Dr Alan Begg discusses the proposed changes to the QOF 2013/14 indicators for hypertension and their potential implications
  • At least one-quarter of adults have high blood pressure
  • The risk of cardiovascular events associated with blood pressure doubles for every 20/10 mmHg rise above a level of 115/70 mmHg
  • For the GMS contract 2013/14, the NICE QOF Advisory Committee is now recommending a two-stage target of:
    • ≤140/90 mmHg for people aged <80 years of age—NM53
    • ≤150/90 mmHg for people aged ≥80 years (i.e. as in the current indicator BP5)—NM54
  • Although the majority of the NICE QOF recommendations for the GMS contract will be implemented in Scotland, some will be omitted and this includes NM53 and NM54
  • A reduction in blood-pressure targets may lead to higher exception rates
  • Possible cases of resistant hypertension should have other potential causes of the condition excluded.

At least 25% of adults have high blood pressure, and this rises to over 50% in the over-60-years age group. In the general population, blood pressure follows a normal distribution, and there is no natural cut-off point at which the risk of raised blood pressure begins. The risk associated with blood pressure is a continuous relationship, and the risk of cardiovascular events doubles for every 20/10 mmHg rise above a level of 115/70 mmHg.1

Currently, the quality and outcomes framework (QOF) guidance on blood pressure has adopted a target audit standard of 150/90 mmHg (BP5). However, this can be confusing as different targets for blood pressure are recommended for patients with co-morbidities, such as diabetes and chronic kidney disease.2

Table 1: QOF targets for blood pressure2
QOF 2012/13 NICE recommendations for QOF 2013/14
Indicator Target blood pressure (mmHg) England Scotland
CHD 6 ≤150/90
STROKE 6 ≤150/90
BP5 ≤150/90 NM53: ≤140/90 mmHg if aged <80 years
NM54: ≤150/90 mmHg if aged <80 years
No change to 2012/13 indicator
DM 30 ≤150/90
DM 31 ≤140/80
CKD 3 ≤140/85
  • QOF=quality and outcomes framework; CHD=coronary heart disease; BP=blood pressure

Targets for diabetes

In the United Kingdom Prospective Diabetes Study of patients with diabetes, a 10 mmHg reduction in systolic blood pressure was shown to be associated with a 15% reduction in the risk of cardiovascular disease and death over 10 years.3 However, the evidence for a target systolic blood pressure of <130 mmHg in patients with and without diabetes is less convincing.4,5 The Hypertension Optimal Treatment (HOT) study revealed that the lowest incidence of major cardiovascular events in all patients with diabetes occurred at a mean achieved diastolic blood pressure of 82.6 mmHg; further reduction below this level was not harmful in patients with diabetes.6 There was a 51% reduction in major cardiovascular events in the group treated to ≤80 mmHg compared with the target group of ≤90 mmHg (p=0.005).4,6

The evidence for control of blood pressure in diabetes is significant because it is so positive for setting a target for diastolic blood pressure, as demonstrated in the HOT study.

Review of QOF indicators

The British Hypertension Society has proposed to NICE that the single target of 150/90 mmHg in the QOF is too high in view of the epidemiological data supporting the relationship between cardiovascular events and systolic blood pressure. It is believed that this target does not reflect the benefit observed in cardiovascular outcome trials investigating the lowering of raised blood pressure.7

A review of the evidence has shown that more intensive blood-pressure-lowering regimens in patients with raised blood pressure result in a lower risk of death and coronary heart disease, and a significantly lower risk of stroke: a greater reduction in blood pressure tended to have a greater reduction in risk of death, coronary heart disease, and stroke.8

NICE has cited evidence that the generous financial incentives (as designed in the UK pay-for-performance policy—the QOF) may not be sufficient to improve quality of care and outcomes for hypertension and other chronic conditions.8,9 A possible reason for this is that the pay-for-performance targets for hypertension are set too low.

Proposed changes to the QOF indicators for hypertension

A two-stage blood pressure target has recently been piloted and the NICE QOF Advisory Committee is now recommending a target of:7

  • ≤140/90 mmHg or less for people aged under 80 years of age—NM53
  • ≤150/90 mmHg for people aged ≥80 years (i.e. as in the current indicator BP5)—NM54.

It is proposed that indicators NM53 and NM54 will replace the current QOF indicator BP5 and, when introduced, will align the QOF with the updated NICE Clinical Guideline (CG) 127 on hypertension.1 The guideline currently recommends a target clinic blood pressure ≤140/90 mmHg in patients aged <80 years with treated hypertension and a clinic blood pressure ≤150/90 mmHg in patients aged ≥80 years who are being treated for hypertension.1

The NICE QOF Advisory Committee has also recommended the retirement of indicator BP4, which covers the requirement to record blood pressure in a patient with hypertension in the preceding 9 months.7

