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Independents' Day

Stroke or transient ischaemic attacks

Continuing our new series on the quality and outcomes framework, Dr John Couch looks at the money available and indicates the degree of effort required to earn points from stroke or TIAs

Points achieved with complete ease

Stroke indicator 1 Practice can produce register of patients with stroke and TIA.

Value four points

Validate your register at least 12-monthly. Remove coding or keep note of incorrectly diagnosed patients. Use alternate searches to pick up missed patients. Use exact dates of diagnosis especially if after 1/1/03. Set up stroke/TIA template that all clinical staff must use for every patient contact. Do you need a stroke/TIA clinic? Call/recall system essential. Do not Read-code until certain of diagnosis. Make list or code patients needing home visits (housebound patients will be greater for this disease area) as you will need to organise nurse or GP home checks to maximise point scores for all indicators.

Stroke 3 Percentage stroke and TIA patients with smoking status recorded in previous 15 months. Once-only recording, since diagnosis, for those who have never smoked.

Value three points ­ payment tiers 25-90 per cent

This is basic data. Aim to see all patients on register between 1/1/04 and 31/3/05. Do computer search at least three months before 31/3/05 and phone patients for missing data. Update smoking status/advice, arrange bloods, invite for review. Mark records for opportunistic checks. Repeat annually.

Stroke 4 Percentage of stroke and TIA patients who smoke whose notes contain record that smoking cessation advice has been offered in the last 15 months.

Value two points ­ payment tiers 25-70 per cent

As for Stroke 3. Ensure correct Read code (8CAL) is on template.

Stroke 5 Percentage of stroke and TIA patients with BP recorded in last 15 months.

Value two points ­ payment tiers 25-90 per cent

Ensure all patients have had a measurement recorded on/after 1/1/04. Check BP at every contact. Aim for bare minimum of annual recording. Chase defaulters quickly as there is a limited safety margin to get BP within range by 31/3/05. Have clear protocol for management of patients with BP >150/90.

Stroke 7 Percentage of stroke and TIA patients who have a record of total cholesterol in last 15 months.

Value two points ­ payment tiers 25-90 per cent

As for Stroke 5. Have clear protocol for management of patients with total fasting cholesterol >5.0mmol/L.

Stroke 9 Percentage of patients with stroke, shown to be non-haemorrhagic, or TIA, who have record that aspirin, an alternative antiplatelet agent or an anticoagulant is being taken (unless a contraindication or side-effects are recorded).

Value four points ­ payment tiers 25-90 per cent

Use correct codes on template. Search under drugs to cross-check. For patients not on relevant drugs check individual records to look for CIs or SEs, code these using the approved codes (see BMA supporting documentation to Q&OF). Phone patients, not apparently on drugs, to record if on OTC aspirin. See patients not on medication.

Points achieved with good planning

Stroke 2 The percentage of new patients (presenting after 1/4/03) with presumptive stroke who have

been referred for confirmation of diagnosis by CT or MRI scan.

Value two points ­ payment tiers 25-80 per cent

Count patients admitted to hospital with stroke as a referral. Ensure this group had or are planned to have CT or MRI, entering code once result known. If unclear ask hospital for details. Refer all patients not seen as in- or outpatient to OPD (preferably at stroke unit or stroke OPD) for CT or MRI, assuming no direct GP access. Code referrals because Q&OF codes for this indicator assume test done: delayed test could affect your figures.

Stroke 10 Percentage of stroke and TIA patients who have had an influenza vaccination in the preceding September 1 to March 31.

Value two points ­ payment tiers 25-85 per cent

Advise patients at each visit and vaccinate if seen within date range. If not, mailshot or phone reminder during flu campaign. Home vaccination where necessary.

Points achieved with real striving

Stroke 6 Percentage of stroke and TIA patients in whom the last recorded BP reading (measured in the last 15 months) is 150/90 or less.

Value five points ­ payment tiers 25-70 per cent

Computer search for current achievement. Does effort and cost required to achieve higher tiers outweigh benefits? GP should review all patients with levels above indicator. Follow stepped treatment protocol including ACE as default where possible. Include weight management if clinically feasible. Consider drug budget implications.

Stroke 8 Percentage of stroke and TIA patients whose last measured total cholesterol (measured in the last 15 months) is 5.0mmol/L or less.

Value five points ­ payment tiers 25-60 per cent

As for Stroke 6. Add statin if not already on and not contraindicated.

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