Maximising your QOF income: Hypertension

Updated QOF for 2020/21:

Only one indicator in Hypertension – for maintaining the patient register – will be actively reported this year, under changes introduced to the GP contract to refocus QOF activity in response to Covid-19. More details are outlined below.

Payment for the remaining indicators will be based on historical payments.

See also our separate guide on how to get the most from the revised QOF for 2020/

Summary – indicators and value

The following summarises current indicators, points and value of the Hypertension area under the GP contract agreed for 2020/21-2023/24:

• Indicators: 3
• Points: 25
• Prevalence (2017-18): 13.9%
• £/patient on the register (est.): £4.09

Revised for 2020/21

The following summarises how the indicators, points and value for the Hypertension area have been changed under the revised QOF guidance for 2020/21:

• Only one indicator active:
  • Maintain patient register
• Points: 25
• £/patient on the register (est.) £0.90

Payment for these points is conditional on practices continuing to accurately maintain the register and for disease prevalence to remain comparable with 2019/20 levels, subject to reasonable assessments of the impact of excess Covid-19 related mortality upon practice list size, patient demographics and access to diagnostic services.

Background

Hypertension has the highest prevalence of any disease area in the QOF. Despite a reasonable number of points, the large number of patients on the register means that the cash value per patient is relatively low. Nevertheless, this is a large and important area.

Active indicator for 2020/21

Indicator 1: Maintain patient register (6 points)

There are six points for maintaining the register. Any code for hypertension will put the patient on the register. Codes for high blood pressure will not, as these are intended to record one-off measurements, rather than a chronic diagnosis.

Many patients who have hypertension will also appear on other cardiovascular disease registers, such as coronary heart disease, diabetes, stroke and peripheral arterial disease.

Where there is another diagnosis, raised blood pressure can often be seen as part of the disease process, and the need to enter hypertension as a separate diagnosis may have been missed. Checking patients with other cardiovascular disease who are being prescribed antihypertensive drugs could also increase your register size

NICE recommends that the diagnosis is confirmed by a 24-hour blood pressure measurement, although this is not part of the QOF rules.

Patients may come off the register if they have a hypertension resolved code. This can happen after lifestyle changes such as exercise, weight loss or changes to diet.

Income protected indicators for 2020/21

Indicator 2: Blood pressure 140/90 or less in under 80 year-olds (14 points)

Indicator 3: Blood pressure 150/90 or less in patients aged 80 years or older (5 points)

From April 2019, there are two new age-stratified outcome indicators for getting patients’ blood pressures below threshold within the QOF year, replacing the previous single indicator for all age groups. This means the return of a lower blood pressure target in patients aged under 80, which now carries the majority of available points and mirrors changes in the CHD and stroke areas for 2019/20. The lower target was last part of QOF in 2014.

The measurement can be made at any time in the QOF year. As usual, only the latest measurement in the QOF year is counted so an effective tactic is to adjust medication and measure blood pressure until it is below 140/90 mmHg (or 150/90 mmHg) and then stop.

It will also make sense to try to measure blood pressure as early as possible in the year to allow time to adjust treatment and re-measure to ensure that the patient has been treated to target.

With the lower systolic pressure threshold for patients under 80 years, it would be sensible to start tackling those with blood pressure above this level as early as possible in order to allow plenty of time for changes to their regimen to take effect.

Exception reporting

There are several ways of exception reporting. There are codes for the hypertension area where patients are not suitable for treatment or have declined treatment. As an outcome measure, patients who have registered with the practice or been diagnosed for the first time after July of the QOF year will be automatically excepted.

There are also a couple of specific codes for exception reporting. The most commonly used is where the patient is on maximal tolerated antihypertensive therapy. The concept of tolerance and what is maximal therapy will be individual for each patient, and the decision to stop escalating treatment will be made between the patient and clinician.

There is also an exception code where the patient refuses to have their blood pressure taken, although this is rarely used.

The final specific exception code is for patients with stage one hypertension (a pre-treatment BP between 140/90 and 160/100 mmHg) without evidence of end organ damage. This isn’t commonly used at the moment, but might be useful in some cases.

Full indicator warning

Indicator 1: The contractor establishes and maintains a register of patients with established hypertension (HYP001)

Indicator 2: 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 (HYP003). Payment threshold: 40-77%

Indicator 3: The percentage of patients with hypertension aged 80 years or over in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less (HYP007). Payment threshold: 40-80%

Dr Gavin Jamie is a GP in Swindon and runs the QOF database website