Dr Sarah Jarvis explains why the blood pressure and total cholesterol levels included in the quality and outcomes framework should be achievable for all patients

All of the targets for the quality and outcomes framework (QOF) indicators relating to the coronary heart disease (CHD) and heart failure domains were altered in QOF2,1 but barely. Lower targets were increased from 25% in QOF12 to 40% in QOF2.1 This was an appropriate response to the high achievements of GPs across the country. The average number of points achieved for the CHD domain was:3

  • 534.2 points (97.1% of the maximum 550 points available) in 2005–2006,
  • 630.7 points (96.3% of the maximum 655 points available) in 2006–2007.

These levels of achievement suggest that the QOF targets are potentially obtainable by all.

The concept behind the original 25% lower target was that this represented a level of care that could not be achieved without an organised, systematic service, with a disease register and a call and recall system. If lower targets are unrealistically ambitious (as is the case with the 50% lower target for cervical cytology under the GP Contract of 19904), there may be a perverse disincentive to make any effort in a particular disease area.

Table 1: QOF2 clinical indicators for coronary heart disease and heart failure

Coronary heart disease — 89 points available
No. Indicator
Points
Payment
stages
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
19
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 angiotensin II receptor blocker
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 — 20 points available
 
 
No. Indicator
Points
Payment stages
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 angiotensin II receptor blocker, who can tolerate therapy and for whom there is no contraindication
10
40–80%
CHD=coronary heart disease; ACE=angiotensin-converting enzyme; LVD=left ventricular dysfunction

Changes to the CHD indicators

Blood pressure targets

In QOF2, the targets for blood pressure (BP) reduction (<150/90 mmHg), and the threshold of patients attaining this target for maximum payments (70%) remained the same as in QOF1.

A major overview of randomised trials showed that a reduction of 5–6 mmHg in diastolic blood pressure, sustained over a 5-year period, results in 20–25% less CHD.5 Each 10/5 mmHg reduction in BP is associated with a 40% lower risk of stroke death and a 30% lower risk of death from ischaemic heart disease or other vascular causes.6

While the British Hypertension Society guideline proposes an ‘audit standard’ of a blood pressure reading of <150/90 mmHg for patients with CHD,7 it also recommends an optimal blood pressure of <140/85 mmHg for the same group of patients. It is, therefore, disappointing that the QOF targets are not tighter.

Earlier uncertainty about the benefits of treating elderly patients was demonstrated as recently as 1986. At that time, some expert panels routinely recommended drug treatment for healthy patients aged 65 to 74 years old with uncomplicated hypertension only when blood pressure levels reached 200/100 mmHg or greater. For healthy patients over 75 years of age, routine drug treatment was only recommended when diastolic blood pressure levels reached >120 mmHg.8 However, it is now accepted that the benefits of tight blood pressure control apply every bit as much to elderly patients as to their younger counterparts.9 The absence of an upper age limit in the CHD indicators is, therefore, entirely appropriate.

Cholesterol targets

With respect to cholesterol targets, only the proportions of patients achieving targets for maximum payment (40–70% in QOF2, compared with 25–60% in QOF1) have changed. The target itself (total cholesterol ?5 mmol/l) is unaffected.1,2 This target reflects the recommendations of the National Service Framework for CHD from 200010 rather than the more recent JBS 2 guideline, which recommends targets of <4 mmol/l and <2 mmol/l for total and low-density lipoprotein (LDL) cholesterol, respectively, and an audit standard of <5mmol/l for total cholesterol.11

Even the draft NICE guideline on lipid modification recommends up-titration of treatment for CHD patients on statins if the total cholesterol is not 4 mmol/l.12

Cholesterol lowering is just as important in elderly patients as blood pressure lowering. Earlier studies often excluded the very elderly, but, studies such as the Heart Protection Study have proved that the benefits of statins are just as great in patients up to the age of 84 years as they are in younger patients.13 The NICE guidance on Statins for the prevention of cardiovascular events suggests that patients at risk should be treated regardless of age.14 The absence of an upper age limit in the relevant indicators is, therefore, to be welcomed.

Other changes

The only other changes to the CHD domain were the addition of angiotensin II receptor blockers (ARBs) as an alternative to angiotensin-converting enzyme (ACE) inhibitor use in patients with myocardial infarction (MI) (reflecting that valsartan now has a licence to be used in the secondary prevention of MI),15 and the raising of the payment threshold for this indicator from 70% to 80%. The two indicators on CHD and smoking have been reconfigured into the smoking indicators

Changes to the heart failure indicators

The major change in the heart failure domain was the inclusion of all patients with heart failure, rather than just those with left ventricular dysfunction and CHD, who make up only about half of the morbidity of this condition.16 Heart failure is an important and increasingly prevalent condition with a very high level of morbidity and mortality, regardless of the underlying cause.17 Therefore, the inclusion of all affected patients is logical.