The NICE-recommended changes to QOF are currently under consultation in England and have yet to be agreed with the Department of Health. In Scotland, agreement has been made with the Scottish General Practitioners Committee and the Scottish Government on the 2013/14 changes to the GMS contract.10 Although the majority of the NICE QOF recommendations will be implemented in Scotland, some will be omitted in an attempt to ameliorate the workload implications for general practices. The replacement of BP5 with NM53 and 54 will not be implemented in Scotland for QOF 2013/14.10

In England, it has been proposed that Records indicator 11 and 17 should be replaced with a single indicator—NM61—on the percentage of patients aged 40 years and over with a blood pressure measurement recorded in the preceding 5 years.11 The proposed UK threshold is 50%–90%, but in Scotland it will be introduced over 2 years with stages of 40%–80% in 2013/14 and 50%–90% in 2014/15.10

Raised blood pressure is a major risk factor for cardiovascular disease and the rate of heart disease in Scotland remains the highest in Western Europe, particularly in men.12 The prevalence of high blood pressure in Scotland in 2008/09 was higher in both sexes than in England in 2012 in all age groups above 55 years so it is of interest that the Scottish Government has agreed not to implement the lower blood-pressure target when the potential benefit could be greater.13

Cost implications of lower QOF blood-pressure targets

The current QOF achievement data for 2010/11 showed that the level of achievement attained in GP practices in England for BP5 was 79.3%.14 Data from the Health Survey for England 2011 revealed that 31.5% of men and 29% of women have a blood pressure above 140/90 mmHg.15

The figures used to calculate the cost of lowering the blood-pressure target in people under the age of 80 years indicate that around 12.5% of the population aged between 18 and 80 years have untreated hypertension and that the impact of the proposed indicator, NM53, would reduce untreated hypertension to 10% of the population.16 The annual cost of this change would be approximately £20 million, taking into account the increased cost of drugs and GP appointments.16 Blood pressure is accepted to be highly cost effective when compared against the treatment of cardiovascular events. The cost impact of NM53 is neutral if 8776 cardiac arrests are avoided (based on each event costing £2247). The figure of 8776 cardiac arrests is 2.7% of the additional people treated.16

The additional costs only relate to individuals aged under 80 years, as covered by NM53, where the target has been lowered (no additional costs would be incurred in those aged over 80 years as covered by NM54, where the target remains unchanged). A net-benefit analysis carried out for NICE suggests that treating blood pressure in the over-80-years age group to the current target is highly cost effective.17

Exception coding

Any reductions in blood-pressure targets could potentially lead to higher exception rates. The exception rate for hypertension in England has remained at 2.5% from 2010/11 to 2011/12. For individual indicators the exception rate for BP4 and BP5 is 1.2% and 3.9%, respectively; BP4 had the fifth lowest exception rate out of all the clinical indicators in the QOF.18 In Scotland the equivalent exemption rates in 2011/12 for BP4 and BP5 are 3.0% and 5.6%, respectively. Eight practices in Scotland had an exception rate higher than 20% for BP5,19 implying that a higher number of patients are being exempted rather than reaching the current target for blood pressure.

Although lowering of targets may increase exception reporting, it may also highlight the problem of resistant hypertension and improve its management.

Resistant and pseudoresistant hypertension

Traditionally, resistant hypertension has been defined as a seated clinic blood pressure >140/90 mmHg despite treatment with at least three blood-pressure lowering agents, where one is usually a diuretic.20 NICE CG127 suggests that the three agents should be in accordance with the recommended ACD treatment algorithm.1 NICE also recommends that (resistant) hypertension should be confirmed by recording a blood pressure level >135/85 mmHg.1 Up to 20% of the hypertensive population may be affected by resistant hypertension,20 but those with a ‘white-coat’ effect should, ideally, be excluded by the use of home or ambulatory measurements.

Pseudoresistant hypertension is inadequate control without resistant hypertension. Possible causes include poor office measurement technique, white-coat effect, poor patient adherence with prescribed therapy, and a suboptimal blood-pressure lowering regimen.20

It is important to exclude pseudoresistant hypertension and other causes of the condition as 5%–10% of people with resistant hypertension may have an underlying reason for their elevated blood pressure.20

Inadequately controlled blood pressure should only be exception coded once resistant and pseudoresistant hypertension and other factors have been excluded. NICE suggests the following practical interventions to improve adherence to therapies that lower blood pressure:1

  • suggest that patients record their medicine taking
  • encourage patients to monitor their blood pressure
  • simplify the dosing regimen
  • use alternative or familiar packaging for the medicine
  • use a multi-compartment medicines system.

Conclusion

All members of the practice team need to be informed of the relevant guidance, the effects of high cardiovascular risk, the benefits of blood-pressure lowering, and the dangers of accepting suboptimal lowering of blood pressure. The introduction of lower blood pressure targets within QOF could lead to reduced cardiovascular outcomes in our patients.

Practice teams need to recognise and guard against any ‘clinical inertia’ that may lead to an increase in exception coding, which may not always be in the patient’s best interest.

