This year has not brought much in the way of significant change to the CHD Business rules. However, there are a few to mention as well as one or two areas of frequent confusion which are worth highlighting.
Firstly, the beta blocker requirement has been retired.
Secondly, there are threshold changes to indicators.
Thirdly, there are changes to CHD6 which are worth focussing on.
Finally, it is important to ensure full prevalence, for instance by ensuring that patients who have had Coronary Interventions have actually been added to the CHD register.
Beta blocker requirement
Until this year, all patients with angina, IHD or CHD read codes, irrespective of when that code was added, were required to be demonstrably on a beta blocker, unless they had a valid exception code to explain why they could not take one. This requirement has now been removed. So now, unless the patient has had a Myocardial Infarction on or after 1.4.11, they no longer need to be on this family of drugs, at least for QOF purposes. Quite why the authors think this is a good idea I don’t know, since I’m sure the benefits of beta blockers to patients with angina, IHD and myocardial infarctions pre-dating 2011 have not disappeared, but that’s what the rules say.
Every one of the CHD indicators has had its threshold changed. All will now be harder to score full points on. The changes are as follows:
CHD2 (BP ≤150/90 in L12M) increased from 40-75% to 53-93%
CHD3 (Cholesterol ≤ 5.0 in L12M) increased from 45-70% to 45-85%
CHD4 (Patient has been given a Flu vaccination) increased from 50-90% to 56-96%
CHD5 (Patient taking aspirin, clopidogrel or anti-coagulant) increased from 50-90% to 56-96%
CHD6 (Patient taking aspirin, a beta blocker, an ACE or ARB and a statin) increased from 45-80% to 60-100%
CHD6 and its catches
It is worth looking at the CHD6 indicator in a little more detail. Firstly, it is one of two indicators that now have maximal thresholds of 100%, so every eligible patient must either score the indicator or be excepted from it to score full points. The other is HF3 (Patients with heart failure caused by left ventricular dysfunction required to be on an ACE).
The CHD6 indicator is tricky to score because the patient has to be on four separate drugs: aspirin any type of beta blocker, either an ACE or an ARB and any statin.
It is important to note the following:
- The patient can be coded as buying their own aspirin as an alternative to having a script, and that can be added any time in the QOF year
- The statin requirement is irrespective of the level of total cholesterol pre-treatment
- From this year, the previous requirement to have a valid exception code to ACE inhibitors if the patient was on an angiotensin receptor blocker has been dropped. So now you can simply have the patient on Losartan, for example, if you wish and they’ll still count for CHD6 as long as they are on the other three families of drugs.
- Apart from the aspirin over-the-counter option mentioned above, all the four families of drugs must be demonstrably prescribed in the six months before the reference date (from 1 October each QOF year) - any earlier and they don’t count.
The importance of prevalence
Finally, it is easy to forget about the financial benefits of increasing your prevalence of the QOF diseases. This is particularly the case this year, when actually scoring all the points is going to be a real challenge. Therefore it is important to try to mitigate any income loss from missing points in the QOF by ensuring that your documented prevalence of the QOF diseases is as high as it should be.
In my practice, we discovered that we had about eight patients who had such severe CHD that they had had coronary interventions (CABG or PCI), but they had never actually had a ‘trigger’ read code added to put them into the CHD register (for example CHD, Angina or IHD.). Since such patients must have been diagnosed as having IHD of one type or another, we were able to have a quick look at the hospital letters, note the comments about angiogram findings and then add the IHD code – thus increasing our prevalence of CHD.
So run a report looking for read codes coding for coronary bypass and PCI, e.g. 792..%, coronary artery operations, 793G.%, stenting ops, and ZV45K, presence of coronary artery graft and then look to see if any of these patients are not in your CHD register. You may well find a few.
Dr Simon Clay is a GP in Erdington, Birmingham