Quality and outcomes framework guidance:
Summary of Indicators - clinical domain 2011/12

Secondary Prevention of Coronary Heart Disease

Indicator Points Target Practice
Records      
CHD 1. The practice can produce a register of patients with coronary heart disease 4 Yes Yes
Diagnosis and initial management      
CHD 13. The percentage of patients with newly diagnosed angina (diagnosed after 1 April 2011) who are referred for exercise testing and/or specialist assessment 7 90%  
Ongoing Management      
CHD 6. 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 71%  
CHD 8. 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 70%  
CHD 9. 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 90%  
CHD 10. 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 60%  
CHD 14. The percentage of patients with a history of myocardial infarction (diagnosed after 1 April 2011) who are currently treated with an ACE inhibitor (or Angiotensin II antagonist if ACE intolerant), aspirin or an alternative anti-platelet agent, beta blocker and statin (unless a contraindication or side effect are recorded). 10 80%  
CHD 12. The percentage of patients with coronary heart disease who have a record of influenza immunisation in the preceding 1 September to 31 March 7 90%  

Primary prevention of cardiovascular disease

Indicator Points Target Practice
Initial diagnosis      
PP1. 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 tool 8 70%  
Ongoing management      
PP2. The percentage of people diagnosed with hypertension (diagnosed after 1 April 2009) who are given lifestyle advice in the preceding 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet 5 70%  

Heart Failure

Indicator Points Target Practice
Records      
HF1: The practice can produce a register of patients with heart failure. 4 Yes Yes
Initial diagnosis      
HF2: 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 90%  
Ongoing management      
HF3: 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 80%  
HF4. 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. 9 60%  

Stroke and TIA

Indicator Points Target Practice
Records      
STROKE 1. The practice can produce a register of patients with Stroke or TIA 2 Yes Yes
STROKE 13. The percentage of new patients with a stroke or TIA who have been referred for further investigation. 2 80%  
Ongoing Management      
STROKE 6. 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 71%  
STROKE 7. The percentage of patients with TIA or stroke who have a record of total cholesterol in the last 15 months 2 90%  
STROKE 8. 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 60%  
STROKE 12. 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 90%  
STROKE 10. The percentage of patients with TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March 2 85%  

Hypertension

Indicator Points Target Practice
Records      
BP 1. The practice can produce a register of patients with established hypertension 6 Yes Yes
Ongoing Management
     
BP 4. The percentage of patients with hypertension in whom there is a record of the blood pressure in the previous 9 months 16 90%  
BP 5. The percentage of patients with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 or less 57 70%  

Diabetes Mellitus

Indicator Points Target Practice
Records      
DM 19.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 Yes Yes
Ongoing Management      
DM 2.The percentage of patients with diabetes whose notes record BMI in the previous 15 months 3 90%  
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 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 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 90%  
DM 21. The percentage of patients with diabetes who have a record of retinal screening in the previous 15 months 5 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 90%  
DM 10. The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months 3 90%  
DM30. The percentage of patients with diabetes in whom the last blood pressure is 150/90 or less 8 71%  
DM30. The percentage of patients with diabetes in whom the last blood pressure is 150/90 or less 8 71%  
DM31. The percentage of patients with diabetes in whom the last blood pressure is 140/80 or less 10 60%  
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 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 90%  
DM 15. The percentage of patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with ACE inhibitors (or A2 antagonists) 3 80%  
DM 17. The percentage of patients with diabetes whose last measured total cholesterol within previous 15 months is 5 mmol/l or less 6 70%  
DM 18. The percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March. 3 85%  

Chronic Obstructive Pulmonary Disease

Indicator Points Target Practice
Records      
COPD 1. The practice can produce a register of patients with COPD 3 Yes Yes
Initial diagnosis      
COPD15. The percentage of all patients with COPD diagnosed after 1 April 2011 in whom the diagnosis has been confirmed by post bronchodilator spirometry 5 80%  
Ongoing management      
COPD 10. The percentage of patients with COPD with a record of FeV1 in the previous 15 months 7 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 90%  
COPD 8. The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March 6 85%  

