The new contract’s clinical indicators for stroke and TIA reflect good evidence-based practice and practices should achieve maximum points, says Dr Nigel Watson
Stroke is the third most common cause of death in the developed world,1 and approximately 25% of strokes occur in patients under 65 years of age.2
The management of stroke and transient ischaemic attack is one of the ten clinical areas set out in the quality and outcomes framework of the new GMS contract.The section is worth a maximum of 31 points out of a possible 550 points for all ten clinical areas.
The first quality indicator for each of the ten clinical areas in the quality and outcomes framework is for the practice to be able to produce a disease register.
Although it is well recognised that disease registers cannot be 100% accurate, the new GMS contract demands that the information they contain is of high quality. Practices must also have systems in place for ongoing validation of these registers.
When the PCO makes its verification visit, the practice may be asked how its disease registers are constructed and to demonstrate this. Payment under the quality framework is based on local prevalence data, so the PCO will compare a practice’s prevalence data with national prevalence data.
It is essential that clinical data entered in the records are accurate and appropriate. For example, take the case of a patient who, following a single episode of numbness, had the Read code for transient ischaemic attack added to his records. Subsequent investigations proved this diagnosis to be incorrect; however, the entry in his record was not amended, and he continued to be included in the disease register for patients with TIA.
Not only is there an incorrect diagnosis among the practice’s medical records; but under the new contract the practice might lose valuable points.
The clinical indicators for stroke
Disease register (Stroke 1)
A disease register is essential to be able to monitor patients and ensure that they are followed up adequately. Suggested Read codes are given in Table 1. Practices will need to be able to extract from their data a list of all patients who have had a stroke or TIA.
|Table 1: Clinical indicators for stroke and transient ischaemic attack|
|Disease/ indicator no||Clinical indicator||Points||Qualifier||Preferred 4-byte (V2) Read codes||Exception reporting and 4 byte (V2) Read codes||Payment stages|
|Stroke 1||A register of patients with stroke and TIA||4||Haemorrhagic stroke: G712 (G61%)
Non-haemorrhagic stroke: G73 - G73Z (G64%)
TIA: G74 (G65%)
|Stroke patient unsuitable: 9H21 (9H21)
Stroke, informed dissent: 9H22 (9H22)
|Stroke 2||% new patients with presumptive stroke referred for confirmation by CT or MRI scan||2||From 1.4.03||CT scan: 567-5673 (567-5673)
MRI, abnormal: 5693 (5693)
MRI, normal: 5692 (5692)
|Stroke 3||% patients with TIA or stroke with smoking status recorded||3||Recorded in past 15 months||Never smoked: 1371 (1371)
Ex-smoker: 137S (137L)
Smoker: 137P (137R)
|Stroke 4||% patients who are smokers offered smoking cessation advice||2||Recorded in past 15 months||Smoking cessation advice: 8CAL (8CAL)||25-70%|
|Stroke 5||% patients with blood pressure recorded||2||Recorded in past 15 months||25-90%|
|Stroke 6||% patients with BP 150/90 mmHg or less||5||Recorded in past 15 months||Blood pressure: 246 (246)||25-70%|
|Stroke 7||% patients with total cholesterol measured||2||Recorded in past 15 months||25-90%|
|Stroke 8||% patients whose cholesterol is 5 mmol/l or less||5||Measured in past 15 months||25-60%|
|Stroke 9||% patients with non-haemorrhagic stroke or history of TIA on antithrombotic therapy||4||OTC aspirin: 66Z2 (8B3T)||Medication stopped, interaction: 8BI6 (8BI6)
Aspirin contraindicated: 8I24 (8I24)
Adverse reaction to warfarin: None (TJ421)
Adverse reaction to salicylates: Q545 (TJ53)
History of aspirin allergy: 14LK (ZV148)
|Stroke 10||% patients given flu vaccination||2||In preceding 1 September to 31 March||Flu vaccination given: 65E (65E)||Flu vaccination contraindicated: 8I2F (8I2F)
Flu vaccine declined 9OX5 (9OX5)
Confirmation of diagnosis (Stroke 2)
In the UK, more than 80% of first strokes are caused by a cerebral infarction, a further 10% arise from a primary intracerebral haemorrhage, and approximately 5% are caused by a subarachnoid haemorrhage.3
It is now standard clinical practice to perform a CT or MRI scan before making the diagnosis of an acute cerebrovascular event.4 Treatment recommended for a cerebral infarction is very different from that for a cerebral haemorrhage, and there is evidence that establishing the cause of the stroke and instigating appropriate management can improve clinical outcomes.5,6
Confirmation of diagnosis by imaging will determine the most appropriate long term preventive treatment for stroke patients.
Secondary prevention of an ischaemic stroke would include the use of antiplatelet or anticoagulant agents, but these should be avoided in patients with a haemorrhagic stroke. Therefore, when diagnosing stroke it is essential to record the cause as ischaemic or haemorrhagic.
TIAs are almost all caused by ischaemic events and it is therefore not considered essential to perform a CT or MRI scan to establish this diagnosis.
Practices will need to demonstrate that from 1 April 2003 all patients with a suspected stroke have been referred for CT or MRI scan.
One possible approach would be that when a patient presents with a suspected stroke it is recorded under a symptom code, for example weakness or loss of speech. The patient is then referred for a CT or MRI scan, and when the result is known and the diagnosis confirmed the scan result and the definitive diagnostic code are added to the patient’s records.
