Dr Alan Begg explains how the QOF indicators for 2011/2012 have been updated to improve identification of cardiovascular risk in people with serious mental illness

The changes to the quality and outcomes framework (QOF) for 2011/12 were published in April of this year. This is the first time that NICE has been involved in the QOF update.1 Indicators that have been amended, have been renumbered to avoid inappropriate cross-year comparison between different indicators (renumbering has not occurred if the changes related to thresholds and ranges for payment stages only). Indicators that have been developed through the NICE process are identified by the NICE menu ID using the letters NM and then a number, which may cause confusion as this does not correspond with the QOF clinical indicator number.

Primary prevention in the QOF

At first glance, with the retirement of two indicators on the measurement of cholesterol (CHD7, DM16) and three indicators on the measurement of blood pressure (CHD5, DM11, and STROKE5), the initial impression is that prevention of cardiovascular disease (CVD) has become less of a priority within the QOF process. However, the requirement for reaching targets in these parameters within the individual stated disease category still remains, with there no longer being a payment for the actual measurement process. A review of the replacement QOF indicators for 2011/12, especially in relation to mental illness, would, however, suggest that the primary prevention of CVD, and in particular, coronary heart disease (CHD), is being given greater prominence.

Patients with mental health disorders

The standard on the primary prevention of CVD published by Quality Improvement Scotland (QIS) states that people with serious and enduring mental health problems are a high-priority group for the identification of cardiovascular risk.2 Once these individuals have been identified, it is essential that a plan is implemented to address this high cardiovascular risk.2 Patients with mental illness are deemed to be at higher CVD risk overall on the basis of their lifestyle and habits, along with the apparent recognition from many case studies of an increase in risk factors within this patient group.3

Previously, there was provision within the QOF for patients with mental health disorders to receive an annual health promotion and prevention review and appropriate advice. However, this year MH9 has been replaced by a series of indicators (MH11, MH12, MH13, MH14, MH15, MH16) defining what should be in a physical review with each of the parameters given their own individual indicator. MH11–15 are related to primary prevention of CHD (see Table 1, below) and MH16 is related to cervical screening. The recording of these risk factors every 15 months is felt to be in keeping with the NICE guidelines on schizophrenia and bipolar disorder, which recommend an annual physical review for patients with these conditions.4,5 Patients with schizophrenia have increased mortality from most major diseases but the increase in cardiovascular mortality has risen significantly in the past 25 years relative to the general population.6,7 Smoking is the most prominent modifiable risk factor associated with this increased mortality, but it is accepted that unhealthy lifestyles may also be influential. A similar pattern is seen in patients with bipolar disorder, with the mortality risk 35% higher than a comparison group and CVD appearing to be responsible for the majority of excess deaths.8 Smoking cessation advice or referral to a specialist service for patients with mental health disorders is addressed under the QOF indicator, Smoking 4.1

Alcohol and mental illness (MH11)
Systematic reviews have shown that small amounts of alcohol may be protective against development of CHD. However, surveys of adults with psychiatric disorders have revealed an association with excessive alcohol consumption,3 which in turn is related to raised blood pressure, an increased risk of both CVD and liver disease.

The current general advice remains that no more than 14 units per week for a female and 21 units for a male constitutes a healthy intake of alcohol.9,10

Weight reduction (MH12) and exclusion of diabetes (MH15)
Patients with psychosis tend to lead a more sedentary life and are more likely to be overweight or obese. There is also good evidence that the newer atypical antipsychotic drugs and phenothiazines will increase weight. Mean weight gains of 4.45 kg with clozapine and 4.15 kg with olanzapine over a 10-week period have been observed.11 Weight control in patients with psychosis will reduce the blood pressure profile and risk of diabetes, which in turn will reduce their cardiovascular risk. Measurement of blood glucose levels (MH15) will identify patients with impaired glucose regulation or overt diabetes. The incidence of diabetes has been found to be up to three-times higher in patients with schizophrenia than in the general population. Furthermore, antipsychotic drugs increase the risk of metabolic syndrome.12 Intensive lifestyle changes and weight reduction can reduce the risk of some people developing overt diabetes and over time, the development of macrovascular disease. A low intake of fruit and vegetables in people with schizophrenia has been documented; however in one trial carried out in the west and south west of Scotland, intake with or without associated instruction doubled if free fruit and vegetables were provided.13 This illustrates that an innovate approach or incentives may be required to encourage lifestyle change in this group of patients.

