Dr Alan Begg discusses the implementation of clinical indicators for registration and review set out under the QOF and how control of high blood pressure can be achieved

The management of blood pressure remains one of the most important aspects of the GMS contract’s quality and outcomes framework (QOF). Its importance is illustrated by the allocation of 28% of the 550 clinical points available in the QOF to the management of blood pressure1 (Table 1 ).

The hypertension clinical domain offers 83 points, with a further 71 points available for managing blood pressure in patients with coronary heart disease (CHD), stroke/transient ischaemic attack (TIA), diabetes, and chronic kidney disease (CKD). In addition to the clinical points, a further 15 points are allocated under the records and information category for the measurement and recording of blood pressure in patients over the age of 45 years.

This practice requirement to record blood pressure every 5 years can be seen as the initial step in an incentivised national screening programme for hypertension. Raised blood pressure goes undetected in many cases. Identifying and managing those patients who have an increased cardiovascular (CV) risk is the major challenge facing primary care in the next few years.  

Table 1: QOF points relating to blood pressure

Clinical domain
Of the total 550 clinical points available in the QOF, 28% relate to management of blood pressure
Hypertension — 83 points available
No. Indicator
Points
Payment stages
BP 1 The practice can produce a register of patients with established hypertension
6
 
BP 4 The % of patients with hypertension in whom there is a record of blood pressure in the previous 9 months
20
40–90%
BP 5 The % of patients with hypertension in whom the last blood pressure measurement (measured in previous 9 months) is ?150/90 mmHg
57
40–70%
Coronary heart disease — 26 points available
No. Indicator
Points
Payment stages
CHD 5 The % of patients with CHD whose notes have a record of blood pressure in the previous 15 months
7
40–90%
CHD 6 The % of patients with CHD in whom the last blood pressure reading (measured in previous 15 months) is ?150/90 mmHg
19
40–70%
Chronic kidney disease — 17 points available
No. Indicator
Points
Payment stages
CKD 2 The % of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months
6
40–90%
CKD 3 The % of patients on the CKD register in whom the last blood pressure reading (measured in previous 15 months) is ?140/85 mmHg
11
40–60%
Diabetes mellitus — 21 points available
No. Indicator
Points
Payment stages
DM 11 The % of patients with diabetes who have a record of blood pressure in previous 15 months
3
40–90%
DM 12 The % of patients with diabetes in whom the last blood pressure reading is ?145/85 mmHg
18
40–60%
Stroke and TIA — 7 points available
No. Indicator
Points
Payment stages
STROKE 5 The % of patients with stroke or TIA who have a record of blood pressure in the notes in the previous 15 months
2
40–90%
STROKE 6 The % of patients with a history of stroke or TIA in whom the last blood pressure reading (measured in previous 15 months) is ?150/90 mmHg
5
40–70%
Organisational domain In the sub-domain of Records and information, 15 additional points are available for blood-pressure measurements
Records and information — 15 points available
No. Indicator
Points
Payment stages
RECORDS 11 The blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 65% of patients
10
 
RECORDS 17 The blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 80% of patients
5
 

Hypertension indicators

Keeping a register of patients—BP 1

The reported national prevalence of hypertension in Scotland has increased from 11.7% in 2005 to 12.1% in 2006 and 12.6% in 2007.2 The rise in these figures reflects the lack of clarity in deciding who should or should not be included on the hypertension register. This is not a straightforward matter and has led to wide variations between practices. A sustained blood pressure ?140/90 mmHg is defined as hypertension,3 but the decision on therapeutic management depends on the overall CV risk and the presence of co-morbidities. However, blood pressure-lowering agents are used in this group of patients to reduce CV risk, even though they may be normotensive.1

The range of hypertension diagnosis terms and Read codes that can be used are extensive, and these are listed in Table 2.

Recording blood pressure—BP 4

The level of blood pressure recorded can vary significantly depending on where it is taken, by whom, and on the equipment used. It is important that all staff involved in measuring blood pressure have received appropriate training and that their competencies are regularly monitored. They also need to be fully aware of the practice protocol that they should be following. Equipment should be standardised within a practice and regularly calibrated, and the routine use of automated ambulatory or home monitoring devices should be avoided in primary care. Evidence on the usefulness and benefit of these devices is inconsistent in this setting and their value has not been adequately established.3 Only clinic blood pressures should be documented for QOF purposes.3,4

Achieving blood pressure targets—BP 5

It is important to emphasise that the levels of blood pressure that will gain QOF points for the practice must be regarded as an audit standard, representing only a minimum standard of care. These levels are:1
  • hypertension—?150/90 mmHg
  • CHD—?150/90 mmHg
  • stroke and TIA—?150/90 mmHg
  • diabetes—?145/85 mmHg
  • CKD—?140/85 mmHg.

