Maximising your QOF payments: Heart failure

• Indicators: 4
• Points: 29 
• Prevalence (2016-17): Indicators 1, 2: 77%, Indicators 3, 4: 0.23%
• £/patient on the register (est) : Indicator 1,2: £28, Indicator 3,4:  £190

The heart failure area sometimes seems like two areas stuck together. It contains four indicators, with the final two effectively being a sub-area for patients with left ventricular systolic dysfunction (LVSD).

Indicator 1: Maintain patient register (4 points)

There are four points for maintaining the register. The drugs used to treat heart failure are not particularly specific. Diuretics, ACE inhibitors and cardioselective beta blockers are all fairly widely used, so a search is likely to return many patients without heart failure.

An alternative plan could be to search for patients with LVSD. It is possible to have LVSD without heart failure symptoms, but it would almost certainly pay off to review these patients. It is also important for staff to remember to code patients, for example after open access echo, outpatients, admissions etc.

Indicator 2: Diagnosis by echocardiogram or specialist assessment (6 points)

There are six points for 90% of patients having had confirmation of the diagnosis by echocardiogram or specialist assessment. This should be less than three months before, or twelve months after, the diagnostic code and applies to all patients diagnosed after 1 April 2006.

As this is how the diagnosis is made then this examination should probably happen before patients have the diagnosis coded, which will lead to full achievement of this indicator.

That date has been fixed for several years and we are now looking back over 12 years. Where patients have moved surgery it is very important that the echocardiogram is coded. Pretty much any echocardiogram code will be valid here, other than those describing an explicitly normal result.

There are general exception codes for the heart failure area and the usual automatic excepting of patients registered or diagnosed between January to March of the QOF year.

LVSD patients

The final two indicators are specifically for patients diagnosed with LSVD. This is the most common cause of heart failure, but with QOF prevalence figures of around a third of those for heart failure, it is almost certainly under-coded. All patients should have had an echocardiogram and to get the payment then there should be an effective system to record the result. The potential reward for coding each patient correctly is likely to be over £150.

The codes available are either for ‘Left Ventricular Systolic Dysfunction’ or ‘Echocardiogram shows left ventricular systolic dysfunction’. No other codes will add patients to these indicators. Time spent checking echocardiogram results for patients on the heart failure register will almost certainly be profitable.

However, you won’t get a payment unless the indicators are met. These are two prescribing indicators which run on from each other like a chain.

Indicator 3: LVSD patients prescribed ACE inhibitor or angiotensin antagonist (10 points)

There are ten points for all patients with LVSD having a prescription for either an ACE inhibitor or an angiotensin antagonist. As with most prescribing indicators, only prescriptions issued from October onwards will count. As the target is 100 per cent, all patients will need either a prescription or an exception code. They need to be excepted from both.

Indicator 4: LVSD patients prescribed beta blockers (9 points)

There are a final nine points for patients who have been prescribed bisoprolol, carvedilol or nebivolol. However, this indicator only applies if they have passed the previous indicator, ie, have been prescribed an ACE inhibitor or angiotensin antagonist.

The upper threshold is only at 65%, making this indicator quite achievable. It is worth being careful, however, when monitoring achievement through the year. Patients only become eligible for beta blockers when they are prescribed an ACE inhibitor.  Increasing the achievement of Indicator 3 may have the effect of reducing achievement in Indicator 4, if these patients have not also received a beta blocker. If these patients have ended up on an ACE inhibitor, then there is usually a good reason for them not being on a beta blocker, so it’s worth looking through and exception reporting beta blockers as appropriate.

Patients receiving a beta blocker other than those listed above will be automatically excepted from this indicator.

Both of these indicators have the usual exception codes for allergies or patient unsuitability, as well as the general area exception codes and the usual three-month grace period after registration or diagnosis.

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

For reference:

Indicator 1: The percentage of patients with coronary heart disease who have had influenza immunisation in the preceding 1 August to 31 March (HF001)

Indicator 2: 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 (HF002). Payment threshold: 50-90%.

Indicator 3: 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 (HF003). Payment threshold: 60-100%.

Indicator 4: 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 (HF004). Payment threshold: 40-65%.