Section 2: clinical indicators
Hypertension
| Indicator | Points | Payment Stages |
| Records |  | |
| BP 1. The practice can produce a register of patients with established hypertension | 9 | |
| | |
| Diagnosis and initial management | | |
| BP 2. The percentage of patients with hypertension whose notes record smoking status at least once since diagnosis | 10 | 25-90% |
| | |
| BP 3. The percentage of patients with hypertension who smoke, whose notes contain a record that smoking cessation advice or referral to a specialist service, if available, has been offered at least once | 10 | 25-90% |
| | |
| Ongoing Management | | |
| BP 4. The percentage of patients with hypertension in whom there is a record of the blood pressure in the past 9 months | 20 | 25-90% |
| | |
| BP 5. The percentage of patients with hypertension in whom the last blood pressure (measured in the last 9 months) is 150/90 or less | 56 | 25-70% |
Hypertension - Rationale for Inclusion of Indicator Set
Hypertension is a common medical condition which is largely managed in primary care and represents a significant workload for GPs and the primary health care team. Trials of anti-hypertensive treatment have confirmed a significant reduction in the incidence of stroke and coronary heart disease in patients with treated hypertension.
Hypertension (BP) Indicator 1
The practice can produce a register of patients with established hypertension
BP 1.1 Rationale
In order to call and recall patients effectively and in order to be able to report on indicators for hypertension, practices must be able to identify their population of patients who have established hypertension. A number of patients may be wrongly coded in this group, for example patients who have had one-off high blood pressure readings or women who have been hypertensive in pregnancy.
The British Hypertension Society recommends that drug therapy should be started in all patients with sustained systolic blood pressures of greater than or equal to 160mmHg or sustained diastolic blood pressures of greater than or equal to 100mmHg despite non-pharmacological measures.
Drug treatment is also indicated in patients with sustained systolic blood pressures of 140-159mmHg or diastolic pressures of 90-99mmHg if target organ damage is present or there is evidence of established cardiovascular disease or diabetes or the 10 year risk of CHD is raised.
Elevated blood pressure readings on three separate occasions are generally taken to confirm sustained high blood pressure.
British Hypertension Society Guidelines 1999.
Further information
http://bmj.bmjjournals.com/cgi/content/full/319/7210/630
http://www.hyp.ac.uk/bhs/resources/guidelines.htm
The routine surveillance of the patient population for hypertension is dealt with in the organisational indicators.
BP 1.2 Reporting and Verification
The practice reports the number of patients on its hypertension disease register and the number of patients on its hypertension register as a proportion of total list size.
Verification - PCOs may compare the expected prevalence with the reported prevalence.
Hypertension (BP) Indicator 2
The percentage of patients with hypertension whose notes record smoking status at least once since diagnosis
BP 2.1 Rationale
The only indicator relating to overall assessment included in the Quality and Outcomes Framework relates to smoking cessation. This is partly because of its importance, and partly because of the difficulties of consistently recording other aspects of the assessment of patients with hypertension.
In addition to smoking history, the British Hypertension Society recommends that all patients with hypertension should have a thorough history and physical examination. The aims are to elicit and document:
- Causes of hypertension, eg renal disease, endocrine disease
- Contributory factors eg obesity, excess alcohol intake
- Complications of hypertension eg previous stroke, left ventricular hypertrophy
- Cardiovascular risk eg smoking, family history.
- Urine strip test for blood and protein
- Serum creatinine and electrolytes
- Blood glucose
- Serum total cholesterol
- ECG.
Further information: http://www.wellclosesquare.co.uk/protocol/bhsgui/bhsgui.htm
Formal estimation of CHD risk using a recognised chart eg Joint British Societies Recommendations should be undertaken.
A number of risk calculators are available at http://www.wellclosesquare.co.uk/protocol/bhsgui/bhsgui.htm
The British Hypertension Society Guideline cites evidence that current management of patients with hypertension leaves patients at an unacceptably high risk of cardiovascular complications and death, particularly from CHD but also from stroke. In part this is a consequence of suboptimal blood pressure control but other factors have been shown to be important. These are:
- Evidence of target organ damage before treatment
- A history of cigarette smoking before treatment
- The serum cholesterol values before and during treatment.
BP 2.2 Reporting and Verification
Practices should report the percentage of patients on the hypertension disease register who have had their smoking status recorded at least once.
Hypertension (BP) Indicator 3
The percentage of patients with hypertension who smoke, whose notes contain a record that smoking cessation advice or referral to a specialist clinic, if available, has been offered at least once
BP 3.1 Rationale
Evidence for smoking cessation is largely extrapolated from studies of patients with CHD.
Many strategies have been used to help people to stop smoking. A meta-analysis of controlled trials in patients post myocardial infarction showed that a combination of individual and group smoking cessation advice, and assistance reinforced on multiple occasions - initially during cardiac rehabilitation and reinforced by primary care teams - gave the highest success rates.
Reference Grade B recommendation SIGN guidelines 41/51
Further information: http://www.sign.ac.uk/guidelines/fulltext/51/index.html
Further information: http://www.sign.ac.uk/guidelines/fulltext/41/index.html
A number of studies have recently shown benefits from the prescription of nicotine replacement therapy or buproprion in patients who have indicated a wish to quit smoking. Further guidance is available from NICE.
Further information: http://www.nice.org.uk/pdf/NiceNRT39GUIDANCE.pdf
In a significant number of PCOs across the UK specialist smoking cessation clinics are now available. Referral to such clinics, where they are available, can be discussed with patients. This should also be recorded as smoking cessation advice.
BP 3.2 Reporting and Verification
The practice should report the percentage of patients on the hypertension disease register who smoke who have been offered smoking cessation advice at least once.
Hypertension (BP) Indicator 4
The percentage of patients with hypertension in whom there is a record of the blood pressure in the past 9 months
BP 4.1 Rationale
The frequency of follow-up for treated patients after adequate blood pressure control is attained depends upon factors such as the severity of the hypertension, variability of blood pressure, complexity of the treatment regime, patient compliance and the need for non-pharmacological advice.
British Hypertension Society Guidelines 1999
Further information: http://www.wellclosesquare.co.uk/protocol/bhsgui/bhsgui.htm
There is no specific recommendation in the British Hypertension Society Guidelines regarding frequency of follow-up in patients with hypertension. For the purposes of the contract it has been assumed that this will be undertaken at least six-monthly with the audit standard being set at nine months.
BP 4.2 Reporting and Verification
Practices should report the percentage of patients on their hypertension register who have had a blood pressure measured in the last 9 months.
Hypertension (BP) Indicator 5
The percentage of patients with hypertension in whom the last blood pressure (measured in the last 9 months) is 150/90 or less
BP 5.1 Rationale
For most patients a target of 140/85 is recommended. However, the British Hypertension Society suggests an audit standard of 150/90 which has been adopted for the contract.
BP 5.2 Reporting and Verification
Practices should report the percentage of patients on their hypertension register whose last recorded blood pressure is 150/90 or less. The blood pressure must have been recorded in the last 9 months.