Measurement of blood pressure (MH13)
The benefits of identifying individuals within the general population with raised blood pressure and lowering it effectively to reduce CVD are not in doubt. Cohort studies have suggested that hypertension may be more prevalent in patients with mental illness and therefore less likely to be identified in this hard-to-reach group.3

Lipids (MH14)
Patients taking the newer antipsychotics have been found to have higher levels of cholesterol and triglycerides.10 Data from UK general practice have shown that patients who received olanzapine have an increased risk of developing hyperlipidemia compared with patients who received no antipsychotics (adjusted odds ratio 4.65; 95% confidence interval, 2.44–8.85; p<0.001).14 This increase in lipid levels will increase cardiovascular risk and on this basis the measurement of total cholesterol to high-density lipoprotein cholesterol ratio is now included as a QOF indicator in patients with a mental health disorder.

Risk assessment
Patients with mental health disorders are a high priority for risk assessment as a result of the higher prevalence of risk factors and the risk of CVD. Addressing individual risk factors will help to reduce the global cardiovascular risk. Patients with mental health problems identified as being hypertensive under MH13 will be required to undergo a face-to-face cardiovascular risk assessment using an agreed risk assessment tool as per indicator PP1 (see Table 2). However, NICE Clinical Guideline 67 on lipid modification advises that CVD risk scores may not be an appropriate way of assessing risk if the patient is being treated with antipsychotic therapy.10 Primary care should provide interventions to patients with mental health disorders regardless because they are recognised to be at a higher cardiovascular risk due to risk factors and the effects of pharmacological treatment. This makes them a high-priority group to identify all their risk factors and address these accordingly.



Table 1: QOF indicators relating to primary prevention of coronary heart disease in patients with mental health disorders13
No. Indicator Points Payment stages

MH11

The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses who have a record of alcohol consumption in the preceding 15 months

NICE menu ID: NM15

4

40–90%

MH12

The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses who have a record of BMI in the preceding 15 months

NICE menu ID: NM16

4

40–90%

MH13

The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses who have a record of blood pressure in the preceding 15 months

NICE menu ID: NM17

4

40–90%

MH14

The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder, and other psychoses who have a record of total cholesterol:hdl ratio in the preceding 15 months

NICE menu ID: NM18

5

40–80%

MH15

The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder, and other psychoses who have a record of blood glucose in the preceding 15 months

NICE menu ID: NM19

5

40–80%

Table 2: Cardiovascular disease primary prevention indicator set1

 

No. Indicator Points Payment stages
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

NICE menu ID: NM06
8 40–70%
PP2 The percentage of people diagnosed with hypertension (diagnosed after 1 April 2009) who are given lifestyle advice in the preceding 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption, and healthy diet 5 40–70%

Other at-risk groups

There has been no change in the requirement to address or record other cardiovascular risk factors within the QOF. The QOF indicators relating to primary prevention of cardiovascular risk are summarised in Table 3 and relate to the following clinical areas: hypertension, chronic kidney disease, obesity, smoking, and diabetes. Patients with type 2 diabetes are at especially high risk of both microvascular and macrovascular complications and achievement of several of the indicators within the QOF (e.g. through appropriate interventions) will result in reduced cardiovascular problems (see Table 3).

In addition to good blood pressure control and reduction in cholesterol, tight glycaemic control can also improve vascular complications. Based on the recent ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation) and ACCORD (Action to Control Cardiovascular Risk in Diabetes) studies, the debate still remains as to how quickly target glucose levels should be reached and the value of optimum level.15 There are three QOF indicators—DM26, DM27, and DM28—relating to glycaemic control in patients with diabetes.

Table 3: QOF indicators relating to primary prevention of cardiovascular risk1
No. Indicator Points Payment stages
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
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 16 40–90%
BP5 The percentage of patients with hypertension in whom the last blood pressure (measured in the preceding 9 months) is 150/90 or less 57 40–70%
CKD2 The percentage of patients on the CKD register whose notes have a record of blood pressure in the preceding 15 months 6 40–90%
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 or less 11 40–70%
OB1 The practice can produce a register of patients aged 16 years and over with a BMI greater than or equal to 30 in the preceding 15 months 8
Smoking 3 The percentage of patients with any or any combination of the following conditions: CHD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder, or other psychoses whose notes record smoking status in the preceding 15 months 30 40–90%
Smoking 4 The percentage of patients with any or any combination of the following conditions: CHD, 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 preceding 15 months 30 40–90%
Information 5 The practice supports smokers in stopping smoking by a strategy that includes providing literature and offering appropriate therapy 2
DM2 The percentage of patients with diabetes whose notes record BMI in the preceding 15 months 3 40–90%
DM30 The percentage of patients with diabetes in whom the last blood pressure is 150/90 or less NICE menu ID: NM01 8 40–71%
DM31 The percentage of patients with diabetes in whom the last blood pressure is 140/80 or less NICE menu ID: NM02 10 40–60%
DM17 The percentage of patients with diabetes whose last measured total cholesterol within the preceding 15 months is 5 mmol/l or less 6 40–70%

Risk assessment tools

In its initial guidance on lipid modification, NICE advised using the Framingham risk estimation for risk assessment, but this recommendation has now been rescinded, allowing local NHS organisations to use the method best suited to their requirements. Indicator PP1 has been updated to introduce a lower and upper age threshold of 30 and 74 years, respectively (see Table 2). This indicator refers to the use of ‘an agreed risk assessment tool’ and the QOF guidance discusses the following options (see Table 4):

  • Framingham
  • Joint British Societies’ 2 (JBS 2)
  • QRISK
  • ASSIGN (assessing cardiovascular risk using SIGN guidelines to assign preventive treatment)—Scotland only.

