Full guidance on the contract changes to the quality and outcomes framework (QOF) for 2009/10 was jointly published by NHS Employers and the General Practitioners Committee of the British Medical Association.1 All of the current indicators are likely to be reviewed prior to the start of 2011/12 and will take into account the changing priorities for both health and healthcare. The National Institute for Health and Care Excellence is now responsible for the process of delivering and reviewing the clinical and health improvement indicators in the QOF. Its role will include producing an annual ‘menu’ of new evidence-based clinical and cost-effective indicators where there is a strong case for encouraging uptake of good practice. Recommending which indicators should remain part of the QOF will also be part of this process. For example, if an activity being measured has become part of standard clinical practice, it will no longer be necessary to provide a financial incentive for the work to continue.2
This article focuses on the changes to the coronary heart disease (CHD) and heart failure indicators in the 2009/10 contract. The full set of these indicators are listed in Table 1.
Table 1: Quality and outcomes framework clinical indicators 2009/10 for coronary heart disease and heart failure
|Coronary heart disease — 87 points available|
|CHD 1||The practice can produce a register of patients with CHD||4|
|CHD 2||The percentage of patients with newly diagnosed angina (diagnosed after 1 April 2003) who are referred for exercise testing and/or specialist assessment||7||40–90%|
|CHD 5||The percentage of patients with CHD whose notes have a record of blood pressure in the previous 15 months||7||40–90%|
|CHD 6||The percentage of patients with CHD in whom the last blood pressure reading (measured in the previous 15 months) is ?150/90 mmHg||17||40–70%|
|CHD 7||The percentage of patients with CHD whose notes have a record of total cholesterol in the previous 15 months||7||40–90%|
|CHD 8||The percentage of patients with CHD whose last measured total cholesterol (measured in the previous 15 months) is ?5 mmol/l||17||40–70%|
|CHD 9||The percentage of patients with CHD with a record in the previous 15 months that aspirin, an alternative antiplatelet therapy, or an anticoagulant is being taken (unless a contraindication or side-effects are recorded)||7||40–90%|
|CHD 10||The percentage of patients with CHD who are currently treated with a beta blocker (unless a contraindication or side-effects are recorded)||7||40–60%|
|CHD 11||The percentage of patients with a history of myocardial infarction (diagnosed after 1 April 2003) who are currently treated with an ACE inhibitor or ARB||7||40–80%|
|CHD 12||The percentage of patients with CHD who have a record of influenza immunisation in the preceding 1 September to 31 March||7||40–90%|
|Heart failure — 29 points available|
|HF 1||The practice can produce a register of patients with heart failure||4|
|HF 2||The percentage of patients with a diagnosis of heart failure (diagnosed after 1 April 2006), which has been confirmed by an echocardiogram or by specialist assessment||6||40–90%|
|HF 3||The percentage of patients with a current diagnosis of heart failure due to LVD who are currently treated with an ACE inhibitor or ARB, who can tolerate therapy and for whom there is no contraindication||10||40–80%|
|HF 4||The percentage of patients with a current diagnosis of heart failure due to LVD who are currently treated with an ACE inhibitor or ARB, who are additionally treated with a beta blocker licensed for heart failure, or recorded as intolerant to or having a contraindication to beta blockers||9||40–60%|
|CHD=coronary heart disease; ACE=angiotensin-converting enzyme; ARB=angiotensin II receptor blocker; LVD=left ventricular dysfunction|
Changes to the coronary heart disease indicators
There has only been one change to the coronary heart disease indicators: two points have been removed from CHD 6 making this indicator now worth 17 points. These points are gained for the percentage of patients with CHD whose blood pressure in the previous 15 months has reached a minimum audit standard of ?150/90 mmHg.
