The old adage that 'prevention is better than cure' has seldom been closer to mainstream health official policy than it is now.
The old adage that 'prevention is better than cure' has seldom been closer to mainstream health official policy than it is now.
The recent report from the NHS Future Forum propelled this into the headlines but was preceded by a commitment that 10% of the points in the Quality and Outcomes Framework (QOF) should come from public health measures.(1) The actual public health measures included in the QOF predate even this announcement by some time and seem unlikely to change in the near future.
Two main areas seem to match the criteria for public health. The most obvious are the primary prevention indicators, which deal with patients newly diagnosed with hypertension. Less obvious are the chronic kidney disease (CKD) indicators, which were introduced with a fair degree of confusion a few years ago.
The criterion to entry to the CKD register is a diagnosis of stages three, four or five. These levels are based on the glomerular filtration rate (GFR) or more normally on a mathematical estimate of this (eGFR). The eGFR should be measured at least twice, two months apart, before the diagnosis is made. Stage three is defined as an eGFR of less than 60ml/min/m2. Stage four is less than 30 and stage five, which is likely to be symptomatic, starts at 15. The patient is not entered on the register automatically, based on the blood results, but an explicit diagnosis code is required – relevant codes start with '1Z1'. Six points are given for compiling this register.
The significance of the diagnosis is not so much the progression to more severe disease, which is rare, but as an independent risk factor for cardiovascular disease. This area can be seen as an attempt at primary prevention of disease in a similar way to hypertension or cholesterol measurement.
While practices should not be reluctant to make the diagnosis, some care is needed. Once a patient has a diagnosis of stage three or above then there is no concept of the condition having resolved, even if the renal function later improves. So a patient will remain on the register for as long as they remain registered with the practice.
Renal function is such a common blood test that effectively there is a national ad hoc screening programme for CKD. However, the conditions in which the measurement is taken can influence the results. The estimation is based on the serum creatinine level.
This can be increased (and the eGFR reduced) by dehydration as is commonly seen in a fasting blood test. As creatinine is the body's final excretion path for protein, ingestion of large quantities of protein will also increase the serum levels. Patients need not starve but should not eat any meat in the 12 hours before the blood test.
While the first blood test may act as a screening investigation, it is worth ensuring that the second blood test is in optimum conditions. The results of calculators, which automatically scan computer records, should also be checked, as they are unlikely to take into account the conditions of the test.
The calculations from the laboratory will take into account the age and sex of the patient. They are unlikely to know the ethnicity of the patient. The estimated GFR should be multiplied by 1.21 in patients of Afro-Caribbean ethnicity. Effectively this means that raw laboratory results of under 50ml/min/m2 are likely to be diagnostic of stage three in this group.
The actual actions required for patients on the register are fairly straightforward and typical of those seen in several other areas. Blood pressure is a significant modifiable risk factor for renal disease and is a major part of this area.
Six points are available for measuring blood pressure in 90% of patients. A further 11 points are available for treating to a target of 140/85. This is lower than the targets in the hypertension area, although a little less so than the tighter of the diabetes indicators (140/80). The upper threshold for payment is at 70%.
Patients with severe kidney disease are some of the most difficult patients to treat with hypertension and may be excepted if they are having maximum treatment.
Both of these indicators look back over 15 months. As always for outcomes measures, only the last reading will count – so if a measurement of blood pressure is in range there is an incentive to stop measuring. If patients are also on the hypertension register – which they commonly will be – they will need a reading for that area within nine months of the year-end (ie, from 1 July onwards).
The final two indicators deal with proteinuria. This is a further risk factor for renal disease and it is suggested that the grades of CKD are further subdivided as with or without proteinuria, particularly stages two and three. This should be measured as a protein or albumin to creatinine ratio, preferably on an early-morning specimen.
Twenty-four-hour urine protein collection is usually considered the gold standard but will not count for QOF purposes and neither will a dipstick test, no matter how much protein is seen. There are six points for this indicator. If significant proteinuria is seen this should be coded – this will not be automatically monitored by the QOF rules.
The final indicator deals with the treatment of hypertension. The treatments of choice in CKD are ACE (angiotensin-converting enzyme) inhibitors or angiotensin two antagonists. If a patient is on both the hypertension register and the CKD register and is further coded as having proteinuria, an ACE inhibitor should be prescribed. This is one of the reasons it is important to code proteinuria, as it is essential to get the nine points here that having at least one patient will qualify the practice for.
As with other similar indicators, if an angiotensin two antagonist is used then an exception code for ACE inhibitor should be used. If neither class of drugs is suitable or tolerated then two exception codes should be used. Also standard in prescribing indicators is the need for a prescription to be issued in the last six months of the QOF year.
The primary prevention area should really be considered part of the hypertension area as the patients covered are a subset of the patients on the hypertension register. There are only two indicators and both relate to different groups of patients; the first is a subset of the second.
The first indicator relates only to patients with a recent diagnosis of hypertension. The guidelines would suggest that only those diagnosed within the QOF year would be counted, but in practice patients diagnosed up to 15 months before the end of the year may be counted.
The requirement is for an assessment of cardiac risk in person within three months of the first diagnosis in patients between the ages of 30 and 74 years old. The risk should be calculated using a validated system. Approved methods are Framingham, Joint British Societies' guidelines (JBS2, as found at the back of the British National Formulary), QRISK2 or, for practices in Scotland, ASSIGN. Only the last two are validated for the whole age range of patients covered by this indicator.
Patients with pre-existing coronary heart diseaseor diabetes and patients with a history of stroke or transient ischemic attack (TIA) are excluded from this indicator.
The information required for each of these formulae varies. Framingham and JBS2 require only the age, sex, smoking status and cholesterol. QRISK2 additionally requires a postcode, ethnicity, body mass index and information on family history, as well as history of atrial fibrillation, rheumatoid arthritis, diabetes and renal disease. ASSIGN has similar requirements to QRISK2; both of these work most effectively when they integrated into the electronic record.
Although not specified in the QOF, it is advised to initiate a statin where the 10-year risk is greater than 20%. This is considered to be high risk, although objectively it is only 2% a year.
The second indicator is about giving lifestyle advice to patients who have been diagnosed with hypertension. Only patients diagnosed since 1 April 2009 are included in this indicator. This date is fixed so more patients will be included in this indicator every year – the five available points remain constant. As we are in the third year, the number of patients has roughly tripled since the first year of this indicator.
The four areas that advice should cover are smoking, exercise, diet and alcohol consumption. Although there are individual codes under '67H' for each of these areas they do not automatically count towards the indicator. The code '67H' itself needs to be entered. This should be repeated annually.
Despite the dilution of the points as patient numbers increase, this remains, for the moment, a reasonably financially worthwhile indicator with the payment per patient probably just under the £10 mark. This value will continue to drop in each successive year.
Primary prevention can be a particularly challenging area to encourage patient compliance. In both these areas there are no symptoms and the assessment is based on some fairly opaque mathematics. More than in most areas, treatment is based around population health improvement rather than a guarantee of benefit to an individual patient. For this reason these can be particularly challenging areas to tackle. An efficient system for identifying and calling in patients is key to ensuring success in these areas.
Reference
1. NHS Future Forum. The NHS's role in the public's health. London: DH; 2012. Available from: www.dh.gov.uk
Resources
ASSIGN score
www.assign-score.com
QRISK2 2011 risk calclulator
qrisk.org
