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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
  • Osteoporosis - go to this
  • PAD - go to this
  • Palliative Care - go to this
  • Rheumatoid Arthritis - go to this
  • Secondary prevention of coronary heart disease - go to this
  • Stroke and TIA - go to this

    Cardiovascular disease – primary prevention - this has moved to the Public Health Domain

    Secondary Prevention of Coronary Heart Disease

    Indicator
    Points
    Achievement Thresholds
    Records
    CHD001. The contractor establishes and maintains a register of patients with coronary heart disease
    4
    Ongoing Management
    CHD002. The percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less
    17
    53-93%
    CHD003. The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less
    17
    45-85%
    CHD004. The percentage of patients with coronary heart disease who have had influenza immunisation in the preceding 1 September to 31 March
    7
    56-96%
    CHD005. The percentage of patients with coronary heart disease with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken
    7
    56-96%
    CHD006. The percentage of patients with a history of myocardial infarction (on or after 1 April 2011) currently treated with an ACE-I (or ARB if ACE-I intolerant), aspirin or an alternative anti-platelet therapy, beta-blocker and statin
    10
    60-100%

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    Heart Failure

    Indicator
    Points
    Achievement Thresholds
    Records
    HF001: The contractor establishes and maintains a register of patients with heart failure
    4
    Initial diagnosis
    HF002: The percentage of patients with a diagnosis of heart failure (diagnosed on or after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment 3 months before or 12 months after entering on to the register
    6
    50-90%
    Ongoing management
    HF003: In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, the percentage of patients who are currently treated with an ACE-I or ARB
    10
    60-100%
    HF004: In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction who are currently treated with an ACE-I or ARB, the percentage of patients who are additionally currently treated with a beta-blocker licensed for heart failure
    9
    40-65%

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    Stroke and TIA

    Indicator
    Points
    Achievement Thresholds
    Records
    STIA001. The contractor establishes and maintains a register of patients with stroke or TIA
    2
    Initial diagnosis    
    STIA002. The percentage of patients with a stroke or TIA (diagnosed on or after 1 April 2008) who have a record of a referral for further investigation between 3 months before or 1 month after the date of the latest recorded stroke or TIA
    2
    45-80%
    Ongoing Management
    STIA003. The percentage of patients with a history of stroke or TIA in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less
    5
    40-75%
    STIA004. The percentage of patients with stroke or TIA who have a record of total cholesterol in the preceding 12 months
    2
    50-90%
    STIA005. The percentage of patients with stroke shown to be non-haemorrhagic, or a history of TIA, whose last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less
    5
    40-65%
    STIA006. The percentage of patients with stroke or TIA who have had influenza immunisation in the preceding 1 September to 31 March
    2
    55-95%
    STIA007. The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken
    4
    57-97%

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    Hypertension

    Indicator
    Points
    Achievement Thresholds
    Records
    HYP001. The contractor establishes and maintains a register of patients with established hypertension
    6
    Ongoing Management
    HYP002. The percentage of patients with hypertension in whom the last blood pressure reading (measured in the preceding 9 months) is 150/90 mmHg or less
    10
    44-84%
    HYP003. The percentage of patients aged 79 or under with hypertension in whom the last blood pressure reading (measured in the preceding 9 months) is 140/90 mmHg or less
    50
    40-80%
    HYP004. The percentage of patients with hypertension aged 16 or over and who have not attained the age of 75 in whom there is an assessment of physical activity, using GPPAQ, in the preceding 12 months
    5
    40-80%
    HYP005. The percentage of patients with hypertension aged 16 or over and who have not attained the age of 75 who score ‘less than active’ on GPPAQ in the preceding 12 months, who also have a record of a brief intervention in the preceding 12 months
    6
    40-80%

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    Diabetes Mellitus

    Indicator
    Points
    Achievement Thresholds
    Records
    DM001. The contractor establishes and maintains a register of all patients aged 17 or over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed
    6
    Ongoing Management
    DM002. The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less
    8
    53-93%
    DM003. The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less
    10
    38-78%
    DM004. The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less
    6
    40-75%
    DM005. The percentage of patients with diabetes, on the register, who have a record of an albumin:creatinine ratio test in the preceding 12 months
    3
    50-90%
    DM006. The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with an ACE-I (or ARBs)
    3
    57-97%
    DM007. The percentage of patients with diabetes in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 15 monthsThe percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months
    17
    35-75%
    DM008. The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 12 months
    8
    43-83%
    DM009. The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months
    10
    52-92%
    DM010. The percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 September to 31 March
    3
    55-95%
    DM011. The percentage of patients with diabetes, on the register, who have a record of retinal screening in the preceding 12 months
    5
    50-90%
    DM012.The percentage of patients with diabetes, on the register, 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 12 months
    4
    50-90%
    DM013. The percentage of patients with diabetes, on the register, who have a record of a dietary review by a suitably competent professional in the preceding 12 months
    3
    40-90%
    DM014. The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register
    11
    40-90%
    DM015. The percentage of male patients with diabetes, on the register, with a record of being asked about erectile dysfunction in the preceding 12 months
    4
    40-90%
    DM016. The percentage of male patients with diabetes, on the register, who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 12 months
    6
    40-90%

