By Lilian Anekwe
The QOF’s hypertension indicators could be tightened up to encourage GPs to ramp up the management of hypertension in primary care, after secondary care consultants lobbied NICE to pilot new indicators.
The British Hypertension Society, a stakeholder in the NICE process, submitted a request to NICE to consider developing new indicators for piloting that would encourage GPs to intensify their management of patients with hypertension, and to bring the QOF into line with NICE guidance, which recommends a blood pressure target of 140/90 mmHg in most patients.
At a meeting of the independent primary care QOF indicator advisory committee in London yesterday, two potential new indicators were recommended for piloting – a target of 150/90 mmHG with a 90% upper threshold, and a tougher 140/90 mmHg target with a lower, 50%, threshold.
The staggered indicators were proposed after the committee heard concerns that general practice achievement in hypertension has reached a plateau.
The committee also discussed an analysis, published in the BMJ in January, which found ‘pay for performance had no discernible effects on processes of care or on hypertension-related clinical outcomes’, and suggested the management of hypertension was already improving before the introduction of the QOF.
The study was controversial and was fiercely rebuffed by GP leaders at the time, with GPC chair Dr Laurence Buckman defending GP performance and arguing that the QOF was more than ‘simply an incentive scheme’.
The committee also heard the plateau could be due to the performance threshold being set too low – and could be overcome by raising thresholds, either for individual indicators or across the whole clinical domain of the QOF.
But the advisory committee decided to pilot the indicator – with extra ‘flexibility’ granted to allow the indicators to be piloted with an age cap, that could either exclude patients over 80, or only apply the lower target of 150/90 mmHg to avoid concerns that elderly patients could be treated over-aggressively and put at risk of harm.
Several further changes and amendments to existing indicators were also recommended at the meeting:
• Two indicators for screening of blood pressure in the community – Records 11 and Records 17 – should be widened from the ages of 45 and over, to 40 and over, ‘to bring them in line with vascular checks’
• The wording of MH15 – the percentage of patients with severe mental illnesses who have a record of blood glucose in the previous 15 months – should be amended to allow GPs to use HbA1c testing, as well as plasma glucose, to incentivise case finding, and because ‘in the light of the updated World Health Organisation 2011 diagnostic criteria for diabetes there is a need to review the indicator wording’
• Amending the QOF diabetes register to include other kinds of diabetes, after an audit by the RCGP found ‘patients coded with diabetes other than type 1 or type 2 may miss out on recall and screening’