The QOF guidance, however, seems to encourage practices to use the QRISK tool in England and ASSIGN in Scotland.1

The four risk tools measure the short-term absolute cardiovascular risk and help to identify high-risk patients. This approach may not identify younger patients who on the basis of their age have a low absolute risk, but have a high relative risk when compared with people of a similar age group. Younger people with multiple risk factors may have more to gain by having that risk addressed over a much longer period of time. As a result of the high prevalence of CVD within the UK, the national lifetime risk is high and we should all pay attention to lifestyle changes and address appropriate risk factors for CVD. Previously this lifetime risk has been used to inform national policy rather than individual healthcare.

A new QRISK 3 model, which has been developed to estimate lifetime risk of CVD, has been shown to identify different high-risk individuals, compared with the QRISK 2 score.16 It identified patients for intervention at a younger age, a higher proportion of men, more people from ethnic minority groups, and more with a family history of premature CHD.

It is not clear however if there is a net benefit of intervening at an early age in terms of patient acceptability and cost effectiveness. The concern is that the situation may become even more confusing when the Joint British Societies’ 3 (JBS 3) guideline is published later this year as it is expected to endorse a move to the measurement of lifetime risk.17

Table 4: Cardiovascular risk assessment tools in the QOF1
Risk Tool Cohort used Advantages and disadvantages Age range (years)
Framingham Based on historic American Framingham equations, which are of 'limited use in UK'
  • Overestimated risk by up to 50% in Northern European population especially if living in affluent areas
  • Underestimated risk in higher risk populations
  • No allowance for family history of premature CHD
  • Does not take account of ethnicity
  • Underestimates risk if socially deprived
35–74
Joint British Societies' 2
(JBS 2)
40 years and older
QRISK Uses data from UK general practices database Uses Townsend deprivation score and treated hypertension Includes variables such as social deprivation, ethnicity and family history 30–84
ASSIGN Developed using Scottish cohort and only validated in a Scottish population Uses Scottish Index of Multiple Deprivation (SIMD) 30–74

Conclusion

The 2011/12 update to the QOF has, through its component parts, further increased the assessment of CVD risk factors and the measurement of that risk. Rather than introduce nationwide population-based screening, the approach is to use high-priority groups as a trigger for measuring risk and identifying risk factors. Unfortunately this step-by-step approach may appear to be fragmented, especially as it is scattered across a variety of categories within the QOF and it may not result in improved outcomes without evidence of cost effectiveness. A health economic report has concluded that although the indicators for primary prevention of CHD in patients with mental health disorders (MH11, MH12, MH13, MH14, and MH15) can be assumed to affect the treatment decision of the clinician for patients for whom the information was previously unavailable, they do not have a direct therapeutic benefit and evidence of their cost effectiveness is therefore lacking.18

  • The new QOF indicators for primary prevention of CVD place specific emphasis on interventions for those with psychotic or bipolar disorder
  • There is still uncertainty over which CVD risk tools to use and whether these work well for those with mental health issues—local guidelines may be useful here
  • GP commissioners could also target CVD screening programs for those in socially excluded groups perhaps through pharmacies, but this data needs to be fed back to practices to help meet QOF targets
  • GP commissioners should ensure that local formularies focus on drugs of low acquisition cost for lipid modification and antihypertensive drugs
  • Incentives for practices to use cost efficient drugs such as statins can be included in the new quality and productivity indicators (QP1–QP5), which are to be set locally.
  1. 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
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  10. National Institute for Health and Care Excellence. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG67 nhs_accreditation
  11. Marder S, Essock S, Miller A et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry 2004; 161 (8): 1334–1449.
  12. Oud M, Meyboom-de Jong B. Somatic diseases in patients with schizophrenia in general practice: their prevalence and health care. BMC Family Practice 2009; 10: 32.
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  15. Scottish Intercollegiate Guidelines Network. Management of diabetes. SIGN 116. Edinburgh: SIGN, 2010. Available at: www.sign.ac.uk/guidelines/fulltext/116/index.html nhs_accreditation
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  17. Joint British Societies' guideline on the prevention of cardiovascular disease (JBS3) prototype of risk calculator. www.slideshare.net/grumplet/jbs3-cadiovascular-risk-calculator
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