Secondary Prevention of Coronary Heart Disease
|
Indicator |
Points
2004-5 |
Points |
Payment Stages |
Max % score 2004-5 |
|
Records |
|
|
|
|
|
CHD 1. The practice can produce a
register of patients with coronary heart disease |
6 |
4 |
|
|
|
Diagnosis and initial management |
|
|
|
|
|
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% |
|
|
Ongoing Management |
|
|
|
|
|
Smoking (CVD 3 and CVD4) removed to new domain CHD 5. The percentage of patients
with coronary heart disease whose notes have a record of blood pressure in
the previous 15 months |
|
7 |
40-90% |
|
|
CHD 6. The percentage of patients with
coronary heart disease in whom the last blood pressure reading (measured in
the previous 15 months) is 150/90 or less |
|
19 |
40-70% |
|
|
CHD 7. The percentage of patients with
coronary heart disease whose notes have a record of total cholesterol in the
previous 15 months |
|
7 |
40-90% |
|
|
CHD 8. The percentage of patients
with coronary heart disease whose last measured total cholesterol (measured
in the previous 15 months) is 5 mmol/l or less |
16 |
17 |
40-70% |
60% |
|
CHD 9. The percentage of patients
with coronary heart disease with a record in the previous 15 months that
aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken
(unless a contraindication or side-effects are recorded) |
|
7 |
40-90% |
|
|
CHD 10. The percentage of patients
with coronary heart disease who are currently treated with a beta blocker
(unless a contraindication or side-effects are recorded) |
|
7 |
40-60% |
50% |
|
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 antagonist |
|
7 |
40-80% |
70% |
|
CHD 12. The percentage of patients
with coronary heart disease who have a record of influenza immunisation in
the preceding 1 September to 31 March |
|
7 |
40-90% |
85% |
Heart Failure (replaces
left ventricular dysfunction)
|
Indicator |
|
Points |
Payment Stages |
|
|
Records |
|
|
|
|
|
HF1: The practice can produce a
register of patients with heart failure. |
|
4 |
|
|
|
Initial diagnosis |
|
|
|
|
|
HF2: 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% |
|
|
Ongoing management |
|
|
|
|
|
HF3: The percentage of patients with a
current diagnosis of heart failure due to LVD who are currently treated with
an ACE inhibitor or Angiotensin Receptor Blocker,
who can tolerate therapy and for whom there is no contra-indication. |
|
10 |
40-80% |
70% |
|
Indicator |
|
Points |
Payment Stages |
|
Records |
|
|
|
|
STROKE 1. The practice can produce a
register of patients with Stroke or TIA |
4 |
2 |
|
|
STROKE 11. The percentage of new patients
with a stroke who have been referred for further investigation. |
|
2 |
40-80% |
|
Ongoing Management |
|
|
|
|
Smoking (Stroke 3 and Stroke 4) removed
to new domain STROKE 5. The percentage of patients with
TIA or stroke 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 TIA or stroke in whom the last blood pressure reading (measured
in the previous 15 months) is 150/90 or less |
|
5 |
40-70% |
|
STROKE 7. The percentage of patients
with TIA or stroke who have a record of total cholesterol in the last 15
months |
|
2 |
40-90% |
|
STROKE 8. The percentage of patients with
TIA or stroke whose last measured total cholesterol (measured in the previous
15 months) is 5 mmol/l or less |
|
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 anti-platelet agent (aspirin, clopidogrel,
dipyridamole or a combination), or an
anti-coagulant is being taken (unless a contraindication or side-effects are
recorded) |
|
4 |
40-90% |
|
STROKE 10. The percentage of patients
with TIA or stroke who have had influenza immunisation in the preceding 1
September to 31 March |
|
2 |
40-85% |
|
Indicator |
|
Points |
Payment Stages |
|
Records |
|
|
|
|
BP 1. The practice can produce a register
of patients with established hypertension |
9 |
6 |
|
|
Ongoing Management |
|
|
|
|
Smoking (BP 2 and BP 3) removed to new
