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Clinical Indicators

  • Asthma - go to this
  • Atrial fibrillation - go to this
  • Cancer - go to this
  • Chronic obstructive pulmonary disease - go to this
  • Chronic kidney disease - go to this
  • Dementia - go to this
  • Depression - go to this
  • Diabetes mellitus - go to this
  • Epilepsy - go to this
  • Heart failure - go to this
  • Hypertension - go to this
  • Hypothyroid - go to this
  • Learning disabilities - go to this
  • Mental health - go to this
  • Obesity - go to this
  • Osteoporosis - go to this
  • PAD - go to this
  • Palliative Care - go to this
  • Secondary prevention of coronary heart disease - go to this
  • Smoking indicators - go to this
  • Stroke and TIA - go to this
  • Cardiovascular disease – primary prevention - go to this

    Secondary Prevention of Coronary Heart Disease

    Indicator Points Payment Stages
    Records    
    CHD01. The practice can produce a register of patients with coronary heart disease 4  
    Diagnosis and initial management    
    Ongoing Management    
    CHD06. The percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the preceding 15 months) is 150/90 or less 17
    40-75%
    CHD08. The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the preceding 15 months) is 5 mmol/l or less 17 45-70%
    CHD09. The percentage of patients with coronary heart disease with a record in the preceding 15 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken 7 50-90%
    CHD10. The percentage of patients with coronary heart disease who are currently treated with a beta blocker 7 40-65%
    CHD12. The percentage of patients with coronary heart disease who have had influenza immunisation in the preceding 1 September to 31 March 7 50-90%
    CHD14. The percentage of patients with a history of myocardial infarction (from 1 April 2011) currently treated with an ACE inhibitor (or ARB if ACE intolerant), aspirin or an alternative anti-platelet therapy, beta blocker and statin 10 45-80%

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    Heart Failure

    Indicator Points Payment Stages
    Records    
    HF01: The practice can produce a register of patients with heart failure. 4  
    Initial diagnosis    
    HF02: The percentage of patients with a diagnosis of heart failure (diagnosed after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment. 6 50-90%
    Ongoing management    
    HF03: The percentage of patients with a current diagnosis of heart failure due to Left Ventricular Dysfunction (LVD) who are currently treated with an ACE inhibitor or Angiotensin Receptor Blocker (ARB), who can tolerate therapy and for whom there is no contraindication. 10 45-80%
    HF04: The percentage of patients with a current diagnosis of heart failure due to Left Ventricular Dysfunction (LVD) who are currently treated with an ACE inhibitor or Angiotensin Receptor Blocker (ARB), who are additionally treated with a beta-blocker licensed for heart failure, or recorded as intolerant to or having a contraindication to beta-blockers. 9 40-65%

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    Stroke and TIA

    Indicator Points Payment Stages
    Records    
    STROKE01. The practice can produce a register of patients with Stroke or TIA 2  
    STROKE13. The percentage of new patients with a stroke or TIA who have been referred for further investigation. 2 45-80%
    Ongoing Management    
    STROKE06. The percentage of patients with a history of stroke or TIA in whom the last blood pressure reading (measured in the preceding 15 months) is 150/90 or less 5 40-75%
    STROKE07. The percentage of patients with stroke or TIA who have a record of total cholesterol in the preceding 15 months 2 50-90%
    STROKE08. The percentage of patients with stroke or TIA whose last measured total cholesterol (measured in the preceding 15 months) is 5 mmol/l or less 5 40-65%
    STROKE12. The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that an anti-platelet agent (aspirin, clopidogrel, dipyridamole or a combination), or an anti-coagulant is being taken. 4 50-90%
    STROKE10. The percentage of patients with stroke or TIA who have had influenza immunisation in the preceding 1 September to 31 March 2 45-85%

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    Hypertension

    Indicator Points Payment Stages
    Records    
    BP01. The practice can produce a register of patients with established hypertension 6  
    Ongoing Management
       
    BP04. The percentage of patients with hypertension in whom there is a record of the blood pressure in the preceding 9 months 8 50-90%
    BP05. The percentage of patients with hypertension in whom the last blood pressure (measured in the preceding 9 months) is 150/90 or less 55 45-80%

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    Diabetes Mellitus

    Indicator Points Payment Stages
    Records    
    DM32. The practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed 6  
    Ongoing Management  
    DM02.The percentage of patients with diabetes whose notes record BMI in the preceding 15 months 1 50-90%
    DM21. The percentage of patients with diabetes who have a record of retinal screening in the preceding 15 months 5 50-90%
    DM29.The percentage of patients with diabetes with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 15 months. 4 50-90%
    DM10. The percentage of patients with diabetes with a record of neuropathy testing in the preceding 15 months 3 50-90%
    DM13. The percentage of patients with diabetes who have a record of micro-albuminuria testing in the preceding 15 months (exception reporting for patients with proteinuria) 3 50-90%
    DM22. The percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the preceding 15 months 1 50-90%
    DM15. The percentage of patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with ACE inhibitors (or A2 antagonists) 3 45-80%
    DM17. The percentage of patients with diabetes whose last measured total cholesterol within preceding 15 months is 5 mmol/l or less 6 40-75%
    DM18. The percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March. 3 45-85%
    DM26. The percentage of patients with diabetes in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 15 months 17 40-50%
    DM27: The percentage of patients with diabetes in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 15 months 8 45-70%
    DM28. The percentage of patients with diabetes in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 15 months. 10 50-90%
    DM30. The percentage of patients with diabetes in whom the last blood pressure is 150/90 or less 8 45-71%
    DM31. The percentage of patients with diabetes in whom the last blood pressure is 140/80 or less 10 40-65%