Changes to the heart failure indicators
The original indicators introduced in 2004 referred only to patients with CHD and left ventricular dysfunction (LVD).3 In 2006, the indicators were changed to include all patients with heart failure as confirmed by echocardiogram or specialist assessment. The evidence for treating heart failure is reflected in indicator HF 3: patients with heart failure due to LVD should receive therapy with an angiotensin-converting enzyme (ACE) inhibitor, or alternatively an angiotensin II receptor blocker (ARB) if tolerated, and in the absence of contraindications. A new indicator in this clinical domain, HF 4, applies to the same group of patients in HF 3 with the additional requirement that they are also treated with a beta blocker licensed for heart failure, or recorded as intolerant to, or having a contraindication to beta blockers.1
Prevalence and diagnosis of heart failure
Heart failure is a constellation of symptoms and signs and not a single disease so seeking the underlying diagnosis and aetiology will ensure that optimum treatment is provided. An echocardiogram provides an assessment of left ventricular systolic and diastolic function as well as elaborating on any possible valve disorders.4 Assessment by a specialist or analysis of an echocardiogram is key to confirming a diagnosis of heart failure and achieving the points for HF 2.
Recent data from the QOF process indicates a relative degree of consistency in prevalence rate (determined from point prevalence information sent to the Quality Management and Analysis System) based on this assessment across all of the devolved UK (see Table 2).5 This consistency reflects a degree of uniformity and standardisation in the diagnosis of heart failure and LVD and contrasts with the variation seen in earlier population and practice-based studies, which have tended to use a variety of differing diagnostic criteria.5 The increasing use of brain natriuretic peptide (BNP) will help this diagnostic process. A low level of BNP and a normal electrocardiogram helps to exclude the possibility of chronic heart failure, encouraging the GP to consider alternative causes for the patient’s symptoms.4
Table 2: Prevalence rate of heart failure and left ventricular dysfunction in
2007/2008 per 100 patients registered to GPs
|Heart failure||Left ventricular dysfunction|
ACE inhibitors and ARBs
The benefits of ACE inhibitors on morbidity and mortality are clear from major clinical trials and their use should be considered in all patients with heart failure due to left ventricular systolic dysfunction (LVSD).4 Monitoring is needed to detect any possible renal impairment or hyperkalaemia, with cough being the most troublesome and common side-effect for the patient. The SIGN guideline recommends ARB therapy as an alternative for those unable to tolerate an ACE inhibitor.4 Although, in terms of the QOF, points are gained for ensuring the patient is on either of these drugs regardless of whether an ACE inhibitor is given first.
Two ARBs are licensed for use in heart failure in the UK: candesartan and losartan. The CHARM trial showed that adding candesartan to standard heart failure treatment—ACE inhibitor, beta blocker, aldosterone antagonist—reduced the risk of cardiovascular death, admission to hospital for heart failure, and all-cause mortality. This treatment benefit was observed soon after the initiation of therapy, and maintained throughout the whole treatment period with a 1-year 33% risk reduction in all-cause mortality (p<0.001).6
The ELITE II study was a comparison of losartan and captopril in patients aged over 60 years with heart failure and a left ventricular ejection fraction ?40%.7 In this trial there was no significant difference between the groups in all-cause mortality or hospital admissions, but losartan was significantly better tolerated. Of the subsets of patients, the only group in which there was a significant difference was in that taking beta blockers at randomisation: in this group the hazard ratio of death was 1.77 in favour of captopril. This effect was also suggested by the Val-HeFT study comparing valsartan to placebo: this trial showed a trend towards an increase in the combined endpoint of mortality and morbidity (p=0.10) in patients in the valsartan group who were receiving both a beta blocker and an ACE inhibitor at base line.8 This pattern may be important if a patient on a beta blocker is unable to tolerate an ACE inhibitor and treatment is changed to an ARB.
Treatment with beta blockers
The evidence for using beta blockers in heart failure is as strong as that for the use of ACE inhibitors.1 Beta-blocker therapy has been shown to reduce:4
- risk of mortality from cardiovascular causes by 29%
- mortality due to pump failure by 36%
- all-cause mortality by 23%.
