive targets may lead to more side-effects for patients.
|Table 3: Blood pressure targets for different conditions|
|QOF||Ideal (supporting guidance)|
|Coronary heart disease||150/90||?140/85||NICE CG4814|
|Stroke/transient ischaemic attack||150/90||?140/85||-|
|Chronic kidney disease||?140/85|| ?140/90
With proteinuria: ?130/80
|Peripheral arterial disease||?150/90||?140/90||SIGN 8917|
| QOF=quality outcomes framework; CG=Clinical Guideline
aDM31 sets a target of 140/80 mmHg as per the target recommended by NICE, while the target of 150/90 mmHg has been set for those patients who cannot manage this, such as those with retinopathy, microalbuminuria, or cerebrovascular disease.
In general, guidelines from NICE,7,10 the European Society of Hypertension Task Force,21 and the American Society of Hypertension22 emphasise the use of different drugs in different patient groups. However, the principle is to adopt a stepwise approach and combine different agents to reach a target blood pressure. Many patients usually need to take multiple therapies to reach their target, with the aim of getting blood pressure as low as possible.
Indicator CKD5 specifies that patients who have CKD, proteinuria, and hypertension should be treated with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) because of the protective effect of these drugs for the kidneys.2
Peripheral arterial disease—PAD3
Patients with peripheral arterial disease should receive treatment to reduce high blood pressure on the basis that they are at high risk of a subsequent vascular event (PAD3). The audit standard of 150/90 mmHg is accepted as the minimum target, but the optimum target is ?140/90 mmHg.17 This indicator attracts a total of 2 points.2
Organisational indicators—RECORDS 11 and RECORDS 17
Hypertension is common and patients are normally asymptomatic, but it is an important risk factor associated with increased morbidity and mortality worldwide both in the developed and developing world.23 More than half of people older than 65 years in England have hypertension,24 and most will be asymptomatic and possibly unaware of the problem. Early detection and treatment is therefore encouraged. The various sources discussed previously can be used to help document blood pressure in people aged ?45 years.2 Encouraging new patients to check their blood pressure on an automated machine in the waiting room can go a long way towards hitting this target.
Hypertension is an important cause of increased morbidity and mortality in the world. This is also recognised by the importance put on the hypertension targets in QOF. Targets are becoming harder in terms of having to achieve lower blood pressure in more groups and in a greater number of people to achieve payments. However, with the stepping stone of previous years, the targets represent a progression in our work towards better care.
- The QOF has many indicators for control of blood pressure but achievement against these is often at thresholds higher than ideal management
- Clinical commissioning groups should try to ensure practices treat to the ideal targets, not just the audit standards, and also include ABPM or HBPM in the diagnosis of new hypertension
- Local formularies should identify the key antihypertensive agents as recommended by NICE as these are now available as generics at low acquisition cost
- There are many different threshold figures for control of blood pressure in various conditions and a simple summary reminder chart for primary care staff could help simplify this complexity
- Practices should review their PAD register and ensure that patients receive optimal treatment as this is a new focus for QOF.
QOF=quality and outcomes framework; ABPM=ambulatory blood pressure monitoring; HBPM=home blood pressure monitoring; PAD=peripheral arterial disease
- Health and Social Care Information Centre. Quality and outcomes framework. Online GP practice results database. Available at: www.qof.ic.nhs.uk/index.asp (accessed 17 July 2012).
- NHS Employers and General Practitioners Committee. Quality and outcomes framework for 2012/13. Guidance for PCOs and practices. London: NHS Employers, 2012. Available at: www.nhsemployers.org/Aboutus/Publications/Documents/QOF_2012-13.pdf (accessed
17 July 2012).
- Cushman W. The burden of uncontrolled hypertension: morbidity and mortality associated with disease progression. J Clin Hypertens (Greenwich) 2003; 5 (3 Suppl 2): 14-22.
- Lewington S, Clarke R, Peto R et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360: 1903-1913.
- NHS Employers website. Changes to QOF 2012/13. www.nhsemployers.org/payandcontracts/generalmedicalservicescontract/qof/Pages/Changestoqof2013.aspx (accessed 17 July 2012).
- Macdonald L, Sackett R, Haynes R, Taylor D. Labelling in hypertension: a review of the behavioural and psychological consequences. J Chron Dis 1984; 37 (12): 933-942
- National Institute for Health and Care Excellence, British Hypertension Society. Hypertension: management of hypertension in adults in primary care. Clinical Guideline 34. London: NICE, 2006.
- Padwal R, Straus S, McAlister F. Cardiovascular risk factors and their effects on the decision to treat hypertension: evidence based review. BMJ 2001; 322 (7292): 977-980.
- Begg A. Effective management of hypertension is a key aim for primary care. Guidelines in Practice 2007; 10 (10): 25-32.
- National Institute for Health and Care Excellence. Hypertension: clinical management of primary hypertension in adults. Clinical Guideline 127. London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG127
- Hodgkinson J, Mant J, Martin U et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ 2011; 342: d3621.
- Taylor P. Evidence for key recommendation in NICE guidance on hypertension is poor. BMJ 2011; 343: d6494.
- Brown M, Cruickshank J, MacDonald T. Navigating the shoals in hypertension: discovery and guidance. BMJ 2012; 344: d8218.
- Cooper A, Skinner J, Nherera L et al. Clinical guidelines and evidence review for post myocardial infarction: secondary prevention in primary and secondary care for patients following a myocardial infarction. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners, 2007. Available at: www.nice.org.uk/CG48
- Scottish Intercollegiate Guidelines Network. Management of diabetes. SIGN 116. Edinburgh: SIGN, 2010. Available at: www.sign.ac.uk/guidelines/fulltext/116/index.html
- National Institute for Health and Care Excellence. Chronic kidney disease: national clinical guideline for early identification and management in adults in primary and secondary care. Full guideline. London: NICE, 2008. Available at: www.nice.org.uk/guidance/CG73
- Scottish Intercollegiate Guidelines Network. Diagnosis and management of peripheral arterial disease. SIGN 89. Edinburgh: SIGN, 2006. Available at: www.sign.ac.uk/guidelines/fulltext/89/index.html
- Turnbull F; Blood Pressure Lowering Treatment Trialists' Collaboration. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet 2003; 362 (9395): 1527-1535.
- Arauz-Pacheco C, Parrott M, Raskin P. The treatment of hypertension in adult patients with diabetes. Diabetes Care 2002; 25: 134-147.
- National Institute for Health and Care Excellence. Consultation on potential new indicators for the 2013/14 quality and outcomes framework (QOF). Available at: www.nice.org.uk/aboutnice/qof/Recommendationsindicatorretirement.jsp (accessed 9 August 2012).
- Giuseppe M, Stephane L, Agabiti-Rosei E et al. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens 2009; 27 (11): 2121-2158.
- American Society of Hypertension website. ASH position papers. www.ash-us.org/Publications/ASH-Position-Papers.aspx (accessed 2 August 2012).
- Kearney P, Whelton M, Reynolds K et al. Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365 (9455): 217-223.
- Department of Health. Health survey for England—2009. London: DH, 2010. Available at: www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles-related-surveys/health-survey-for-england (accessed 17 July 2012). G