Epilepsy

Indicator Points Target Practice
Records      
EPILEPSY 5. The practice can produce a register of patients aged 18 and over receiving drug treatment for epilepsy 1 Yes Yes
Ongoing management      
EPILEPSY 6. 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 90%  
EPILEPSY 8. 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 70%  
EPILEPSY 9. 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 90%  

Hypothyroid

Indicator Points Target Practice
Records      
THYROID 1. The practice can produce a register of patients with hypothyroidism 1 Yes Yes
Ongoing management      
THYROID 2. The percentage of patients with hypothyroidism with thyroid function tests recorded in the previous 15 months
6 90%  

Cancer

Indicator Points Target Practice
Records      
CANCER 1. 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 Yes Yes
Ongoing management      
CANCER 3. The percentage of patients with cancer, diagnosed within the last 18 months who have a patient review recorded as occurring within 6 months of the practice receiving confirmation of the diagnosis
6 90%  

Palliative Care

Indicator Points Target Practice
Records      
PC1: The practice has a complete register available of all patients in need of palliative care/support irrespective of age 3 Yes Yes
Ongoing management      
PC2: The practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed. 3 Yes Yes, monthly

Mental Health

Indicator Points Target Practice
Records      
MH 8. The practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses 4 Yes Yes
Ongoing management      
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 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 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 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 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 preceding15 months 5 80%  
MH16. The percentage of patients (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 five years 5 80%  
MH17. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding nine months 1 90%  
MH18. The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range in the preceding four months 2 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 50%  

Asthma

Indicator Points Target Practice
Records      
ASTHMA 1. 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 Yes Yes
Initial Management      
ASTHMA 8. The percentage of patients aged eight and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility 15 80%  
Ongoing management      
ASTHMA 3. 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 80%  
ASTHMA 6. The percentage of patients with asthma who have had an asthma review in the previous 15 months 20 70%  

Dementia

Indicator Points Target Practice
Records      
DEM1: The practice can produce a register of patients diagnosed with dementia 5 Yes Yes
Ongoing management      
DEM2: The percentage of patients diagnosed with dementia whose care has been reviewed in the previous 15 months 15 60%  
DEM3. The percentage of patients with a new diagnosis of dementia (from 1 April 2011) with a record of FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded six months before or after entering on to the register 6 80%  

Depression

Indicator Points Target Practice
Diagnosis and initial management
     
DEP1: The percentage of patients on the diabetes register and /or the CHD register for whom case finding for depression has been undertaken on one occasion during the previous 15 months using two standard screening questions 6 90%  
DEP4. In those patients with a new diagnosis of depression, recorded between the preceding 1 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 90%  
DEP5. 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 80%  


Chronic Kidney Disease

Indicator Points Target Practice
Records
      
CKD1: 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 Yes Yes
Initial Management      
CKD2: The percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months 6 90%  
Ongoing Management      
CKD3: 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 70%  
CKD5. 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 80%  
CKD6. 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 6 80%  

Atrial Fibrillation

Indicator Points Target Practice
Records
      
AF1: The practice can produce a register of patients with atrial fibrillation. 5 Yes Yes
Initial diagnosis      
AF4. The percentage of patients with atrial fibrillation diagnosed after 1 April 2008 with ECG or specialist confirmed diagnosis 10 90%  
Ongoing Management      
AF3: The percentage of patients with atrial fibrillation who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy. 12 90%  

Obesity

Indicator Points Target Practice
Records
      
OB1: 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 Yes Yes

Learning Disabilities

Indicator Points Target Practice
Records
      
LD1. The practice can produce a register of patients aged 18 years and over with learning disabilities 4 Yes Yes
LD2. The 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 70%  

Smoking Indicators

Indicator Points Target Practice
Ongoing management
     
Smoking 3. The percentage of patients with any or any combination of the following conditions: CHD, 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 30 90%  
Smoking 4. The percentage of patients with any or any combination of the following conditions: CHD, 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 90%