Updated November 2022
*Prevalence is an estimate based on latest available QOF data and current trends. For further explanation read more details here.
The heart failure area sometimes seems like two areas stuck together. It contains five indicators, two of which are in a sub-area for patients with left ventricular systolic dysfunction (LVSD).
Some changes to the indicators were introduced as part of the 2020/21-2023/24 GP Contract as follows:
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, outpatient appointments and admissions.
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 six months after, the diagnostic code and applies to all patients diagnosed after 1 April 2020.
As this is how the diagnosis is made, this examination should probably happen before patients have the diagnosis coded, which will lead to full achievement of this indicator. Pretty much any echocardiogram code will be valid here, other than those describing an explicitly normal result.
When patients join the practice they may well have a previous echocardiogram recorded, in which case no action is needed. If they register with a previous diagnosis of heart failure but no coded echo then the clock starts again and an echocardiogram should be requested or performed within six months of registration.
The time limit for echocardiography is currently within six months after diagnosis. If echocardiography is not available locally then there are two actions that the practice can take:
As long as one of these is entered within the six-month window then the patient will not be included in the indicator.
To get the points at least one patient with new heart failure (or recently registered) should have a referral or echocardiogram during the year.
There are general codes for exception reporting (now termed ‘personalised care adjustment’) for the heart failure area and the usual automatic excepting of patients registered or diagnosed between January to March of the QOF year.
This indicator applies to all patients with heart failure. There are two parts and both are required although they do not have to occur on the same day.
The first part is a heart failure review that must be coded during the year. This should include a functional assessment, ie, a review of what the patient can physically do.
Secondly, a medication review must be carried out and coded. The code used does not have to be a specific code for a heart failure medication review – any medication review code will count here. This does not have to be done by a GP but could be performed by a nurse or pharmacist. Medication reviews should be an annual event for most patients in any case.
The aim should be to increase to the highest licenced dose tolerated by the patient, although the choice of medication will be affected by the type of heart failure. Although all patients are eligible for this indicator most medications are indicated only in patients with left ventricular systolic dysfunction (LVSD).
The next 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 so the payment depends on an effective system to record the result.
The codes available are either for ‘Left Ventricular Systolic Dysfunction’ or ‘Echocardiogram shows left ventricular systolic dysfunction’. Alternatively, codes for reduced ejection fraction in heart failure will qualify. 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 you also meet one or other of the indicators, below.
There are six points for 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. The target is high at 92% and these drugs have contraindications in small but important groups of patients. They would need to be excepted from both ACE inhibitors and angiotensin antagonists.
There are a final nine points for patients who have been prescribed bisoprolol, carvedilol or nebivolol.
The upper threshold is also 92%. Exception reporting will be helpful in those patients who would not tolerate beta blockers for whatever reason.
Patients receiving a beta blocker other than those listed above (eg, atenolol) 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
Indicator 1: The contractor establishes and maintains a register of patients with heart failure (HF001). 4 points
Indicator 2: The percentage of patients with a diagnosis of heart failure after 1 April 2020 which has been confirmed by:
1) an echocardiogram or by specialist assessment between 3 months before or 6 months after entering on to the register; or
2) if newly registered in the preceding 12 months, with a record of an echocardiogram or a specialist assessment within 6 months of the date of registration. (HF005)
6 points; payment threshold: 50-90%.
Indicator 3: The percentage of patients with heart failure on the register, who had a review in the preceding 12 months, including an assessment of function capacity and a review of medication to ensure medicines optimisation at maximum tolerated doses. (HF007) 7 points; payment threshold: 50-90%.
Indicator 4: The percentage of patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, who are currently treated with an ACE-I or ARB (HF003). 6 points; Payment threshold: 60-92%.
Indicator 5: The percentage of patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, who are currently treated with a beta-blocker licensed for heart failure (HF006). 6 points; payment threshold: 60-92%.
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