10 Points to Quality - Hypertension, hypothyroidism and cancer
Know who has hypertension
Your practice can earn nine points for creating a register of patients with hypertension, but it is important to be clear about the criteria for inclusion. The diagnosis of hypertension requires a sustained systolic blood pressure of 160mmHg or more and/or diastolic blood pressure of 100mmHg or more. Levels as low as 140/90mmHg apply in patients who have established cardiovascular disease, diabetes, or target organ damage. Unless you suspect accelerated hypertension (which is a medical emergency), measure blood pressure on three or four separate occasions at least a month apart and calculate the arithmetical mean. Patients who have had a single high blood pressure measurement, or pregnancy-induced hypertension which resolved after delivery, should not be included in your hypertension register.
Record smoking status
Unlike other indicator sets, in which the information has to be updated annually, you need only record the smoking status of patients on your hypertension register once to earn up to 10 points, with a further 10 points available for offering smoking cessation advice to 90 per cent of smokers. As hypertension is a very common condition, this will make a significant contribution towards meeting the organisational indicator targets for recording smoking status.
Set up a system for reviewing patients every six months
Six months can pass very quickly, It is important to have a structured recall system. That way you can earn as many as possible of the 20 points available for measuring the blood pressure of 90 per cent of patients on your hypertension register within the previous nine months.
Look beyond the listed indicators
The six-monthly review should also be an opportunity to assess overall cardiovascular risk (including measuring cholesterol and screening for diabetes), check compliance and ask about drug side-effects. It's also a chance to look for signs of target organ damage. The new contract document says 'it is anticipated that clinicians will address risk factors in all patients with hypertension', and these other risk factors may be added to the indicator set in future.
Treat hypertension logically and aggressively
With 56 points more than 5 per cent of the total number of quality indicator points available for reducing the blood pressure of at least 70 per cent of your hypertensive patients to 150/90mmHg or less, it is worth making sure that you are using the most appropriate treatment for each patient. Make the British Hypertension Society guidelines the cornerstone of your hypertension management, and be prepared to switch and/or add in antihypertensive drugs depending on response and side-effects. Use the exception reporting system to exclude patients whose blood pressure is not controlled on maximal therapy from your statistics.
Search for patients on thyroxine
There are only eight points available in the hypothyroidism indicator set, but it is possible to earn these with relatively little effort. Producing a register of patients with hypothyroidism should be straightforward, as they will all be prescribed thyroxine, which is not used in conventional medical practice to treat any other condition.
Search for the date of the most recent TFT results
The other six points in this indicator set are for having checked thyroid function within the previous 15 months. It is not necessary to record the actual result, only that the test has been done. However, entering the TSH and/or T4 level requires only a few extra keystrokes and will make it easy to audit your performance in the treatment of hypothyroidism an area in which most GPs can demonstrate good practice.
Set up an annual recall system for hypothyroid patients
As with hypertension, it is all too easy for GPs to lose track of time, and for patients to drift into the habit of postponing their blood tests, or to increase or discontinue their thyroxine without seeking medical advice.
Use the review facility on your computerised prescribing system.
Standardise the codes used for recording cancer diagnoses on computer
Having a register of patients diagnosed with cancer since April 1, 2003 can earn your practice six points. Some of the common cancers can be entered under several different codes, and reporting will be easier if your practice uses the preferred codes listed in the new contract document. The only cancers which need not be included on the register are non-melanoma skin cancers.
Ensure you see patients within six months of a diagnosis of cancer being made
This indicator, which is worth up to six points, looks very vague beside some of the more target-oriented tasks, but is no less important. Although almost all patients suspected of having cancer will be referred to secondary care for diagnosis and initial treatment, the overall quality of their care is likely to be strongly influenced by the level of interest taken by their GP. The most important function of this review is to ensure that follow-up arrangements are clear. It is also a good opportunity to allow patients and relatives to talk through their experience and ask questions, and, if appropriate, to discuss palliative care and organise referral to cancer services in the community.