Dr Alan Begg comments on the revised hypertension indicators in QOF2, and how they are affected by the partial update of the NICE hypertension guideline

In QOF2, the number of disease indicators for hypertension has been reduced from five (in QOF1) to three (Table 1). The two smoking indicators have been moved to their own disease category in keeping with the approach taken for coronary heart disease, stroke and TIA, diabetes, COPD and asthma.

There is a reduction of three points for keeping the hypertension register up to date, and an additional point is added for reaching blood pressure targets.

The only other change is an increase in the minimum payment stage for measuring and reaching blood pressure targets to 40%, with the upper payment stage remaining the same. However, there are a substantial number of points available across other clinical domains for the identification and management of raised blood pressure (Table 2).

Table 1: Clinical indicators for hypertension
Disease indicator Clinical indicator Points Payment stages
      Min (%) Max (%)
BP 1
The practice can produce a register of patients with established hypertension
6    
BP 4
% patients with hypertension in whom there is a record of the blood pressure in the previous 9 months
20 40 90
BP 5
% patients with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 mmHg or less
57 40 70

 

Table 2: QOF2 points available for managing and recording blood pressure
Clinical/organizational indicator
Points available
Chronic kidney disease
17
Coronary heart disease
26
Diabetes
21
Hypertension
83
Stroke and TIA
7
Records and information
15

Updating the register – BP1

In England, for the 2005/2006 year, 98.1% of points available were achieved in the hypertension category.1 Of all the disease areas, hypertension is the one that has shown the greatest area-wide or practice-to-practice variation in prevalence.1,2 Disease prevalance in England was 12% in 2005/2006 and 11.3% in 2004/2005.1

On 14 February 2006, Scotland's national prevalence of hypertension was 12.4, with the rate from individual health boards varying from 11.1 to 15.5.3 One area, however, recorded a prevalence of 25.2, although it was stated that this level was felt to be relatively 'unstable' because of the small number of patients involved.3

One of the reasons for this variation may be a lack of clarity about when to make the diagnosis of hypertension, and then when to subsequently add people to the register.

Current guidance suggests that all patients with a sustained blood pressure greater than 140/90 mmHg should be registered as hypertensive.4

Those with a persistent blood pressure greater than 160/100 mmHg require drug treatment to lower their blood pressure.

In those with a blood pressure between 140/90 mmHg and 160/100 mmHg, the decision to treat with drugs would depend on the patient having a cardiovascular disease (CVD) risk >20%, or the presence of pre-existing CVD and other target organ damage, which includes diabetes and chronic kidney disease (CKD).4

Annual review – BP4

Most general practices will, by now, have a process for systematic review and monitoring of hypertensive patients in place, rather than relying on opportunistic checks. The NICE hypertension guideline gives clear advice on the technique that should be followed when taking blood pressure (Box 1).4

NICE also suggests monitoring blood pressure in well-controlled hypertensive patients annually. This annual review should include:

  • providing full patient support
  • discussion of lifestyle
  • identification of symptoms
  • medication review.

The guidance also suggests that consideration should be given to a trial reduction or withdrawal of antihypertensive drug therapy if the CVD risk is low, the blood pressure is well controlled, and the patient will continue to comply with appropriate lifestyle guidance and ongoing clinic review.

Box 1: Estimation of blood pressure by auscultation (from NICE hypertension guideline)4
  • Standardize the environment as much as possible:
    – relaxed temperate setting, with the patient seated
    – arm out-stretched, in line with mid-sternum, and supported
  • Correctly wrap a cuff, containing an appropriately sized bladder, around the upper arm and connect to a manometer. Cuffs should be marked to indicate the range of permissable arm circumferences; these marks should be easily seen when the cuff is being applied to the arm
  • Palpate the brachial pulse in the antecubital fossa of that arm
  • Rapidly inflate the cuff to 20 mmHg above the point where the brachial pulse disappears
  • Deflate the cuff and note the pressure at which the pulse re-appeas – the approximate systolic pressure
  • Re-inflate the cuff to 20 mmHg above the point at which the brachial pulse disappears
  • Using one hand, place the stethoscope over the brachial artery ensuring complete skin contact with no clothing in between
  • Slowly deflate the cuff at 2–3 mmHg per second, listening for Korotkoff sounds:
 
Phase I
The first appearance of faint repetitive clear tapping sounds gradually increasing in intensity and lasting for at least two consecutive beats; note the systolic pressure
 
Phase II
A brief period may follow when the sounds soften or 'swish'
 
Auscultatory gap
In some patients, the sounds may disappear altogether
 
Phase III
The return of sharper sounds becoming crisper for a short time
 
Phase IV
The distinct, abrupt muffling of sounds, becoming soft and blowing in quality
 
Phase V
The point at which all sounds disappear completely; note the diastolic pressure
  • When the sounds have disappeared, quickly deflate the cuff completely if repeating the measurement
  • When possible, take readings at the beginning and end of consultations

Reproduced by kind permission of the National Institute for Health and Care Excellence

Reaching blood pressure targets – BP 5

Lifestyle

Lifestyle interventions to lower blood pressure remain important. The key elements are:

  • a healthy low-calorie diet
  • aerobic exercise for 30–60 minutes, 3–5 times each week
  • consideration of relaxation therapies – stress management, meditation, cognitive therapies, muscle relaxation and biofeedback
  • reducing alcohol intake to <21 units per week in men, and <14 units per week in women
  • discouraging excess consumption of coffee and caffeine-rich products
  • reduction of dietary salt or use of salt substitute.