domain BP 4. The percentage of patients with
hypertension in whom there is a record of the blood pressure in the previous
9 months |
|
20 |
40-90% |
|
BP 5. The percentage of patients with
hypertension in whom the last blood pressure (measured in the previous 9
months) is 150/90 or less |
56 |
57 |
40-70% |
|
Indicator |
|
Points |
Payment Stages |
|
|
Records |
|
|
|
|
|
DM 19.The practice can produce a
register of all patients aged 17 years and
over with diabetes mellitus, which specifies whether the patient has Type 1 or Type 2 diabetes. |
|
6 |
|
|
|
Ongoing Management |
|
|
|
|
|
DM 2.The percentage of patients with
diabetes whose notes record BMI in the previous 15 months Smoking (DM 3 and DM 4) removed to new domain |
|
3 |
40-90% |
|
|
DM 5. The percentage of diabetic
patients who have a record of HbA1c or equivalent in the previous 15 months |
|
3 |
40-90% |
|
|
DM 20. The percentage of patients
with diabetes in whom the last HbA1c is 7.5 (7.4) or less (or equivalent test/reference range depending on local
laboratory) in the previous 15 months |
16 |
17 |
40-50% |
|
|
DM 7. The percentage of patients with
diabetes in whom the last HbA1c is 10 or less (or equivalent test/reference range
depending on local laboratory) in the previous 15 months |
|
11 |
40-90% |
85% |
|
DM 21. The percentage of patients
with diabetes who have a record of retinal screening in the previous 15
months |
|
5 |
40-90% |
|
|
DM 9.The percentage of patients with
diabetes with a record of the presence or absence of peripheral pulses in the
previous 15 months |
|
3 |
40-90% |
|
|
DM 10. The percentage of patients with
diabetes with a record of neuropathy testing in the previous 15 months |
|
3 |
40-90% |
|
|
DM 11. The percentage of patients
with diabetes who have a record of the blood pressure in the previous 15
months |
|
3 |
40-90% |
|
|
DM 12. The percentage of patients
with diabetes in whom the last blood pressure is 145/85 or less |
17 |
18 |
40-60% |
55% |
|
DM 13. The percentage of patients
with diabetes who have a record of micro-albuminuria
testing in the previous 15 months (exception reporting for patients with proteinuria) |
|
3 |
40-90% |
|
|
DM 22. The percentage of patients
with diabetes who have a record of estimated
glomerular filtration rate (eGFR)
or serum creatinine
testing in the previous 15 months |
|
3 |
40-90% |
|
|
DM 15. The percentage of patients
with diabetes with a diagnosis of proteinuria or
micro-albuminuria who are treated with ACE
inhibitors (or A2 antagonists) |
|
3 |
40-80% |
70% |
|
DM 16. The percentage of patients
with diabetes who have a record of total cholesterol in the previous 15
months |
|
3 |
40-90% |
|
|
DM 17. The percentage of patients
with diabetes whose last measured total cholesterol within previous 15 months
is 5 mmol/l or less |
|
6 |
40-70% |
60% |
|
DM 18. The percentage of patients
with diabetes who have had influenza immunisation in the preceding 1
September to 31 March. |
|
3 |
40-85% |
|
Chronic
Obstructive Pulmonary Disease
COPD is diagnosed
if:
• the
patient has an FEV1 of less than 70% of predicted normal
• and has
an FEV1/FVC ratio of less than 70%
• and
there is a less than 15% response to a reversibility test.
All of these
elements are required to make the diagnosis of COPD and to exclude
co-existing
asthma. It is acknowledged that COPD and asthma can co-exist and that
many patients
with asthma who smoke will eventually develop irreversible airways
obstruction.
However, where asthma is present, these patients should be managed as
asthma patients
as well as COPD patients.
While it is
recognised that there may be an element of reversibility in patients with
COPD, the
definition centres on the lack of reversibility.
·
Patients with reversible airways obstruction should be included in
the asthma disease register.
·
Patients with co-existing asthma and COPD should be included on the
register for both conditions.