The lower the blood pressure, the lower the CV risk, and that risk reduction, especially for diastolic blood pressure, remains linear as blood pressure is lowered.5 On this basis, the JBS guidance on optimum blood pressure levels,6 which is reiterated in SIGN Guideline 97,7 should be followed. These optimum levels are:

  • cardiovascular disease (CVD) risk ?20% (the level at which blood pressure-lowering therapy would start)—<140/85 mmHg
  • established CVD—<140/85 mmHg
  • those with established CVD and diabetes, CKD or target organ damage—<130/80 mmHg.

Table 2: Hypertension diagnosis terms and Read codes

Essential hypertension G20.00
Malignant essential hypertension

 

G200.00

 

Benign essential hypertension

 

G201.00

 

Systolic hypertension

 

G202.00

 

Essential hypertension

 

G20z.00

 

Hypertensive disease NOS

 

G2z.00

 

Other specified hypertensive disease

 

G2y.00

 

Hypertensive disease

 

G2..00

 

Blood pressure—hypertensive disease

 

G2…11

 

Secondary hypertension

 

G24..00

 

Secondary malignant hypertension

 

G240.00

 

Secondary malignant renovascular hypertension

 

G240000

 

Secondary malignant hypertension NOS

 

G240z.00

 

Secondary benign hypertension

 

G241.00

 

Secondary benign renovascular hypertension

 

G241000

 

Secondary benign hypertension NOS G241z.00
Hypertension secondary to endocrine disorders G244.00
Secondary hypertension NOS G24z.00
Secondary renovascular hypertension NOS G24z000
Hypertension secondary to drug G24z100
Secondary hypertension NOS G24zz00
NOS=non organ-specific

Blood pressure management

One of the most difficult aspects of managing high blood pressure is achieving effective, tight blood pressure control. Full engagement with the patient on all aspects of their care is essential if targets are to be met. Lifestyle measures to reduce blood pressure are important and must not be overlooked.3 The patient should be advised to:
  • eat a healthy, low calorie diet, and control their weight
  • avoid excess coffee intake and consumption of caffeine-rich products
  • take less dietary salt or use a salt substitute
  • undertake aerobic exercise—30 to 60 minutes exercise three to five times each week
  • reduce alcohol intake—<21 units per week for men and <14 units per week for women
  • consider relaxation therapies—stress management, meditation, cognitive therapies, muscle relaxation, and biofeedback.

The majority of patients are likely to require two or more blood pressure-lowering agents to reach their target blood pressure level, and for newly diagnosed patients with essential hypertension the ACD algorithm for the sequencing of drugs should be followed (see Figure 1).3 For those patients with specific co-morbidities — for example, diabetes, angina, chronic kidney disease, acute coronary syndrome — there may be compelling indications to prescribe one particular class of drugs.

Figure 1: ACD algorithm for the sequencing of drugs in newly diagnosed hypertensive patients

Figure 1: ACD algorithm for the sequenceing of drugs in newly diagnosed hypertensive patients
National Institute for Health and Care Excellence (NICE) (2006) Choosing drugs for patients newly diagnosed with hypertension in CG34 Hypertension: management of hypertension in adults in primary care (Quick Reference Guide) London: NICE. Available from www.nice.org.uk.
Reproduced with permission.

Regular review

For QOF purposes, blood pressure recording should have been carried out within the previous 9 months. The traditional approach advises that in the case of patients with controlled hypertension, blood pressure should be monitored every 6 months.4 The components of a structured annual review are listed in Table 3. This approach ensures that all aspects of the patient’s care are addressed and that steps are taken to ensure that CV risk reduction is maximised. This includes offering smoking cessation advice, if appropriate, as well as the use of lipid-lowering therapy and prescribed aspirin.

Table 3: Components of structured care

  • Ensure register is up-to-date
  • Enquire about development of any symptoms
  • Update current lifestyle risk factors
  • Carry out dietary assessment
  • Arrange appropriate lifestyle and behavioural change
  • Review blood monitoring results
  • Identify and record any specific side-effects
  • Carry out drug monitoring review and compliance
  • Reinforce the need for ongoing treatment
  • Answer any specific questions on medication or lifestyle
  • Provide patient information and drug literature as indicated
  • Arrange next follow-up appointment

Exception coding

Provision is made within the QOF process to ensure that practices are not penalised when targets are not met, despite their best efforts. It is, however, essential that practices have in place the necessary protocol to be able to justify why a patient has been rendered exempt. Table 4 suggests a possible management scheme for these circumstances (see Table 4).

