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 | ||
| CHD02. 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 | ||
| CHD05. The percentage of patients with coronary heart disease whose notes have a record of blood pressure in the previous 15 months | 7 | 40-90% |
| CHD06. 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%
|
| CHD07. The percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months | 7 | 40-90% |
| CHD08. 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 | 17 | 40-70% |
| CHD09. 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% |
| 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% |
| CHD11. 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% |
| 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% |
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 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% |
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. |
2 | 40-80% |
| Ongoing Management | ||
| STROKE05. 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% |
| STROKE06. 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% |
| STROKE07. The percentage of patients with TIA or stroke who have a record of total cholesterol in the last 15 months | 2 | 40-90% |
| STROKE08. 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% |
| 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 previous 9 months | 20 | 40-90% |
| BP05. The percentage of patients with hypertension in whom the last blood pressure (measured in the previous 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 previous 15 months | 3 | 40-90% |
| DM05. The percentage of diabetic patients who have a record of HbA1c or equivalent in the previous 15 months | 3 | 40-90% |
| DM20. The percentage of patients with diabetes in whom the last HbA1c is 7.5 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months | 17 | 40-50% |
| DM07. 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% |
| DM21. The percentage of patients with diabetes who have a record of retinal screening in the previous 15 months | 5 | 40-90% |
| DM09.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% |
| DM10. The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months | 3 | 40-90% |
| DM11. The percentage of patients with diabetes who have a record of the blood pressure in the previous 15 months | 3 | 40-90% |
| DM12. The percentage of patients with diabetes in whom the last blood pressure is 145/85 or less | 18 | 40-60% |
| DM13. 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% |
| DM22. 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% |
| 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% |
| DM16. The percentage of patients with diabetes who have a record of total cholesterol in the previous 15 months | 3 | 40-90% |
| DM17. The percentage of patients with diabetes whose last measured total cholesterol within previous 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% |
Chronic Obstructive Pulmonary Disease
| Indicator | Points | Payment Stages |
| Records | ||
| COPD01. The practice can produce a register of patients with COPD | 3 | |
| Initial diagnosis | ||
| COPD12.
The percentage of all patients
with COPD diagnosed after 1st April 2008
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 | ||
| COPD10. The percentage of patients with COPD with a record of FeV1 in the previous 15 months | 7 | 40-70% |
| COPD11. 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 | 7 | 40-90% |
| COPD08. The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March | 6 | 40-85% |
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 previous 15 months | 4 | 40-90% |
| EPILEPSY07. The percentage of patients age 18 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% |
| 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 previous 15 months | 6 | 40-70% |
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 previous 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 previous 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 | ||
| MH09. 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% |
| MH04. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months | 1 | 40-90% |
| MH05. The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months | 2 | 40-90% |
| MH06. 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% |
| MH07. 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% |
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 previous 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 previous 15 months | 6 | 40-80% |
| ASTHMA06. The percentage of patients with asthma who have had an asthma review in the previous 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 previous 15 months | 15 | 25-60% |
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 previous 15 months using two standard screening questions | 8 | 40-90% |
| DEP02: 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 outset of treatment using an assessment tool validated for use in primary care | 25 | 40-90% |
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 previous 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 previous 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) | 4 | 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. | 15 | 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 previous 15 months. | 8 |
Learning Disabilities
| Indicator | Points | Payment Stages |
| Records |
||
| LD01:The practice can produce a register of patients with learning disabilities | 4 |
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 previous 15 months. Except those who have never smoked where smoking status need only be recorded once since diagnosis | 33 | 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 previous 15 months | 35 | 40-90% |
Prepared By Jean Keenan