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    Chronic Obstructive Pulmonary Disease

    Indicator
    Points
    Achievement Thresholds
    Records
    COPD001. The contractor establishes and maintains a register of patients with COPD
    3
    Initial diagnosis
    COPD002. The percentage of patients with COPD (diagnosed on or after 1 April 2011) in whom the diagnosis has been confirmed by post bronchodilator spirometry between 3 months before and 12 months after entering on to the register
    5
    45-80%
    Ongoing management
    COPD003. The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 12 months
    9
    50-90%
    COPD004. The percentage of patients with COPD with a record of FEV1 in the preceding 12 months
    7
    40-75%
    COPD005. The percentage of patients with COPD and Medical Research Council dyspnoea grade >=3 at any time in the preceding 12 months, with a record of oxygen saturation value within the preceding 12 months
    5
    40-90%
    COPD006. The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March
    6
    57-97%

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    Epilepsy

    Indicator
    Points
    Achievement Thresholds
    Records
    EP001. The contractor establishes and maintains a register of patients aged 18 or over receiving drug treatment for epilepsy
    1
    Ongoing management
    EP002. The percentage of patients aged 18 or over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the preceding 12 months
    6
    45-70%
    EP003. The percentage of women aged 18 or over and who have not attained the age of 55 who are taking antiepileptic drugs who have a record of information and counselling about contraception, conception and pregnancy in the preceding 12 months
    3
    50-90%

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    Hypothyroid

    Indicator
    Points
    Achievement Thresholds
    Records
    THY001. The contractor establishes and maintains a register of patients with hypothyroidism who are currently treated with levothyroxine.
    1
    Ongoing management
    THY002. The percentage of patients with hypothyroidism, on the register, with thyroid function tests recorded in the preceding 12 months
    6
    50-90%

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    Cancer

    Indicator
    Points
    Achievement Thresholds
    Records
    CAN001. The contractor establishes and maintains a register of all cancer patients defined as a ‘register of patients with a diagnosis of cancer excluding non-melanotic skin cancers diagnosed on or after 1 April 2003’
    5
    Ongoing management
    CAN002. The percentage of patients with cancer, diagnosed within the preceding 15 months, who have a patient review recorded as occurring within 3 months of the contractor receiving confirmation of the diagnosis
    6
    50-90%

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    Palliative Care

    Indicator
    Points
    Achievement Thresholds
    Records
    PC001: The contractor establishes and maintains a register of all patients in need of palliative care/support irrespective of age
    3
    Ongoing management
    PC002. The contractor has regular (at least 3 monthly) multi-disciplinary case review meetings where all patients on the palliative care register are discussed
    3

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    Mental Health

    Indicator
    Points
    Achievement Thresholds
    Records
    MH001. The contractor establishes and maintains a register of patients with schizophrenia, bipolar affective disorder and other psychoses and other patients on lithium therapy
    4
    Ongoing management
    MH002. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive care plan documented in the record, in the preceding 12 months, agreed between individuals, their family and/or carers as appropriate
    6
    40-90%
    MH003. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 12 months
    4
    50-90%

    MH004. The percentage of patients aged 40 or over with schizophrenia, bipolar affective disorder and other psychoses who have a record of total cholesterol:hdl ratio in the preceding 12 months

    5
    45-80%
    MH005. The percentage of patients aged 40 or over with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood glucose or HbA1c in the preceding 12 months
    5
    45-80%
    MH006. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 12 months
    4
    50-90%
    MH007. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 12 months
    4
    50-90%
    MH008. The percentage of women aged 25 or over and who have not attained the age of 65 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%
    MH009. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 9 months
    1
    50-90%
    MH010. The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range in the preceding 4 months
    2
    50-90%

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    Asthma

    Indicator
    Points
    Achievement Thresholds
    Records
    AST001. The contractor establishes and maintains 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 Diagnosis
    AST002. The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months before or anytime after diagnosis
    15
    45-80%
    Ongoing management
    AST003. The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using the 3 RCP questions
    20
    45-70%
    AST004. The percentage of patients with asthma aged 14 or over and who have not attained the age of 20, on the register, in whom there is a record of smoking status in the preceding 12 months
    6
    45-80%

