Cardiovascular disease – primary prevention - go to this
Secondary Prevention of Coronary Heart Disease
| Indicator | Points | Payment Stages |
| Records | ||
| CHD01. The practice can produce a register of patients with coronary heart disease | 4 | |
| Diagnosis and initial management | ||
| CHD13. For patients with newly diagnosed angina (diagnosed after 1 April 2011), the percentage who are referred for specialist assessment | 7 | 40–90% |
| Ongoing Management | ||
| CHD06. The percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the preceding 15 months) is 150/90 or less | 17 |
40-71%
|
| CHD08. The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the preceding 15 months) is 5 mmol/l or less | 17 | 40-70% |
| CHD09. The percentage of patients with coronary heart disease with a record in the preceding 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% |
| CHD10. 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% |
| CHD12. 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% |
| CHD14. The percentage of patients with a history of myocardial infarction (from 1 April 2011) currently treated with an ACE inhibitor (or ARB if ACE intolerant), aspirin or an alternative anti-platelet therapy, beta blocker and statin (unless a contraindication or side effects are recorded) | 10 | 40-80% |
Heart Failure
| Indicator | Points | Payment Stages |
| Records | ||
| HF01: The practice can produce a register of patients with heart failure. | 4 | |
| Initial diagnosis | ||
| HF02: 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 | ||
| HF03: The percentage of patients with a current diagnosis of heart failure due to Left Ventricular Dysfunction (LVD) who are currently treated with an ACE inhibitor or Angiotensin Receptor Blocker, who can tolerate therapy and for whom there is no contraindication. | 10 | 40-80% |
| HF04: 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 are additionally treated with a beta-blocker licensed for heart failure, or recorded as intolerant to or having a contraindication to beta-blockers.(v14) | 9 | 40-60% |
Stroke and TIA
| Indicator | Points | Payment Stages |
| Records | ||
| STROKE01. The practice can produce a register of patients with Stroke or TIA | 2 | |
| STROKE13.
The percentage of new patients with a
stroke or TIA who have been referred for further investigation. (Referral should be within three months before and up to one month after diagnosis of presumptive Stroke or TIA) |
2 | 40-80% |
| Ongoing Management | ||
| STROKE06. The percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in the preceding 15 months) is 150/90 or less | 5 | 40-71% |
| STROKE07. The percentage of patients with TIA or stroke who have a record of total cholesterol in the preceding 15 months | 2 | 40-90% |
| STROKE08. The percentage of patients with TIA or stroke whose last measured total cholesterol (measured in the preceding 15 months) is 5 mmol/l or less | 5 | 40-60% |
| STROKE12. 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% |
| STROKE10. The percentage of patients with TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March | 2 | 40-85% |
Hypertension
| Indicator | Points | Payment Stages |
| Records | ||
| BP01. The practice can produce a register of patients with established hypertension | 6 | |
| Ongoing Management |
||
| BP04. The percentage of patients with hypertension in whom there is a record of the blood pressure in the preceding 9 months | 16 | 40-90% |
| BP05. The percentage of patients with hypertension in whom the last blood pressure (measured in the preceding 9 months) is 150/90 or less | 57 | 40-70% |
Diabetes Mellitus
| Indicator | Points | Payment Stages |
| Records | ||
| DM19.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 | ||
| DM02.The percentage of patients with diabetes whose notes record BMI in the preceding 15 months | 3 | 40-90% |
| DM21. The percentage of patients with diabetes who have a record of retinal screening in the preceding 15 months | 5 | 40-90% |
| DM29.The percentage of patients with diabetes with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 15 months. | 4 | 40-90% |
| DM10. The percentage of patients with diabetes with a record of neuropathy testing in the preceding 15 months | 3 | 40-90% |
| DM13. The percentage of patients with diabetes who have a record of micro-albuminuria testing in the preceding 15 months (exception reporting for patients with proteinuria) | 3 | 40-90% |
| DM22. The percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the preceding 15 months | 3 | 40-90% |
| DM15. 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% |
| DM17. The percentage of patients with diabetes whose last measured total cholesterol within preceding 15 months is 5 mmol/l or less | 6 | 40-70% |
| DM18. The percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March. | 3 | 40-85% |
| DM26. The percentage of patients with diabetes in whom the last IFCC-HbA1c is 59 mmol/mol (equivalent to HbA1c of 7.5% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 15 months. | 17 | 40-50% |
| DM27: The percentage of patients with diabetes in whom the last IFCC-HbA1c is 64 mmol/mol (equivalent to HbA1c of 8% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 15 months | 8 | 40-70% |
| DM28. The percentage of patients with diabetes in whom the last IFCC-HbA1c is 75 mmol/mol (equivalent to HbA1c of 9% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 15 months. | 10 | 40-90% |
| DM30. The percentage of patients with diabetes in whom the last blood pressure is 150/90 or less in the preceding 15 months | 8 | 40-71% |
| DM31. The percentage of patients with diabetes in whom the last blood pressure is 140/80 or less in the preceding 15 months | 10 | 40-60% |
Chronic Obstructive Pulmonary Disease
| Indicator | Points | Payment Stages |
| Records | ||
| COPD14. The practice can produce a register of patients with COPD | 3 | |
| Initial diagnosis | ||
| COPD15.