Variation in the level of exemptions is one area that is likely to be given increased attention at this year’s QOF monitoring visits. In 2005–2006 the overall effective exception rate recorded on the Quality Management and Analysis System (QMAS) for England was 5.55%, with 5.4% of practices having rates in excess of 10%, with the overall exception rate for hypertension being 2.46%.9

Table 4: Coding of maximally tolerated blood pressure

  • Develop a clear, documented practice policy
  • Ensure management approach follows national evidence-based guidelines
  • Involve patient fully in any decision on current and further drug management
  • Aim to use up to four classes of drugs, if necessary, to control blood pressure
  • Record all drug contraindications and side-effects
  • Consider whether to exclude a whole class of drugs if there is an adverse reaction to one particular medication
  • Document if drug appears ineffective with a fall in systolic blood pressure of less than 5 mmHg8
  • Consider referral for further treatment and investigation as appropriate
  • Practices should be able to justify why an exception has been made
QOF=quality and outcomes framework

QOF update

It was announced in August 2007 that the current evidence-gathering phase for the development of the revised QOF was now complete.10 The review is led by Professor Helen Lester at the University of Manchester, and the expert review panel of over 40 senior academic GPs now has to decide what changes to recommend to the QOF for 2008–2009.

It has recently been suggested that attention should be focused on patients with low intensity treatment and blood pressures well above guideline ideal targets. The implication is that there is therapeutic inertia, with a reluctance to intensify treatment, yet it is still possible to obtain maximum points.11

The most obvious and pressing change needed to the QOF hypertension category is the removal of the management of blood pressure in patients with CHD, stroke/TIA, diabetes, or CKD. This would have the benefit of:

  • clearly defining who should be included in the hypertension clinical domain
  • avoiding current ‘double counting’
  • allowing for specific evidence-based targets based on risk in each category
  • encouraging an evidence-based risk assessment of all patients whose blood pressure is ?140/90 mmHg
  • acting as a basis for the development of further indicators within the clinical domain on risk reduction, including the use of lipid-lowering and antiplatelet therapy
  • providing a platform for a national screening programme for the primary prevention of CVD.

Conclusion

The credibility of the QOF process will only be enhanced within the profession if any updates are evidence-based, logical, and clearly in the interest of a large number of patients. Changes to the QOF should not be driven by the political process or by a vocal minority with their own special interests.
 

 

  • Treating hypertension represents an ‘invest to save’ strategy for PBC—costs of antihypertensive drugs are immediate, while reduction in costs by lessening of cases of coronary heart disease, stroke, and heart failure, although real, are delayed
  • Most anti-hypertensive drugs are now available in an inexpensive generic form (angiotensin-II receptor antagonists being the current exception)
  • Hypertension should be defined using clinic BP—there is little evidence for use of ambulatory or home BP monitoring
  • Cardiovascular risk reduces linearly as BP is lowered—even below current quality and outcome framework targets
  • Most patients need two or more antihypertensive medications to reach target levels
  1. British Medical Association. Revisions to the GMS contract 2006/2007: Delivering Investment in General Practice. London: BMA, 2006.
  2. Information Services Division (ISD). National prevalence of hypertension in Scotland. http://www.isdscotland.org/isd/4897.html#Hypertension
  3. National Institute for Health and Care Excellence. Hypertension: management of hypertension in adults in primary care (partial update). Clinical guideline 34. London: NICE, 2006.
  4. Williams B, Poulter N, Brown M et al. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. Br Med J 2004; 328 (7440): 634–640.
  5. 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.
  6. JBS2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91 (suppl 5): v1–52.
  7. Scottish Intercollegiate Guidelines Network (SIGN 97). Risk estimation and the prevention of cardiovascular disease. A national clinical guideline. Edinburgh: SIGN, 2007.
  8. Brown M, Cruickshank J, Dominiczak A et al; Executive Committee, British Hypertension Society. Better blood pressure control: how to combine drugs. J Hum Hypertens 2003; 17 (2): 81–86.
  9. National QOF Exception Reporting Statistics for England 2005/06. www.ic.nhs.uk/pubs/qofexrep
  10. NHS Employers and GPC conclude evidence-gathering process on QOF. www.nhsemployers.org/primary/primary-2816.cfm
  11. Guthrie B, Inkster M, Fahey T. Tackling therapeutic inertia: role of treatment data in quality indicators. Br Med J 2007; 335 (7619): 542–544.G