Dr Stewart Findlay explains the changes to the revised stroke and TIA indicators, and comments on the differences between the QOF2 and JBS2 targets

There has been very little change to the indicators for stroke and transient ischaemic attack (TIA) in the 2006–2007 revision to the GMS contract.1 The main differences are that all indicators now have a minimum payment stage of 40% and the two smoking indicators have been removed. In QOF2, smoking now has its own clinical domain.1

In one of the stroke indicators, STROKE 1, the number of points available has decreased: a reduction from four points in QOF1 to two points in QOF2 for producing a register of patients with a diagnosis of stroke or TIA. It seems likely that in time even these two points will be reallocated to a more clinical indicator, as it is now the norm for practices to maintain disease registers in all areas of their work.

The stroke and TIA indicators are listed in Table 1.

Table 1: Clinical indicators for stroke and TIA

Disease indicator Clinical indicator
Points
Payment stages
Min (%)
Max (%)
STROKE 1 The practice can produce a register of patients with stroke or TIA
2
 
 
STROKE 11 The percentage of new patients with a stroke who have been referred for further investigation
2
40
80
STROKE 5 The percentage of patients with stroke or TIA who have a record of blood pressure in the notes in the preceding 15 months
2
40
90
STROKE 6 The percentage of patients with a history of stroke or TIA in whom the last blood pressure reading (measured in the previous 15 months) is ?150/90 mmHg
5
40
70
STROKE 7 The percentage of patients with stroke or TIA who have a record of total cholesterol in the past 15 months
2
40
90
STROKE 8 The percentage of patients with stroke or TIA whose last measured total cholesterol (measured in the previous 15 months) is ?5 mmol/l
5
40
60

STROKE 12
The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that an antiplatelet agent (aspirin, clopidogrel, dipyridamole, or a combination), or an anticoagulant is being
taken (unless a contraindication or side-effects are recorded)
4
40
90
STROKE 1 The percentage of patients with stroke or TIA who have had influenza immunisation in the preceding 1 September to 31 March
2
40
85
 
Total points
24
   

Stroke statistics

The prevalence of stroke from the 2005–2006 QOF results was 1.6%.2 However, stroke affects over 130,000 patients per year in the UK and is a major cause of mortality and morbidity.3 After a first stroke, a patient's risk of having a further stroke within the next 5 years is increased to between 30% and 43%.4 This same group of patients is also at high risk of having a myocardial infarction, developing angina, or having another vascular event, such as peripheral vascular disease or erectile dysfunction.5 The rapid implementation of evidence-based secondary prevention, by controlling blood pressure and total cholesterol levels, and by prescribing aspirin or an equivalent medication, is essential.

The 2005–2006 QOF data showed that general practices achieved 97.1% of the clinical points available for stroke and TIA indicators.2 This implies that there is little left to teach GPs and primary care nurses about the secondary prevention of this condition. For those practices that are still struggling to achieve maximum points, the rest of this article will cover the indicators and will also touch on the importance of managing both stroke and TIA as urgent, if not emergency, situations.

Patient register — STROKE 1

All records in primary care should by now be 100% computerised, which facilitates the production of a register of patients with stroke or TIA. However GPs need to discipline themselves to use computers exclusively and to code every diagnosis accurately.

Patient referral — STROKE 11

A specialist should assess all stroke patients, unless the patient chooses otherwise, or if they have another condition, such as terminal cancer, which means that they require palliative care only.

A stroke should be classed as an emergency and all cases should be sent to a specialist stroke unit via a 999 ambulance, as a stroke that can be diagnosed over the telephone indicates hemiplegia. These patients are often difficult to manoeuvre and may also have breathing difficulties, hence the recommendation for an ambulance.

Brain imaging should be undertaken as a matter of urgency, and a minimum standard is that all patients with suspected stroke should undergo imaging within 24 hours of admission.5 Some patients may be suitable for thrombolysis but this can only be undertaken in recognised stroke units, as thrombolysis is only for use in cases of thrombotic stroke. This treatment to dissolve blood clots would be disastrous in haemorrhagic stroke.5

The risk of developing a stroke after a TIA can be as high as 20% over the following month, with the highest incidence of stroke occurring in the 72 hours immediately after the TIA.5

These patients need an urgent outpatient appointment and all should be seen within 7 days of the incident. If a patient has a second TIA within a week, they should be seen immediately or admitted directly to hospital.