|
Indicator |
|
Points |
Payment Stages |
|
|
|
Records |
|
|
|
|
|
|
COPD 1. The practice can produce a
register of patients with COPD |
5 |
3 |
|
|
|
|
Initial diagnosis |
|
|
|
|
|
|
COPD 9. The percentage of all
patients with COPD in whom diagnosis has been confirmed by spirometry including reversibility testing (previously, COPD 2 and COPD 3
distinguished between new and existing patients) |
|
10 |
40-80% |
90 |
|
|
Ongoing management Smoking (COPD 4 and COPD 5) removed to
new domain |
|
|
|
|
|
|
COPD 10. The percentage of patients
with COPD with a record of FeV1 in the previous 15 months (previously 27 months) |
6 |
7 |
40-70% |
|
|
|
COPD 11. The percentage of patients
with COPD receiving inhaled treatment in whom there is a record that inhaler
technique has been checked in the previous 15 months |
6 |
7 |
40-90% |
|
|
|
COPD 8. The percentage of patients
with COPD who have had influenza immunisation in the preceding 1 September to
31 March |
|
6 |
40-85% |
|
|
|
Indicator |
|
Points |
Payment Stages |
|
|
Records |
|
|
|
|
|
ASTHMA 1. The practice can produce a
register of patients with asthma, excluding patients with asthma who have
been prescribed no asthma-related drugs in the previous twelve months |
7 |
4 |
|
|
|
Initial Management |
|
|
|
|
|
ASTHMA 8. The percentage of patients
aged eight and over diagnosed as having asthma from 1 April 2006 with
measures of variability or reversibility (previously,
confirmed by spirometry or PEF measurement) |
|
15 |
40-80% |
70% |
|
Ongoing management |
|
|
|
|
|
ASTHMA 3. The percentage of patients
with asthma between the ages of 14 and Smoking (ASTHMA 4 and 5) is now removed |
|
6 |
40-80% |
70% |
|
ASTHMA 6. The percentage of patients
with asthma who have had an asthma review in the previous 15 months |
|
20 |
40-70% |
|
ASTHMA 7, flu vaccination in patients with asthma in previous 12 months,
previously worth 12 points, is now removed
|
Indicator |
|
Points |
Payment Stages |
|
Records |
|
|
|
|
EPILEPSY 5. The practice can produce
a register of patients aged 18 and over receiving drug treatment for epilepsy |
2 |
1 |
|
|
Ongoing management |
|
|
|
|
EPILEPSY 6. The percentage of
patients age 18 (previously 16) and over on drug treatment for epilepsy who have a record of seizure
frequency in the previous 15 months |
|
4 |
40-90% |
|
EPILEPSY 7. The percentage of patients
age 18 (previously 16) and over on drug treatment for epilepsy who have a record of
medication review involving the patient and/or
carer in the previous 15 months |
|
4 |
40-90% |
|
EPILEPSY 8. The percentage of
patients age 18 (previously 16) and over on drug treatment for epilepsy who have been seizure free
for the last 12 months recorded in the previous 15 months |
|
6 |
40-70% |
|
Indicator |
|
Points |
Payment Stages |
|
Records |
|
|
|
|
THYROID 1. The practice can produce a
register of patients with hypothyroidism |
2 |
1 |
|
|
Ongoing management |
|
|
|
|
THYROID 2. The percentage of patients
with hypothyroidism with thyroid function tests recorded in the previous 15
months |
|
6 |
40-90% |
|
Indicator |
|
Points |
Payment Stages |
|
Records |
|
|
|
|
CANCER 1. The practice can produce a
register of all cancer patients defined as a ‘register of patients with
a diagnosis of cancer excluding non-melanotic skin
cancers from 1 April 2003 |
6 |
5 |
|
|
Ongoing management |
|
|
|
|
CANCER 3. The percentage of patients
with cancer, diagnosed within the last 18 months who have a patient review recorded
as occurring within 6 months of the practice receiving confirmation of the
diagnosis |
|
6 |
40-90% |
Mental Health
|
Indicator |
|
Points |
Payment Stages |
|
Records |
|
|
|
|
MH 8. The practice can produce a register
of people with schizophrenia, bipolar disorder and other psychoses (previously, long term mental health problems) |
7 |
4 |
|
|
Ongoing management |
|
|
|
|
MH 9. The percentage of patients with
schizophrenia, bipolar affective disorder and other psychoses with a review
recorded in the preceding 15 months. In the
review there should be evidence that the patient has been offered routine
health promotion and prevention advice appropriate to their age, gender and
health status |
|
23 |
40-90% |
|
MH 4. The percentage of patients on
lithium therapy with a record of serum creatinine
and TSH in the preceding 15 months |
3 |
1 |
40-90% |
|
MH 5. The percentage of patients on lithium
therapy with a record of lithium levels in the
therapeutic range within the previous 6 months |
8 |
2 |
40-90% |
|
MH6: The percentage of patients on the
register who have a comprehensive care plan documented in the records agreed between
individuals, their family and/or carers as appropriate |
|
6 |
25-50% |
|
MH7: The percentage of patients with
schizophrenia, bipolar affective disorder and other psychoses who do not attend
the practice for their annual review who are identified and followed up by
the practice team within 14 days of non-attendance |
|
3 |
40-90% |
Dementia (new for 2006)
|
Indicator |
Points |
Payment Stages |
|
Records |
|
|
|
DEM1: The practice can produce a
register of patients diagnosed with dementia |
5 |
|
|
Ongoing management |
|
|
|
DEM2: The percentage of patients
diagnosed with dementia whose care has been reviewed in the previous 15
months |
15 |
25-60% |
Depression (new for 2006)
|
Indicator |
Points |
Payment Stages |
|
Diagnosis and initial management |
|
|
|
DEP1: The percentage of patients on the diabetes register and /or the CHD
register for whom case finding for depression has been undertaken on one
occasion during the previous 15 months using two standard screening questions During the
last month, have you often been bothered by feeling down, depressed or hopeless? and During the
last month, have you often been bothered by having little interest or pleasure in doing things?” |
8 |
40-90% |
|
DEP2: In those patients with a new
diagnosis of depression, recorded between the preceding 1 April to 31 March, the
percentage of patients who have had an assessment of severity at the outset
of treatment using an assessment tool validated for use in primary care |
25 |
40-90% |
The three suggested
severity measures validated for use in a primary care setting are the
•
Patient Health Questionnaire (PHQ-9)
•
Beck Depression Inventory Second Edition (BDI-II)
•
Hospital Anxiety and Depression Scale (HADS).