  • Tighter targets for blood pressure control in the QOF next year are likely to increase prescribing costs, but have the potential to result in savings in reduced cardiovascular events
  • CCGs should ensure local formularies are in place for antihypertensive drugs as the vast majority of these are now available generically at low acquisition costs
  • CCGs might wish to consider funding practices to acquire devices for ABPM, which are recommended by NICE for use in the diagnosis of hypertension, as the cost is likely to be more than offset by reductions in prescribing budgets
  • NICE is now consulting on the use of ABPM in the diagnosis of hypertension as part of its indicators for QOF in 2014
  • Achievement of tighter blood-pressure targets may increase the risk of more iatrogenic falls, thereby causing fractures in the elderly; CCGs should encourage measurement of standing, as well as sitting blood pressures to detect postural hypotension
  • CCGs should work with colleagues in public health to encourage population measures to reduce the incidence of hypertension (e.g. providing advice on exercise, diet, salt, and alcohol reduction).
  1. National Institute for Health and Care Excellence. Hypertension: the clinical management of primary hypertension in adults. Full guideline. Clinical Guideline 127. London: National Clinical Guideline Centre, 2011. Available at: www.nice.org.uk/CG127  nhs_accreditation
  2. NHS Employers and General Practitioners Committee. Quality and outcomes framework 2012/13. Guidance for PCOs and practices. London: NHS. Available at: www.nhsemployers.org/Aboutus/Publications/Documents/QOF_2012-13.pdf
  3. Adler A, Stratton I, Neil H et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000; 321 (7258): 412–419. Available at: www.bmj.com/content/321/7258/412.pdf%2Bhtml
  4. Scottish Intercollegiate Guidelines Network. Management of diabetes. SIGN 116. Edinburgh: SIGN, 2010. Available at: www.sign.ac.uk/pdf/sign116.pdf  nhs_accreditation
  5. Scottish Intercollegiate Guidelines Network. Risk estimation and the prevention of cardiovascular disease. SIGN 97. Edinburgh: SIGN, 2007. Available at: www.sign.ac.uk/pdf/sign97.pdf
  6. Hansson L, Zanchetti A, Carruthers S et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998; 351 (9118): 1755–1762.
  7. National Institute for Health and Care Excellence. Quality and outcomes framework (QOF) indicator development programme. NICE indicator guidance for QOF (NM53). London: NICE, 2012. Available at: www.nice.org.uk/aboutnice/qof/indicators_detail.jsp?summary=13811
  8. National Institute for Health and Care Excellence. Quality and outcomes framework (QOF) indicator development programme. Review of QOF indicators: hypertension (BP5). London: NICE, 2012. Available at: www.nice.org.uk/aboutnice/qof/download.jsp?download=60081
  9. Serumaga B, Ross-Degnan D, Avery A et al. Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study. BMJ 2011; 342: d108.
  10. British Medical Association. Letter to all GPs in Scotland on GMS contract 2013/14. Scottish General Practitioners Committee. Available at: bma.org.uk/working-for-change/negotiating-for-the-profession/general-practitioners-committee/contract-agreement-scotland
  11. National Institute for Health and Care Excellence. Quality and outcomes framework (QOF) indicator development programme (NM61) NICE indicator guidance for QOF. London:
    NICE, 2012. Available at: www.nice.org.uk/nicemedia/live/13814/60118/60118.pdf
  12. Begg A. Men’s health: a tale of two nations. Trends in Urology & Men’s Health 2012; 3 (6): 19–22.
  13. British Heart Foundation. Coronary heart disease statistics. London: BHF, 2012. Available at: www.bhf.org.uk/publications/view-publication.aspx?ps=1002097
  14. GP contract website. Data for BP5. www.gpcontract.co.uk/child/ENG/BP%205/11 (accessed 4 January 2013).
  15. The Health and Social Care Information Centre. Health survey for England 2011. Trend tables. Leeds: Health and Social Care Information Centre, 2012. Available at: catalogue.ic.nhs.uk/publications/public-health/surveys/heal-survey-eng-2011-tren-tabl/HSE2011-Trend-commentary.pdf
  16. National Institute for Health and Care Excellence. Quality and outcomes framework (QOF) indicator development programme. Cost impact statement: hypertension. London: NICE, 2012. Available at: www.nice.org.uk/aboutnice/qof/download.jsp?download=60084
  17. University of Birmingham and University of York Health Economics Consortium. Health economic report on piloted indicator. www.nice.org.uk/nicemedia/live/13812/60090/60090.pdf
  18. Health and Social Care Information Centre, Prescribing and Primary Care team. Quality and outcomes framework: achievement, prevalence and exceptions data, 2011/12. London: Health and Social Care Information Centre. Available at: www.ic.nhs.uk/catalogue/PUB08135
  19. Information Services Division website. Quality and outcomes framework 2011/12: exception reporting. Available at: www.isdscotland.org/Health-Topics/General-Practice/Quality-And-Outcomes-Framework/2011-12/Exception-reporting-in-clinical-indicators.asp
  20. Myat A, Redwood S, Qureshi A et al. Resistant hypertension. BMJ 2012 ;345: e7473. G