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    Dementia

    Indicator
    Points
    Achievement Thresholds
    Records
    DEM001: The contractor establishes and maintains a register of patients diagnosed with dementia
    5
    Ongoing management
    DEM002: The percentage of patients diagnosed with dementia whose care has been reviewed in a face-to-face review in the preceding 12 months
    15
    35-70%
    DEM003: The percentage of patients with a new diagnosis of dementia recorded in 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 between 6 months before or after entering on to the register
    6
    45-80%

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    Depression

    Indicator
    Points
    Achievement Thresholds
    Initial Diagnosis
    DEP001: The percentage of patients aged 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March, who have had a bio-psychosocial assessment by the point of diagnosis. The completion of the assessment is to be recorded on the same day as the diagnosis is recorded
    21
    50-90%
    Initial management    
    DEP002: The percentage of patients aged 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March, who have been reviewed not earlier than 10 days after and not later than 35 days after the date of diagnosis
    10
    45-80%

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    Chronic Kidney Disease

    Indicator
    Points
    Achievement Thresholds
    Records
    CKD001: The contractor establishes and maintains a register of patients aged 18 or over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD)
    6
    Ongoing Management
    CKD002: The percentage of patients on the CKD register in whom the last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less
    11
    41-81%
    CKD003: The percentage of patients on the CKD register with hypertension and proteinuria who are currently treated with an ACE-I or ARB
    9
    45-80%
    CKD004: 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 12 months
    6
    45-80%

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    Atrial Fibrillation

    Indicator
    Points
    Achievement Thresholds
    Records
    AF001: The contractor establishes and maintains a register of patients with atrial fibrillation
    5
    Ongoing Management
    AF002: The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHADS2 risk stratification scoring system in the preceding 12 months (excluding those whose previous CHADS2 score is greater than 1)
    10
    40-90%
    AF003: In those patients with atrial fibrillation in whom there is a record of a CHADS2 score of 1 (latest in the preceding 12 months), the percentage of patients who are currently treated with anti-coagulation drug therapy or anti-platelet therapy
    6
    57-97%
    AF004. 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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    Learning Disabilities

    Indicator
    Points
    Achievement Thresholds
    Records
    LD001: The contractor establishes and maintains a register of patients aged 18 or over with learning disabilities
    4
    LD002: The percentage of patients on the learning disability register with Down’s Syndrome aged 18 or over who have a record of blood TSH in the preceding 12 months (excluding those who are on the thyroid disease register)
    3
    45-70%

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    Peripheral Arterial disease (PAD) Indicators

    Records
    Points
    Achievement Thresholds
    PAD001. The contractor establishes and maintains a register of patients with peripheral arterial disease
    2
    Ongoing management
    PAD002. The percentage of patients with peripheral arterial disease in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less
    2
    40-90%
    PAD003. The percentage of patients with peripheral arterial disease in whom the last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less
    3
    40-90%
    PAD004. The percentage of patients with peripheral arterial disease with a record in the preceding 12 months that aspirin or an alternative anti-platelet is being taken
    2
    40-90%

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    Osteoporosis: secondary prevention of fragility fractures (OST)

    Records
    Points
    Achievement Thresholds

    OST001. The contractor establishes and maintains a register of patients:

    1. Aged 50 or over and who have not attained the age of 75 with a record of a fragility fracture on or after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan, and

    2. Aged 75 or over with a record of a fragility fracture on or after 1 April 2012

    3
    Ongoing management
    OST002. The percentage of patients aged 50 or over and who have not attained the age of 75, with a fragility fracture on or after 1 April 2012, in whom osteoporosis is confirmed on DXA scan, who are currently treated with an appropriate bone-sparing agent
    3
    30-60%
    OST003. The percentage of patients aged 75 or over with a fragility fracture on or after 1 April 2012, who are currently treated with an appropriate bone-sparing agent
    3
    30-60%

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    Rheumatoid Arthritis (RA)

    Records
    Points
    Achievement Thresholds

    RA001. The contractor establishes and maintains a register of patients aged 16 or over with rheumatoid arthritis

    1
    Ongoing management
    RA002. The percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face review in the preceding 12 months
    5
    40-90%
    RA003. The percentage of patients with rheumatoid arthritis aged 30 or over and who have not attained the age of 85 who have had a cardiovascular risk assessment using a CVD risk assessment tool adjusted for RA in the preceding 12 months
    7
    40-90%
    RA004. The percentage of patients aged 50 or over and who have not attained the age of 91 with rheumatoid arthritis who have had an assessment of fracture risk using a risk assessment tool adjusted for RA in the preceding 24 months
    5
    40-90%

    Prepared By Jean Keenan