It is advisable for a
practice to choose one of these three measures and become familiar with its
questions and scoring systems.
The PHQ-9 is a nine
question self-report measure of severity and can be downloaded free of charge
from:
www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/questionnaire/
The HADS is a 7 question scale and can be purchased (£41.50 for
100) from www.onestopeducation.co.uk/icat/hospitalanxietyanddepress
The Beck is a 21-item scale and can be purchased (£36 for 25) from
Whichever method is used, the scoring must be done within 1 month of
diagnosis (ie the date of coding of depression on
your system)
Chronic Kidney Disease (new for 2006)
|
Indicator |
Points |
Payment Stages |
|
Records |
|
|
|
CKD1: The practice can produce a
register of patients aged 18 years and over with CKD (US National Kidney
Foundation: Stage 3 to 5 CKD) |
6 |
|
|
Initial Management |
|
|
|
CKD2: The percentage of patients on the
CKD register whose notes have a record of blood pressure in the previous 15
months |
6 |
40-90% |
|
Ongoing Management |
|
|
|
CKD3: The percentage of patients on
the CKD register in whom the last blood pressure reading, measured in the
previous 15 months, is 140/85 or less |
11 |
40-70% |
|
CKD4: The percentage of patients on
the CKD register with hypertension who are treated with an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication
or side effects are recorded) |
4 |
40-80% |
CKD info
Chronic Kidney Disease guidelines for Primary Care
http://www.swtirr.org.uk/st_helier_renal_guidelines_gp_jan_06.pdf
eGFR: Frequently asked questions
http://www.renal.org/eGFR/resources/eGFRFAQs020306.doc
Atrial Fibrillation (new for 2006)
|
Indicator |
Points |
Payment Stages |
|
Records |
|
|
|
AF1: The practice can produce a
register of patients with atrial fibrillation. |
5 |
|
|
Initial diagnosis |
|
|
|
AF2: The percentage of patients with atrial fibrillation diagnosed after 1 April 2006 with ECG
or specialist confirmed diagnosis. |
10 |
40-90% |
|
Ongoing Management |
|
|
|
AF3: The percentage of patients with atrial fibrillation who are currently treated with
anti-coagulation drug therapy or an anti-platelet therapy. |
15 |
40-90% |
Obesity
|
Indicator |
Points |
|
|
Records |
|
|
|
OB1: The practice can produce a
register of patients aged 16 and over with a BMI greater than or equal to |
8 |
|
Learning Disabilities
|
Indicator |
Points |
|
|
Records |
|
|
|
The practice can produce a register
of patients with learning disabilities |
4 |
|
Smoking Indicators
|
Indicator |
|
Points |
Payment Stages |
|
Ongoing management |
|
|
|
|
Smoking 1: The percentage of patients
with any or any combination of the following conditions: coronary heart
disease, stroke or TIA, hypertension, diabetes, COPD or asthma whose notes record
smoking status in the previous 15 months. Except those who have never smoked
where smoking status need only be recorded once since diagnosis |
35 |
33 |
40-90% |
|
Smoking 2: The percentage of patients
with any or any combination of the following conditions: coronary heart
disease, stroke or TIA, hypertension, diabetes, COPD or asthma who smoke
whose notes contain a record that smoking cessation advice or referral to a
specialist service, where available, has been offered within the previous 15
months |
33 |
35 |
40-90% |
Palliative Care (new for 2006)
|
Indicator |
Points |
Payment Stages |
|
Records |
|
|
|
PC1: The practice has a complete
register available of all patients in need of palliative care/support. |
3 |
|
|
Ongoing management |
|
|
|
PC2: The practice has regular (at
least 3 monthly) multidisciplinary case review meetings where all patients on
the palliative care register are discussed. |
3 |
|