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    Chronic Obstructive Pulmonary Disease

    Indicator Points Payment Stages
    Records    
    COPD14. The practice can produce a register of patients with COPD 3  
    Initial diagnosis    
    COPD15. The percentage of all patients with COPD diagnosed after 1st April 2011 in whom the diagnosis has been confirmed by post bronchodilator spirometry. 5 45-80%
    Ongoing management    
    COPD08. The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March 6 45-85%
    COPD10. The percentage of patients with COPD with a record of FEV1 in the preceding 15 months 7 40-75%
    COPD13. The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the MRC dyspnoea score in the preceding 15 months 9 50-90%

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    Epilepsy

    Indicator Points Payment Stages
    Records    
    EPILEPSY05. The practice can produce a register of patients aged 18 and over receiving drug treatment for epilepsy 1  
    Ongoing management    
    EPILEPSY06. The percentage of patients aged 18 and over on drug treatment for epilepsy who have a record of seizure frequency in the preceding 15 months 4 50-90%
    EPILEPSY08. The percentage of patients aged 18 and over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the preceding 15 months 6 45-70%
    EPILEPSY09. The percentage of women under the age of 55 years who are taking antiepileptic drugs who have a record of information and counselling about contraception, conception and pregnancy in the preceding 15 months. 3 50-90%

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    Hypothyroid

    Indicator Points Payment Stages
    Records    
    THYROID01. The practice can produce a register of patients with hypothyroidism 1  
    Ongoing management    
    THYROID02. The percentage of patients with hypothyroidism with thyroid function tests recorded in the preceding 15 months
    6 50-90%

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    Cancer

    Indicator Points Payment Stages
    Records    
    CANCER01. The practice can produce a register of all cancer patients defined as a ‘register of patients with a diagnosis of cancer excluding non-melanotic skin cancers from 1 April 2003'. 5  
    Ongoing management    
    CANCER03. The percentage of patients with cancer, diagnosed within the preceding 18 months who have a patient review recorded as occurring within 6 months of the practice receiving confirmation of the diagnosis
    6 50-90%

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    Palliative Care

    Indicator Points Payment Stages
    Records    
    PC03: The practice has a complete register available of all patients in need of palliative care/support irrespective of age 3  
    Ongoing management    
    PC02: The practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed. 3  

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    Mental Health

    Indicator Points Payment Stages
    Records    
    MH08. The practice can produce a register of patients with schizophrenia, bipolar disorder and other psychoses 4  
    Ongoing management    
    MH17. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 9 months 1 50-90%
    MH18. The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the preceding 4 months 2 50-90%
    MH10. The percentage of patients on the register who have a comprehensive care plan documented in the records agreed between individuals, their family and/or carers as appropriate 6 30-55%
    MH11. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 15 months 4 50-90%
    MH12. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 15 months 4 50-90%
    MH13. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 15 months 4 50-90%
    MH19. The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder and other psychoses who have a record of total cholesterol:hdl ratio in the preceding 15 months 5 45-80%
    MH20. The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood glucose or HbA1c in the preceding15 months 5 45-80%
    MH16. The percentage of women (aged from 25 to 64 in England and Northern Ireland, from 20 to 60 in Scotland and from 20 to 64 in Wales) with schizophrenia, bipolar affective disorder and other psychoses whose notes record that a cervical screening test has been performed in the preceding 5 years 5 45-80%

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    Asthma

    Indicator Points Payment Stages
    Records    
    ASTHMA01. The practice can produce a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months 4  
    Initial Management    
    ASTHMA08. The percentage of patients aged 8 years and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility 15 45-80%
    Ongoing management    
    ASTHMA10. The percentage of patients with asthma between the ages of 14 and 19 years in whom there is a record of smoking status in the preceding 15 months 6 45-80%
    ASTHMA09. The percentage of patients with asthma who have had an asthma review in the preceding 15 months that includes an assessment of asthma control using the 3 RCP questions 20 45-70%

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    Dementia

    Indicator Points Payment Stages
    Records    
    DEM01: The practice can produce a register of patients diagnosed with dementia 5  
    Ongoing management    
    DEM02: The percentage of patients diagnosed with dementia whose care has been reviewed in the preceding 15 months 15 35-70%
    DEM04: The percentage of patients with a new diagnosis of dementia recorded between the preceding 1 April to 31 March with a record of FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded 6 months before or after entering on to the register 6 45-80%