The beta blockers that are licensed for use in heart failure due to LVSD, which can be used to meet the requirement of HF 4, are bisoprolol, carvedilol, and nebivolol. Information on starting and target doses for these medicines are included in the annex of the SIGN guideline, which is available at www.sign.ac.uk.4 Management with beta blockers should include the following parameters:4
- initiate at low dose
- double dose at not less than 2 weekly intervals
- aim for target dose or highest tolerated dose
- monitor heart rate, blood pressure, and clinical status (particularly of congestion, body weight)
- check blood urea, creatinine, and electrolytes:
- 1–2 weeks after initiation
- 1–2 weeks after final dose titration
- utilise specialist heart failure nurse.
However, the benefits of beta blockers are not seen immediately and therapy can initially result in decompensation, with worsening of heart failure and hypotension.4 They are contraindicated in patents with asthma, second or third degree atrioventricular heart block, symptomatic hypotension or low initial blood pressure with a systolic blood pressure <90 mmHg.4 There is general agreement that cardio-selective beta blockers are safe to use in patients with heart failure and chronic obstructive airways disease including those with a prominent reversal component to their airways disease.9 Some of the problems associated with the use of beta blockers, and their possible solutions, are listed below:4
- increasing congestion—increase dose of diuretic and/or halve dose of beta blocker
- marked fatigue—halve dose of beta blocker
- serious deterioration—halve dose of beta blocker or stop beta blocker if severe deterioration and seek specialist advice
- heart rate <50 beats/minute and worsening symptoms—halve dose of beta blocker; stop beta blocker if severe deterioration.
Managing patients with heart failure
Patients with heart failure may present to their GP who now has a contractual obligation under QOF to ensure an extended appropriate evidence-based approach to care. A multidisciplinary team approach is essential to provide that care, with a heart failure nurse playing a pivotal role. There may, however, be reluctance in primary care to initiate and titrate up the dose of beta blockers needed to meet the new HF 4 indicator. Involvement of the local heart failure service with specialist nurse care may be necessary in some practices to ensure that all patients with heart failure receive the appropriate treatment to improve their outcome.
- Diagnosis and investigation of heart failure will require prompt access to echocardiography to establish the correct diagnosis
- Commissioners should look to ensure that direct access echocardiography with suitable interpretation of the results are available locally
- Pre-screening with ECG and testing BNP levels can reduce the need for echocardiography in ‘suspected cases’
- There is good evidence for the use of ACE inhibitors, ARBs, and beta blockers in patients with heart failure due to LVSD
- Optimal doses of these drugs are often not reached in practice due to potential initial deterioration in symptoms and the need for close monitoring during dose titration
- Specialist heart failure nurses can ensure that patients are treated optimally in line with an agreed local heart failure care pathway
- Commissioners should ensure that this care pathway is agreed between primary and secondary care
- Cardiology outpatient costs: £189 (new), £91 (follow up)a
- British Medical Association, NHS Employers. Quality and outcomes framework guidance for GMS contract 2009/10. Delivering investment in general practice. London: BMA, NHS Employers, 2009. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qof0309.jsp?page=1
- National Institute for Health and Care Excellence website. Quality and outcomes framework (QOF). www.nice.org.uk/aboutnice/qof/qof.jsp (accessed 29 May 2009).
- British Medical Association. Investing in general practice: the new general medical services contract. London: BMA, 2004.
- Scottish Intercollegiate Guidelines Network. Management of chronic heart failure: a national clinical guideline. SIGN 95. Edinburgh: SIGN, 2007. Available at: www.sign.ac.uk/guidelines/fulltext/93-97/index.html
- Begg A. In: Ward, Witham, eds. Heart failure in the elderly. Chichester: John Wiley & Sons, 2009.
- Young J, Dunlap M, Pfeffer M et al; Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) investigators and committees. Mortality and morbidity reduction with candesartan in patients with chronic heart failure and left ventricular systolic dysfunction: results of the CHARM low-left ventricular ejection fraction trials. Circulation 2004; 110 (17): 2618–2626.
- Pitt B, Poole-Wilson P, Segal R et al. Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial—the Losartan Heart Failure Survival Study ELITE II. Lancet 2000; 355 (9215): 1582–1587.
- Cohn J, Tognoni G, Valsartan Heart Failure Trial Investigators. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med 2001; 345 (23): 1667–1775.
- Salpeter S, Ormiston T, Salpeter E. Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2005; (4): CD003566.G