This area is part of the "Tackling health inequalities" domain. It aims to reduce the gap between identified and estimated prevalence of hypertension in order to minimise population-level CVD risk. 


It includes 6 indicators which focus on:

  • Confirming or excluding a Hypertension diagnosis based on a recent elevated blood pressure reading.
  • Prescribing statins for patients with a high CVD risk score.
  • Referring patients with a high cholesterol for an assessment for familial hypercholesterolaemia.
  • Prescribing DOACs for Atrial Fibrillation patients with a CHADSVASc score of 2 or more for males or 1 or more for females.
  • Prescribing DOACs for Atrial Fibrillation patients depending on their most recent CHADSVASc score who are currently on Edoxaban.


CVD-01 - this indicator will report on patients 18 years or over with an elevated blood pressure reading (>140/90) recorded in the 2 years prior to 1st April 2022 or after 1st April 2022 and are not on the hypertension register. These patients need a follow-up to confirm or exclude a diagnosis of hypertension. 


If the latest BP recording this financial year is <140/90 no further action is required. However, if the latest BP recording this financial year is still >=140/90 then a follow-up is needed and the below is defined as 'clinically appropriate' follow-up:

  • Subsequent change of medication AND subsequent blood pressure reading of <140/90 mmHg.
  • Recording of Ambulatory Blood Pressure Monitoring (including as source of first BP reading in this financial year).
  • Recording of Home Blood Pressure Monitoring (including as source of first BP reading in this financial year).
  • Addition to QOF Hypertension register AND same day referral for specialist assessment.
  • Addition to QOF Hypertension register AND EITHER subsequent commencement of antihypertensive therapy OR patient declined antihypertensive therapy. 


NB - Patients receiving end of life care are excluded from this indicator. 


Personalised care adjustments (PCA or otherwise known as exceptions) can be applied manually for patients who have declined ambulatory/home blood pressure testing. Applying the appropriate decline codes in the patient record will remove the patient from this indicator. 

 

The BP readings and clinical follow up requirements for this indicator can take place in the GP practice or community pharmacy. If taken place in the community pharmacy this information must be coded in the GP clinical system. 

 

CVD-02 - this indicator looks at the increase of patients on the Hypertension register since the 31st March 2022, suggesting that a majority of this is from the worked achieved in CVD-01.

 

CVD-03 - this indicator looks at high risk CVD patients to be treated with statins. The high risk criteria is based on patients aged 25 to 84 years with a QRISK2 or 3 greater than 20 percent. 

 

NB - patients established with CVD or patients receiving end of life care are excluded from this indicator. 


Personalised care adjustments (PCA or otherwise known as exceptions) can be applied manually for patients who have declined ambulatory/home blood pressure testing. Applying the appropriate decline codes in the patient record will remove the patient from this indicator. 

 

The BP readings and clinical follow up requirements for this indicator can take place in the GP practice or community pharmacy. If taken place in the community pharmacy this information must be coded in the GP clinical system. 

  

CVD-04 - this indicator looks at any patients aged 29 years or under with a total cholesterol greater than 7.5 and any patients aged 30 years or over with a total cholesterol greater than 9.0 to be referred for an assessment for familial hypercholesterolaemia. 

 

NB - patients with a genetically confirmed diagnosis of familial hypercholesterolaemia, patients receiving end of life care and patients coded with secondary hyperlipidaemia/hypercholesterolaemia disorders WITHOUT a subsequent code of History of Secondary hyperlipidaemia/hypercholesterolaemia are excluded from this indicator. 

 

Personalised care adjustments (PCA or otherwise known as exceptions) can be applied manually for patients who have declined a referral for assessment. 


Please note - there is currently no code available for "Referral to familial hypercholesterolaemia"

 

CVD-05 - this indicator looks at AF patients with a CHA2DS2-VASc score of 2 or more if female or 1 or more if male to be prescribed a DOAC or a Vitamin K antagonist. This particular indicator follows a sequence of criteria:

  1. Success criterion 1 - patient prescribed a DOAC
  2. Success criterion 2 - if patient unsuitable for DOAC, prescribed a Vitamin K antagonist. 

 

NB - patients with an AF resolved code, a subsequent CHA2DS2-VASc score of less than 2 if female or 1 or more for if male or a mechanical prosthetic valve replacement are excluded from this indicator.

 

Personalised care adjustments (PCA or otherwise known as exceptions) can be applied manually for patients who have declined or not clinically suitable. However, as this indicator has a number of success criterions (mentioned above), if patients decline or are unsuitable for criterion 1, they will shift to criterion 2, a further decline/clinically unsuitable code for Vitamin K antagonist needs to be applied before the patient is removed altogether from the denominator. 

 

CVD-06 - this indicator looks at AF patients currently on Edoxaban with a CHA2DS2-VASc score of 2 or more if female or 1 or more if male to be prescribed a DOAC.

 

NB - patients with an AF resolved code and a subsequent CHA2DS2-VASc score of less than 2 or more if female or 1 or more if male are excluded from this indicator.


Achievement


IndicatorPointsThreshold
CVD-01 - Percentage of patients aged 18 years or over with an elevated blood pressure reading (≥ 140/90mmHg) and not on the QOF Hypertension Register, for whom there is evidence of clinically appropriate follow-up to confirm or exclude a diagnosis of hypertension71LT - 25%
UT - 50%
CVD-02 - Percentage of registered patients on the QOF Hypertension Register35LT - 0.6 percentage point increase
UT - 1.2 percentage point increase
CVD-03 - Percentage of patients aged between 25 and 84 years inclusive and with a CVD risk score (QRISK2 or 3) greater than 20 percent, who are currently treated with statins31LT - 48%
UT - 58%
CVD-04 - Percentage of patients aged 29 and under with a total cholesterol greater than 7.5 OR aged 30 and over with a total cholesterol greater than 9.0 who have been referred for assessment for familial hypercholesterolaemia18LT - 20%
UT - 48%
CVD-05 - Percentage of patients on the QOF Atrial Fibrillation register and with a CHA2DS2-VASc score of 2 or more (1 or more for patients that are not female), who were prescribed a direct-acting oral anticoagulant (DOAC), or, where a DOAC was declined or clinically unsuitable, a Vitamin K antagonist66LT - 70%
UT - 95%
CVD-06 - Number of patients who are currently prescribed Edoxaban, as a percentage of patients on the QOF Atrial Fibrillation register and with a CHA2DS2-VASc score of 2 or more (1 or more for patients that are not female) and who are currently prescribed a direct-acting oral anticoagulant (DOAC)66LT - 25%
UT - 35%

 

Monitoring Network DES Activity for CVD

Navigate to the Ardens Searches > 5.32 Network Contract DES (NCD) (2022-23) > a. Investment and Impact Fund (IIF)

 

The Work done folder will show practice achievement.

 

The Work to do folder will identify outstanding work to be done.


 

For each 'TO DO' search, once run click, on the Population Included tab to view the list of patients.


For further information for outstanding work for CVD-01, please see the following support article.

 

Supporting Ardens Resources

To support practices with the indicators above the following resources are available:


If you require any further assistance on the process above, please contact Ardens support on: support-emis@ardens.org.uk