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GPs go forth

NICE recommends stricter QOF blood pressure targets for patients with CVD

GPs face a major increase in workload under the proposed QOF indicators for next year, with NICE advisors recommending a hike in blood pressure targets to 140/90 mmHg for all patients with cardiovascular disease.

NICE has recommended that the existing QOF targets for hypertension in patients with coronary heart disease, stroke and peripheral arterial disease are raised from 150/90 mmHg to 140/90 mmHg for all patients aged under 80 years old.

The change brings all the indicators for cardiovascular disease in line with the raised threshold for the hypertension indicators in QOF that the GPC warned earlier this year would result in patients experiencing ‘potentially dangerous hypotension’.

The NICE indicator advisory committee also agreed to put forward new indicators on confirming the diagnosis of hypertension with ambulatory blood pressure monitoring (ABPM) and for the proportion of patients with dementia referred to specialist memory assessment services.

The recommended indicators will now be considered in the annual contract negotiations between the GPC and NHS Employers.

The committee considered evidence from 32 practices that piloted the tighter blood pressure target in patients with cardiovascular disease over six months. Despite some concerns about achieving the targets and the potential risks of overtreatment and polypharmacy, nearly 60% of practices supported having a lower target for the under-80s, while 43% said they already were working to a target of 140/90 mmHg or lower.

Exception reporting increased considerably with introduction of the new target across all patient groups, however, and a number of practices expressed concern that GPs would not accept it unless the thresholds for achieving points were cut.

The recommendations for stricter hypertension targets comes after former RCGP president Dr Iona Health said GPs should resist the ‘trend towards overtreatment’ in patients with mild hypertension and only prescribe antihypertensives for those at blood pressures of 160/100 mmHg or higher.

The GPC rejected similar indicators raising the threshold for payment under QOF from 150/90 mmHg to 140/90 mmHg earlier this year, saying that was the ‘single biggest workload change to practices’ and would increase the number of patients suffering from the adverse effects of polypharmacy, including ‘potentially dangerous hypotension’.

But the QOF advisory board at NICE recommended that the three existing indicators for hypertension control in peripheral arterial disease, coronary heart disease and stroke/TIA patients should also be tightened to 140/90mmHg in all patients aged under 80 years.

The targets remain the same at 150/90 mmHg for patients aged 80 years or over.

Results from 36 practices that took part in a pilot study of the indicator on ABPM revealed that 64% of practices felt the indicator was ‘acceptable’ for inclusion in QOF, with many saying they were already working towards it.

Just over 11% of practices were opposed it, citing the lack of availability of ABPM machines and difficulty implementing the measurement, but on hearing the evidence, the QOF advisory committee agreed that on balance use of ABPM would be cost effective – with the points rewarded highly likely to cover the cost of purchasing new devices where needed.

And despite ongoing concerns over a lack of availability of memory clinics in some areas, the committee agreed practices should be rewarded for referring patients to specialist memory assessments services in order to make a formal dementia diagnosis.

GPC deputy chair Dr Richard Vautrey warned that adding more indicators incentivising tighter blood pressure targets would end up driving GPs to chase targets against the best interests of patients.

Dr Vautrey said: ‘Practices are still struggling now with the imposed contract and adverse consequences of the tighter hypertension target, and the potential risks of polypharmacy it may bring have yet to be seen.

‘Thresholds actually went up at the same time as the targets went down last year and there’s no suggestion as yet that the Government intends to reverse that.’

He added: ‘The majority if not all of the indicators will go up again to the 75th percentile from next year, which will make it even harder for practices to achieve the more challenging indicators like the hypertension one, making adverse effects more likely as GPs chase those points. It’s a bit like a mirage, the closer you get the further away it seems to be.’

Dr Vautrey also questioned the decision to reward GPs for referring patients on for dementia diagnosis.

He said: ‘There’s a question mark if that means you’re effectively saying GPs can no longer diagnose dementia. When patients have very clear dementia it undermines the professionalism of the GP to say that they are no longer competent to make that diagnosis.’

Readers' comments (8)

  • I look forward to iatrogenic illness, rising prescribing costs and more clicks on the maximum tolerated therapy and patient unsuitable boxes. Alongside a bit more neutering of my diagnostic capabilities.

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  • We already see patients who are over treated, causing a significant impact on their lives, such as old ladies in church collapsing when the hymn singing begins and their intra thoracic pressure rises. BP is dynamic measurement - will just one raised reading over the target on a 24 ABPM initiate treatment? This is medicine by numbers, not holistic care. ..........but then, numbers are easy to measure and quantify, unlike genuine health and well being.

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  • We should individualise targets but that requires a subjective holistic appraisal of the patient,something which the modern tickbox culture does not permit.

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  • Is the pressure too much, am I going potty? Surely this is already spelled out in - HYP003 (new). This requires that in those hypertensives aged <80, their last BP should be ≤ 140/90 from July each year.

    Bah humbug.

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  • Peter Swinyard

    The problem here is the difference between the "audit target" which was at 150/90 and the "best practice target" which most would agree would be about 135/83 as giving the best outcome possible. What we cannot get through to our lords and masters is that aiming for the audit target means than many will be at the clinical target away from the "white coat" area but aiming for the new 140/90 audit target will cause much iatrogenic (or QOFogenic) illness, falls, fractures, morbidity and mortality. Let's try to persuade the government that this futile target chasing is barmy, bonkers and bad and that holistic care is desirable and actually much more challenging.
    I have also just had to do GPPAQ quaestionnaires this morning on a couch potato of 13 stone and 5ft1 tall and a recently retired firefighter who is now working as a builders navvy and has muscles where I just have aches and pains. Now - the results were fascinating. One was inactive and one was active.
    Wow - I needed the GPPAQ to tell the difference...

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  • I was just pondering what the uptake of the DES for Risk Stratification had been considering the confusing and conflicting guidance?

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  • And....How many practices have signed up to the DES so as not to miss the deadline and are yet to ascertain if it is feasible to make it financially viable. There is no penalty for signing up to a DES and then not carrying out the work, save you don't get the 'reward'. So actual take up could be even less.

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  • "NHS England refused to supply sign-up figures for the rest of the country and blocked other LATs from responding to Pulse’s request for information" Striking a blow for openness and transparency in the NHS - I give you NHS England!

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