GP Dr Gavin Jamie looks at how practices can attain maximum points within the cholesterol control and lipid management area of QOF’s clinical domain
Summary – indicators and value
- Indicators: 2
- Points: 30
- Prevalence*: 5% (this is a rough estimate based on latest available QOF data as this is a new area)
- Estimated £/patient on the register: £6 for CHOL001, £8 for CHOL002
These are two new indicators for 2023/24 and, as we generally find with newer indicators, they are quite complicated. Both take a mix of patients from other registers and combine them into a single population. As they are new and have a hybrid register it is difficult to be accurate about payment, so the figures above are more of an estimate than before.
Indicator CHOL001: Statin prescribing for patients with cardiovascular disease (14 points)
This carries 14 points and requires statins for 95% of patients on the coronary heart disease (CHD), peripheral arterial disease (PAD), stroke, and chronic kidney disease (CKD) registers. In the past there might have been separate indicators in each of these areas but now there is a single, combined, indicator.
The diabetes area still has its own indicator for patients to be prescribed statins. Patients who are 17 years old and over with diabetes are specifically excluded from this new indicator, even if they have CHD etc. (Although, oddly, they do count for prevalence purposes).
Patients are also excluded if they are on the palliative care register. As there is quite a large overlap between cardiovascular disease and diabetes, the number of patients excluded may be considerable.
Patients may be exception reported under the personalised care adjustment if they have declined a statin.
The rules for adverse reactions are more complicated. Most patients will be prescribed a statin. The indicator will also include patients prescribed bempedoic acid, ezetimibe, icosapent ethyl, inclisiran or a PCSK9 inhibitor (antibody therapy) if, and only if, the patient has a recorded adverse reaction to a statin. This also means that recording an adverse reaction or allergy to a statin will not except the patient from the indicator.
Patients may also be excepted if they have a code indicating informed dissent or an adverse reaction to lipid lowering therapy in general.
- The usual timescales apply with respect to prescriptions, which must be issued in the second half of the QOF year – prescriptions of six months or more may not be picked up by this indicator.
- While patients with cardiovascular disease are likely to have a prescription for statins already, the number of patients with chronic kidney disease prescribed statins may be lower. This could be a group to concentrate efforts on at the start of the year.
- Where patients are unable to tolerate statins there is now a much greater emphasis on the use of alternative medications. These patients may have been exception reported in the past and it is worth checking to see whether an alternative cholesterol lowering medication may be suitable.
Indicator CHOL002: Patients with CHD, PAD or stroke/TIA with non-HDL <2.5 or LDL <1.8mmol/L) (16 points)
This looks similar to the other cholesterol indicator but there are some significant differences.
Importantly, it does not include patients with chronic kidney disease. However, it DOES include patients with diabetes or on the palliative care register if they are also on the CHD, PAD or stroke registers. That will mean that the population for this indicator is rather different to CHOL001.
As it stands, there is very little exception reporting available for this indicator. Patients are only excepted if they decline a cholesterol test or register with the practice after July in the QOF year. There would need to be a specific code recording a declined test (e.g. ‘Cholesterol test declined’) recorded to trigger that exception. This may change through the year if a new version of the QOF business rules are published.
In the current set of business rules for 23/24, there are no exception reports for treatment allergy, informed dissent or being on the maximum tolerated treatment dose.
Otherwise, the indicator is as described with non-HDL being required to be below 2.5mmol/L or, if that is not available then LDL cholesterol should be less than 1.8mmol/L. Note that non-HDL will always take priority even if there is a subsequent LDL measurement. This may be significant if local lab reporting changes or if patients move between practices.
- This indicator uses codes that have not been in QOF before, so it is worth checking that these are being recognised. These may be recorded directly from lab tests, point of care patient testing or by transcribing results from hospital letters. It is essential that any templates for manual entry are up to date.
- Identifying patients with higher values, adjusting medication and retesting will take some time so it is important to start as early as possible to have the best chance of scoring highly in this indicator.
- Some of these treatments may be administered in hospital. Make sure that they are coded onto the practice system as discharge summaries or out patient letter are received.
Dr Gavin Jamie is a GP partner in Swindon and runs the QOF Database website
NHS England – Quality and Outcomes Framework guidance for 2023/24. Published 30 March 2023.