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    Depression

    Indicator Points Payment Stages
    Diagnosis and initial management
       
    DEP01: The percentage of patients on the diabetes register and /or the CHD register for whom case finding for depression has been undertaken on 1 occasion during the preceding 15 months using two standard screening questions 6 50-90%
    DEP06: In those patients with a new diagnosis of depression, recorded between the preceding 1 April to 31 March, the percentage of patients who have had an assessment of severity at the time of diagnosis using an assessment tool validated for use in primary care 17 50-90%
    DEP07. In those patients with a new diagnosis of depression and assessment of severity recorded between the preceding 1 April to 31 March, the percentage of patients who have had a further assessment of severity 2 - 12 weeks (inclusive) after the initial recording of the assessment of severity. Both assessments should be completed using an assessment tool validated for use in primary care 8 45-80%

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    Chronic Kidney Disease

    Indicator Points Payment Stages
    Records
       
    CKD01: The practice can produce a register of patients aged 18 years and over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD) 6  
    Initial Management    
    CKD02: The percentage of patients on the CKD register whose notes have a record of blood pressure in the preceding 15 months 4 50-90%
    Ongoing Management    
    CKD03: The percentage of patients on the CKD register in whom the last blood pressure reading, measured in the preceding 15 months, is 140/85 or less 11 45-70%
    CKD05: The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker (ARB) 9 45-80%
    CKD06: The percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio (or protein: creatinine ratio) test in the preceding 15 months 6 45-80%

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    Atrial Fibrillation

    Indicator Points Payment Stages
    Records
       
    AF01: The practice can produce a register of patients with atrial fibrillation. 5  
    Initial diagnosis    
    AF05: The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHADS2 risk stratification scoring system in the preceding 15 months (excluding those whose previous CHADS2 score is greater than 1) 10 40-90%
    Ongoing Management    
    AF06: In those patients with atrial fibrillation in whom there is a record of a CHADS2 score of 1 (latest in the preceding 15 months), the percentage of patients who are currently treated with anti-coagulation drug therapy or anti-platelet therapy 6 50-90%
    AF07. In those patients with atrial fibrillation whose latest record of a CHADS2 score is greater than 1, the percentage of patients who are currently treated with anti-coagulation therapy 6 40-70%

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    Obesity

    Indicator Points Payment Stages
    Records
       
    OB01: The practice can produce a register of patients aged 16 years and over with a BMI greater than or equal to 30 in the preceding 15 months. 8  

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    Learning Disabilities

    Indicator Points Payment Stages
    Records
       
    LD01:The practice can produce a register of patients aged 18 years and over with learning disabilities 4  
    LD02: The percentage of patients on the Learning Disability register with Down’s Syndrome aged 18 years and over who have a record of blood TSH in the preceding 15 months (excluding those who are on the thyroid disease register) 3 45-70%

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    Smoking Indicators

    Indicator Points Payment Stages
    Ongoing management
       
    Smoking05: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 15 months 25 50-90%
    Smoking06: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who smoke whose notes contain a record of an offer of support and treatment within the preceding 15 months 25 50-90%
    Smoking07: The percentage of patients aged 15 years and over whose notes record smoking status in the preceding 27 months 11 50-90%
    Smoking08: The percentage of patients aged 15 years and over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months 12 40-90%

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    Cardiovascular disease – primary prevention

    Indicator Points Payment Stages
    Initial diagnosis    
    PP 1. In those patients with a new diagnosis of hypertension (excluding those with pre-existing CHD, diabetes, stroke and/or TIA) recorded between the preceding 1 April to 31 March: the percentage of patients aged 30 to 74 years who have had a face to face cardiovascular risk assessment at the outset of diagnosis (within 3 months of the initial diagnosis) using an agreed risk assessment treatment tool. 8 40-75%
    Ongoing management
       
    PP 2. The percentage of patients (diagnosed with hypertension diagnosed after 1 April 2009) who are given lifestyle advice in the preceding15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet. 5 40-75%

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    Peripheral Arterial disease (PAD) Indicators

    Records Points Payment Stages
    PAD01. The practice can produce a register of patients with peripheral arterial disease 2  
    Ongoing management
       
    PAD02. The percentage of patients with peripheral arterial disease with a record in the preceding 15 months that aspirin or an alternative anti-platelet is being taken 2 40-90%
    PAD03. The percentage of patients with peripheral arterial disease in whom the last blood pressure reading (measured in the preceding 15 months) is 150/90 or less 2 40-90%
    PAD04. The percentage of patients with peripheral arterial disease in whom the last measured total cholesterol (measured in the preceding 15 months) is 5.0mmol/l or less 3 40-90%

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    Osteoporosis: secondary prevention of fragility fractures (OST)

    Records Points Payment Stages

    OST01. The practice can produce a register of patients:

    1. Aged 50-74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan,

    and

    2. Aged 75 years and over with a record of a fragility fracture after 1 April 2012

    3  
    Ongoing management
       
    OST02. The percentage of patients aged between 50 and 74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, who are currently treated with an appropriate bone-sparing agent 3 30-60%
    OST03. The percentage of patients aged 75 years and over with a fragility fracture, who are currently treated with an appropriate bone-sparing agent 3 30-60%

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    Prepared By Jean Keenan