The percentage of all patients with COPD diagnosed after 1st
April 2011 in whom the diagnosis has been confirmed by post bronchodilator
spirometry. ( undertaken between three months before and twelve months after a diagnosis of COPD being made) |
5 | 40-80% |
| Ongoing management | ||
| COPD08. The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March | 6 | 40-85% |
| COPD10. The percentage of patients with COPD with a record of FeV1 in the preceding 15 months | 7 | 40-70% |
| COPD13. The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the MRC dyspnoea score in the preceding 15 months | 9 | 50-90% |
Epilepsy
| Indicator | Points | Payment Stages |
| Records | ||
| EPILEPSY05. The practice can produce a register of patients aged 18 and over receiving drug treatment for epilepsy | 1 | |
| Ongoing management | ||
| EPILEPSY06. The percentage of patients age 18 and over on drug treatment for epilepsy who have a record of seizure frequency in the preceding 15 months | 4 | 40-90% |
| EPILEPSY08. The percentage of patients age 18 and over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the preceding 15 months | 6 | 40-70% |
| EPILEPSY09. The percentage of women under the age of 55 years who are taking antiepileptic drugs who have a record of information and counselling about contraception, conception and pregnancy in the preceding 15 months. | 3 | 40-90% |
Hypothyroid
| Indicator | Points | Payment Stages |
| Records | ||
| THYROID01. The practice can produce a register of patients with hypothyroidism | 1 | |
| Ongoing management | ||
| THYROID02.
The percentage of patients with hypothyroidism with thyroid function tests
recorded in the preceding 15 months |
6 | 40-90% |
Cancer
| Indicator | Points | Payment Stages |
| Records | ||
| CANCER01. 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'. | 5 | |
| Ongoing management | ||
| CANCER03. The
percentage of patients with cancer, diagnosed
within the preceding 18 months who have a patient review recorded as occurring
within 6 months of the practice receiving confirmation of the diagnosis
|
6 | 40-90% |
Palliative Care
| Indicator | Points | Payment Stages |
| Records | ||
| PC03: The practice has a complete register available of all patients in need of palliative care/support irrespective of age | 3 | |
| Ongoing management | ||
| PC02: The practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed. | 3 |
Mental Health
| Indicator | Points | Payment Stages |
| Records | ||
| MH08. The practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses | 4 | |
| Ongoing management | ||
| MH17. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 9 months | 1 | 40-90% |
| MH18. The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the preceding 4 months | 2 | 40-90% |
| MH10. 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% |
| MH11. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 15 months | 4 | 40-90% |
| MH12. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 15 months | 4 | 40-90% |
| MH13. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 15 months | 4 | 40-90% |
| MH14. The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder and other psychoses who have a record of total cholesterol:hdl ratio in the preceding 15 months | 5 | 40-80% |
| MH15. The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood glucose in the preceding 15 months | 5 | 40-80% |
| MH16. The percentage of women (aged from 25 to 64 in England and Northern Ireland, from 20 to 60 in Scotland and from 20 to 64 in Wales) with schizophrenia, bipolar affective disorder and other psychoses whose notes record that a cervical screening test has been performed in the preceding 5 years | 5 | 40-80% |
Asthma
| Indicator | Points | Payment Stages |
| Records | ||
| ASTHMA01. The practice can produce a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding twelve months | 4 | |
| Initial Management | ||
| ASTHMA08. The percentage of patients aged eight and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility | 15 | 40-80% |
| Ongoing management | ||
| ASTHMA03. The percentage of patients with asthma between the ages of 14 and 19 in whom there is a record of smoking status in the preceding 15 months | 6 | 40-80% |
| ASTHMA06. The percentage of patients with asthma who have had an asthma review in the preceding 15 months | 20 | 40-70% |
Dementia
| Indicator | Points | Payment Stages |
| Records | ||
| DEM01: The practice can produce a register of patients diagnosed with dementia | 5 | |