Smoking status (Stroke 3)
There are few trials that demonstrate that stopping smoking reduces the risk of further stroke or TIA. However, data in a primary prevention trial have demonstrated a benefit in smoking cessation.7 It would make sense to record smoking status immediately after the diagnosis of a TIA or stroke. The smoking status of current and ex-smokers must be reviewed and recorded annually. The indicator assumes that patients whose records show they have never smoked will continue as non-smokers for the rest of their lives. However, it would seem sensible to review the smoking status of these patients every 5 years.
Smoking cessation (Stroke 4)
Studies have demonstrated the benefit of nicotine replacement therapy and buproprion in helping patients who wish to stop smoking.2
All patients who are current smokers should be advised to stop smoking and referred to a smoking cessation service, if there is one locally. Smoking cessation clinics are not available in all parts of the country, but if patients are referred to this service the Read code suggested in Table 1 could be used to demonstrate that the practice has given the appropriate advice.
Blood pressure (Stroke 5 and 6)
All patients who have suffered a stroke or TIA must have their blood pressure checked regularly, and hypertension persisting for more than one month should be treated.8 This is an important factor in preventing a further stroke or TIA.
The GP contract sets the blood pressure target for patients with stroke or TIA at 150/90 mmHg or below. A major study in 1990 showed that a reduction of 5-6 mmHg in usual diastolic blood pressure was associated with a reduction of 35-40% in strokes over a 5-year period.9
Cholesterol lowering (Stroke 7 and 8)
There is evidence that a reduction in total cholesterol by as little as 1.2 mmol/l is associated with a reduced risk of stroke and other major vascular events by between a quarter and a third, without an increased risk of haemorrhagic stroke.8,10
Stroke indicator 8 relates to the fact that most TIAs and strokes are ischaemic in origin. The clinician must weigh up the risks versus the benefits of cholesterol-lowering therapy in a patient who has had a haemorrhagic stroke.
The National Clinical Guidelines for Stroke recommend that for patients who have had a stroke, a statin should be considered if there is a history of ischaemic heart disease and cholesterol level is greater than 5 mmol/l.8
The documentation that supports the new GMS contract does not describe any exemption reporting. However, if cholesterol measurement is not clinically indicated or the target cholesterol of 5 mmol/l is undesirable or unachievable, it would be good clinical practice to record this, but at present there are no Read Codes for doing so.
Antiplatelet therapy (Stroke 9)
Long-term antiplatelet therapy reduces the risk of serious vascular events following a stroke by about 25%.4 Antiplatelet therapy – normally aspirin – should be prescribed for secondary prevention of stroke and other vascular events in patients who have suffered an ischaemic stroke 4 or TIA.
No significant difference has been found between the protective effects using high-dose aspirin (>500 mg per day) and those of low to medium dose (75-325 mg per day).The higher doses are associated with increased adverse events.5
If a patient has an ischaemic stroke while taking aspirin 75 mg, the dose is usually increased to 150 mg, or treatment with warfarin is considered. In some stroke units a combination of low dose aspirin and dipyridamole is recommended.5
For those who are intolerant of aspirin, an alternative antiplatelet agent is recommended, either clopidogrel or dipyridamole.
Warfarin should be considered for use in patients with non-valval atrial fibrillation, those who have had a cardioembolic stroke caused by vascular heart disease and also for those who have suffered a stroke within 3 months of a myocardial infarction where thromboembolism is the cause.4
If the patient is taking aspirin but purchasing it over the counter, this information should be recorded annually.
Flu vaccination (Stroke 10)
The current recommendation from the Department of Health and the Joint Committee on Vaccination and Immunisation does not list patients with stroke or TIA among the clinical groups most at risk.11
One area that needs to be resolved is whether there is any good evidence that vaccination of patients under the age of 65 who have had a stroke or TIA in the past is worthwhile.
The quality indicators for stroke and TIA are evidence based and reflect best practice. Irrespective of any financial incentive these are indicators of clinical care that all GPs should aspire to.
Copies of Investing in General Practice: The New General Medical Services Contract can be downloaded from the BMA website: www.bma.org.uk
- Bonita R. Epidemiology of stroke. Lancet 1992; 339: 342-4.
- New GMS Contract - Supporting documentation. BMA/NHS Confederation 2003.www.bma.org.uk
- Bamford J, Sandercock P, Dennis M et al. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project, 1981-1986. 1. Methodology, demography and incident cases of first-ever stroke. J Neurol Neurosurg Psychiatry 1988; 51: 1373-80.
- Scottish Intercollegiate Guidelines Network. SIGN 13. Management of patients with stroke part 1: Assessment, investigation, immediate management and secondary prevention. Edinburgh: SIGN 1997. www.sign.ac.uk
- Collaborative overview of randomised trials of antiplatelet therapy I: Prevention of death, myocardial infarctin, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists’ Collaboration. Br Med J 1994; 308: 81-106.
- Weir CJ, Murray GD,Adams FG, Muir KW, Gosset DG, Lees KR. Poor accuracy of stroke scoring systems for differential clinical diagnosis of intracranial haemorrhage and infarction. Lancet 1994; 344: 999-1002.
- Dunbabin DW, Sandercock PA. Preventing stroke by the modification of risk factors. Stroke 1990; 21(12 Suppl): IV 36-9.
- The Intercollegiate Working Party for Stroke. National Clinical Guidelines for Stroke. Royal College of Physicians. London: RCP, 2002. www.rcplondon.ac.uk
- Collins R, Peto R, MacMahon S et al. Blood pressure, stroke, and coronary heart disease. Part 2, Short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context.Lancet 1990;335:827-38.
- Oliver MF. Cholesterol and strokes: Cholesterol lowering is indicated for strokes due to carotid atheroma. Br Med J 2000; 320: 459-60.
- www.doh.gov.uk/greenbook/-Chapter 20, p. 114.