Blood pressure measurement — STROKE 5 and 6

In most practices, blood pressure measurements can be taken by healthcare assistants.

Although the QOF2 indicator for stroke and TIA aims to achieve a blood pressure measurement of below 150/90 mmHg, the JBS2 guideline suggests the target should be to reduce this to below 130/80 mmHg in people at high risk or in those with established cardiovascular disease, diabetes, or chronic renal disease.6 The QOF target should, therefore, be considered as a minimum standard for audit purposes only.

Total cholesterol measurement — STROKE 7 and 8

Although JBS2 suggests that this target should be even more stringent and that we should aim for a reduction of the total cholesterol level to below 4.0 mmol/l in high risk patients,6 the QOF2 audit target will remain at 5.0 mmol/l for the foreseeable future and GPs should use the most cost-effective statin to ensure that their patients achieve these targets. Total cholesterol measurements can be taken by the practice phlebotomist or nurse.

Anticoagulation and antiplatelet therapies — STROKE 12

Antiplatelet therapy for patients who have had a non-haemorrhagic stroke or who have a history of TIA includes aspirin, clopidogrel, dipyridamole, a combination of these, or an anticoagulant, unless contraindicated or the patient experiences side-effects.

Anticoagulation should be reserved for patients who have atrial fibrillation and this medication can only be started after brain imaging has excluded a haemorrhagic stroke. Even then, anticoagulation therapy should be given after 14 days have elapsed since the ischaemic stroke.5

Influenza immunisation — STROKE 10

Influenza immunisation may be difficult to achieve in the housebound and this is an area where practices must seek the help of their community nurses. Practice-based commissioners should address this issue in their contracts with their community providers.

We are fortunate in having an excellent nursing team attached to our practice and the former Dales PCT had an enlightened management team that understood the close links that were needed between general practice and its community nursing team. This has resulted in an excellent service for patients and we achieved an 89% influenza immunisation rate in our stroke patients last year (the target level is 85%).

Summary

Most of the work involved in monitoring and managing patients who have had a stroke or TIA can be undertaken by healthcare assistants and qualified primary care nurses. In our practice we now have four practice nurses and four healthcare assistants for a population of 13,000 patients. None of the targets are difficult to hit but require good management and organisation. In the past, cholesterol management in patients who have had a stroke was not addressed as vigorously as it was in patients with coronary heart disease. The QOF has addressed this problem and has dramatically improved the overall management of this group of patients.

Housebound patients deserve the same standard of care and it must be ensured that PCTs in England, and their equivalent commissioning bodies in the rest of the UK, put in place contracts with their providers of community nursing. These contracts should stipulate that community nurses share the responsibility with GPs for ensuring that housebound patients receive the evidence-based monitoring and care outlined above. In our practice, they are visited by community nurses who ensure that all QOF targets are met.

  • Stroke is one of the four conditions where there is specific guidance for unbundling the hospital tariff so diagnostics and rehabilitation can be undertaken by different providers and funded separately1
  • Secondary prevention post-stroke helps win QOF points but also reduces hospital costs and morbidity from further stroke
  • It is vital to commission rapid out-patient assessment including brain and carotid artery imaging for TIA and ambulant strokes
    Standard tariff price:1
    – for stroke admissions = £4400 for 70+ years or £2884 for <70 years
    – for TIA admissions = £1698 for 70+ years or £906 for <70 years
  1. British Medical Association. Revisions to the GMS Contract, 2006/07. Delivering Investment in General Practice. London: BMA, 2006.
  2. National Quality and Outcomes Framework Achievement Data for England 2005–06. www.ic.nhs.uk/pubs/qof
  3. Rudd A, Lowe D, Hoffman A et al. Secondary prevention for stroke in the United Kingdom results from the National Sentinel Audit of Stroke. Age Ageing 2004; 33 (3): 280–286.
  4. Mant J, Wade D, Winner S. Health care needs assessment: stroke. In: Stevens A, Raftery J, Mant J, Simpson S, editors. Health care needs assessment: the epidemiologically based needs assessment reviews. 2nd ed. Oxford: Radcliffe Medical Press, 2004.
  5. Royal College of Physicians. National clinical guidelines for stroke. 2nd ed. Prepared by the Intercollegiate Stroke Working Party, London: RCP, 2004.
  6. JBS2: Joint British Societies' Guidelines on Prevention of Cardiovascular Disease in Clinical Practice. Heart 2005; 91 (suppl v): v1–v52.G