| Ongoing management | ||
| DEM02: The percentage of patients diagnosed with dementia whose care has been reviewed in the preceding 15 months | 15 | 25-60% |
| DEM03: The percentage of patients with a new diagnosis of dementia (from April 2011) with a record of FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded 6 months before or after entering on to the register | 6 | 40-80% |
Depression
| Indicator | Points | Payment Stages |
| Diagnosis and initial management |
||
| DEP01: The percentage of patients with diabetes and /or heart disease for whom case finding for depression has been undertaken on one occasion during the preceding 15 months using two standard screening questions | 6 | 40-90% |
| DEP04: In those patients with a new diagnosis of depression, recorded between the preceeding1 April to 31 March, the percentage of patients who have had an assessment of severity at the time of diagnosis using an assessment tool validated for use in primary care | 17 | 40-90% |
| DEP05. In those patients with a new diagnosis of depression and assessment of severity recorded between the preceding 1 April to 31 March, the percentage of patients who have had a further assessment of severity 4-12 weeks (inclusive) after the initial recording of the assessment of severity. Both assessments should be completed using an assessment tool validated for use in primary care | 8 | 40-80% |
Chronic Kidney Disease
| Indicator | Points | Payment Stages |
| Records |
||
| CKD01: 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 | ||
| CKD02: The percentage of patients on the CKD register whose notes have a record of blood pressure in the preceding 15 months | 6 | 40-90% |
| Ongoing Management | ||
| CKD03: The percentage of patients on the CKD register in whom the last blood pressure reading, measured in the preceding 15 months, is 140/85 or less | 11 | 40-70% |
| CKD05: The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded) | 9 | 40-80% |
| CKD06: The percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio (or protein: creatinine ratio) test in the preceding 15 months (v14) | 6 | 40-80% |
Atrial Fibrillation
| Indicator | Points | Payment Stages |
| Records |
||
| AF01: The practice can produce a register of patients with atrial fibrillation. | 5 | |
| Initial diagnosis | ||
| AF04: The percentage of patients with atrial fibrillation diagnosed after 1 April 2008 with ECG or specialist confirmed diagnosis. | 10 | 40-90% |
| Ongoing Management | ||
| AF03: The percentage of patients with atrial fibrillation who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy. | 12 | 40-90% |
Obesity
| Indicator | Points | Payment Stages |
| Records |
||
| OB01: The practice can produce a register of patients aged 16 and over with a BMI greater than or equal to 30 in the preceding 15 months. | 8 |
Learning Disabilities
| Indicator | Points | Payment Stages |
| Records |
||
| LD01:The practice can produce a register of patients with learning disabilities | 4 | |
| LD02: Percentage of patients on the Learning Disability register with Down’s Syndrome aged 18 years and over who have a record of blood TSH in the preceding 15 months (excluding those who are on the thyroid disease register) | 3 | 40-70% |
Smoking Indicators
| Indicator | Points | Payment Stages |
| Ongoing management |
||
| Smoking03: The percentage of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 15 months. Except those who have never smoked where smoking status needs to be recorded in the preceding 15 months up to and including 25 years of age then only be recorded once after diagnosis. | 30 | 40-90% |
| Smoking04: The percentage of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the preceding 15 months | 30 | 40-90% |
Cardiovascular disease – primary prevention
| Indicator | Points | Payment Stages |
| Initial diagnosis | ||
| PP 1. In those patients with a new diagnosis of hypertension (excluding those with pre-existing CHD, diabetes, stroke and/or TIA) recorded between the preceding 1 April to 31 March: the percentage of patients aged 30 to 74 years who have had a face to face cardiovascular risk assessment at the outset of diagnosis (within three months of the initial diagnosis) using an agreed risk assessment treatment tool. | 8 | 40-70% |
| Ongoing management |
||
| PP 2. The percentage of people diagnosed with hypertension diagnosed after 1 April 2009 who are given lifestyle advice in the last 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet. | 5 | 40-70% |
Prepared By Jean Keenan