The heart failure indicators have a strong evidence base — investigation using echocardiography is standard practice for all patients with heart failure, regardless of the possible cause.18 Likewise, treatment with either ACE inhibitors or ARBs (or in the case of candesartan, both), improves outcomes significantly.19

QOF2 changes — the shortfalls

Although it is reasonable that a set of targets should be achievable by all GPs, I would suggest that the presence of an upper target and the potential for exception reporting means that the payment threshold figures are unrealistically lax. An audit standard is, as the QOF2 supporting document states, a ‘pragmatic’ one that allows for patient factors such as concordance, tolerability, co-morbidity, and side-effects.20

Blood pressure levels of <150/90 mmHg and total cholesterol <5 mmol/l should be considered as minimal competence, and should be achievable in all patients, apart from those where exception reporting criteria apply.

The rationale behind setting pragmatic targets so that they could be aspired to by all GPs and would, therefore, act as an incentive, is understandable. The vast majority of GPs have shown beyond doubt that they are capable of rising to all the challenges that have been set so far.

There is now a real danger that GPs will consider QOF targets, rather than evidence-based national guidelines, as best practice, thereby running the risk that large swathes of a high-risk population will remain untreated. In fact, we have evidence that despite large proportions of those with CHD being treated in accordance with the QOF2 guidance, residual morbidity remains high, with at least one in 10 patients with cardiovascular disease (CVD) suffering another coronary event each year.11

A target for LDL cholesterol was not added in QOF2, despite strong evidence that it reflects risk more accurately than total cholesterol level alone.2,11

Coronary rehabilitation is recommended for all patients post MI,22 yet service provision remains patchy and is hardly available at all in some areas.23 The inclusion of an indicator for referral of all patients with a recently diagnosed MI would certainly have increased pressure for more consistent provision.Any anxiety about discrimination against GPs with no service available to them could have been avoided by the option of exception reporting in the absence of a local coronary rehabilitation service.

Finally, although peripheral arterial disease (PAD) is a manifestation of CVD rather than CHD, the failure to include patients with PAD in the QOF2 indicators is entirely illogical. It could easily be incorporated into the CHD indicators by combining the CHD and stroke/transient ischaemic attack indicators under a new domain of CVD, which would also include PAD. These patients have an even higher risk of a CVD event than patients with a history of CHD, stroke, or diabetes,24 and yet, unlike all the other conditions listed above, these patients are not targeted at all by QOF2.

‘Wishlist’ for QOF3 in 2008

There are several points that I feel should be covered by the CHD and heart failure indicators in next year’s QOF update:

  • removal of either exception reporting or 70% payment threshold for achievement of blood pressure and cholesterol targets

OR lowering of blood pressure target to <140/85 mmHg

AND lowering of total cholesterol target to ?4.5 mmol/l

  • inclusion of LDL cholesterol as a separate target (ideally <2.5 mmol/l, but at least <3 mmol/l)
  • inclusion of an indicator to refer all patients who have an MI from April 2008 for coronary rehabilitation (with exception reporting for documented non-availability of this service)
  • inclusion of PAD (and changing the name of the domain from CHD to CVD).

Conclusion

The implementation of the QOF has ensured that the vast majority of patients are receiving treatment for at least those risk factors for CHD that can be improved in primary care. General practitioners are certainly to be congratulated on their high level of achievement, which could not have been attained without comprehensive, organised systems of care that involve all members of the multidisciplinary primary care team.

However, the payment thresholds in QOF1 were all set at a pragmatic ‘audit standard’ level and were largely not raised in QOF2, despite strong emerging evidence for tighter targets.

The latest round of planning for QOF3 (which is due out in Spring 2008) offers an opportunity for GPs to be encouraged to provide not just adequate, but truly high-quality care for patients with CHD and heart failure.

  • The QOF payment targets for blood pressure and lipid levels are less stringent than evidence suggests
  • Treatment to lower target levels would help save further cardiac events and hospital admissions
  • Further review of the QOF in 2008 may introduce tighter targets and introduce new criteria, such as referral for rehabilitation after myocardial infarction
  • This is likely to cause extra pressure on primary care prescribing budgets
  • For effective PBC it is essential that anti-hypertensive drugs and statins of low acquisition cost are used whenever possible (nearly all of these are now available in generic form)
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