Drug therapy

Recently, there has been a major change in what is considered to be the most appropriate choice of initial drug therapy, and the sequence of drugs prescribed using the ACD algorithm (Figure 1).

The previous ABCD algorithm suggested renin–angiotensin system blockade either with a beta-blocker or angiotensin-converting enzyme (ACE) inhibitor/angiotensin-II receptor antagonist as the initial treatment for lowering blood pressure in non-black patients under the age of 55 years.The beta-blocker has now been removed from Step 1 but remains a possible add-in therapy for Step 4.

These changes have led to less emphasis on the use of beta-blockers. At present, the indication from head to head trials is that beta-blockers are usually less effective than comparative drugs in reducing major cardiovascular events, especially stroke.4

The increased risk of developing diabetes when using a combination of a beta-blocker and a thiazide-type diuretic would also justify the reduced emphasis on the former in blood pressure reduction.

Difficulties may arise in drug choice as a result of QOF2, which includes the recommendation to treat hypertensive patients with CKD with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-II receptor antagonist.

The QOF guidance, however, does not make it clear that renal protection is likely to be limited in those with CKD to those with proteinuria, and that creatinine might rise with the use of an ACE inhibitor.5

Treatment algorithm for patients with newly diagnosed hypertension

Reproduced by kind permission of the National Institute for Health and Care Excellence

Use of beta-blockers

Although beta-blockers are no longer seen as the preferred initial therapy for hypertension, they should still be considered in younger people who have an intolerance to, or a contraindication to, an ACE inhibitor or an angiotensin-II receptor antagonist.

They may also continue to be used in women of childbearing potential or in those with evidence of increased sympathetic drive.

If a beta-blocker is used, then a calcium channel blocker should be the add-on drug of choice, rather than a thiazide-type diuretic, to reduce the risk of developing diabetes.

The following points should be considered for patients taking beta-blockers:

  • revise treatment if blood pressure is not controlled on a regimen that includes a beta-blocker
  • there is no absolute need to replace the beta-blocker if the blood pressure is well controlled on a regimen that includes one
  • step down beta-blocker dose gradually if withdrawing the drug
  • do not withdraw if there is a compelling indication, such as symptomatic angina, heart failure, or where patient has had a myocardial infarction.

Reduction of cardiovascular risk

All hypertensive patients who continue to smoke should be encouraged to stop.4 If their CVD risk has been deemed high enough to justify blood pressure lowering drug therapy then they will also benefit from having their total cholesterol lowered with the use of a statin.6,7

Similarly, low-dose aspirin should be considered once the blood pressure is less than 150/90 mmHg.6,7

Further case identification

Practices should not only be actively managing their patients identified as having high blood pressure, but they should also be identifying other patients whose blood pressure is at a level where intervention would be beneficial.

As a first step towards following QOF2 guidance, this would involve checking the blood pressure of all patients aged 45 years and over, at least every 5 years.8

It is in the patients' interest that action is taken if their blood pressure is raised in order to reduce the risk of a cardiovascular event.

Guidelines in Practice, October 2006, Volume 9( 10 )
© 2006 MGP Ltd
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  1. National Quality and Outcomes Framework Statistics for England 2005/6 www.ic.nhs.uk/servicesnew/qof06/
  2. NHS Health and Social Care Information Centre. National Quality and Outcomes Framework Statistics for England 2004/5. Bulletin: 2005/04/HSCIC. London: Health and Social Care Information Centre, 2005.
  3. Quality & Outcomes Framework. 2005/06 Data at Scotland and NHS Board level www.isdscotland.org
  4. National Institute for Health and Care Excellence. Hypertension: management of hypertension in adults in primary care (partial update). NICE Clinical Guideline 34. London: NICE, 2006.
  5. Casas J, Chua W, Loukogeorgakis S et al. Effect of inhibitors of the renin–angiotensin system and other antihypertensive drugs on renal outcomes: systematic review and meta-analysis. Lancet 2005; 366 (9502): 2026–2033.
  6. Williams B, Poulter N, Brown M et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18 (3): 139–185.
  7. JBS 2: Joint British Societies' Guidelines on Prevention of Cardiovascular Disease in Clinical Practice. Heart 2005; 91 (suppl v): v1–v52.
  8. British Medical Association. Revisions to the GMS Contract, 2006/07. Delivering Investment in General Practice. London: BMA, 2006.