Q&A

There are two ways in which a patient can be recorded as an ex-smoker.

In the preceding 15 months

Or

On three consecutive years (twelve month period) then there is no need to record again as the patient will be considered as a non-smoker unless their status changes and you enter another status code either during this time or after.

In the indicators mentioned in order to succeed in QOF 2012/13 (providing the patient meets the other indicator criteria) they would need a valid Read Code (in the appropriate time frame) from the REFERSSSA_COD (Support and refer Stop Smoking Service/Advisor) cluster OR a valid Read Code from the PHARM_COD (Pharmacotherapy) cluster.  Therefore in your example it would be a logical ‘OR’ rather than an ‘AND’ to link your two statements i.e:

8CAL.     Smoking cessation advice

And/Or

8IEM.    Smoking cessation drug therapy declined or  8B3Y.Over the counter nicotine replacement therapy or an issue of nicotine replacement therapy

You would also need to use the Clopidogrel  contraindicated as the system is looking for both Aspirin or an alternative anti-platelet

CTV 3:    XaJ6Y     Clopidogrel contraindicated

Version 2: 8I2K.    Clopidogrel contraindicated

The indicator is not just looking for a QRISK2 in the preceding 12 months. The patient sitting in work to do will have had a risk of =>20 recorded in their records but have yet been treated with a statin or had a therapy exclusion code entered if a statin is not appropriate. If you record an exclusion, the patient will no longer sit in that indicator and you will be back to zero patients. Excluding a patient will remove them.

Yes, the exclusion for the first three months is to allow practices to arrange the patients care pathway and to call them in, as with any other exclusion if you achieve the indicator it will be superseded. Remember the indication is not just about the diagnosis but also about the therapy prescribed. Without a prescription for a statin having been issued, the patient will not appear in the achieved.

The register is made up of patients with a new diagnosis of hypertension in the preceding 12 months who don’t have specific pre-existing conditions. This is then adjusted in the indicator to exclude certain age groups and to include patients who specifically have CVD risk assessment (QRISK2) scores >= 20% in the preceding 12 months. Your 49 patients are the newly diagnosed Hypertensives but they will not all fulfil the criteria.

It could be one of three reasons why you have zero patients for CVD-PP001.

1. The patients have a QRISK2 score in their clinical record but all are below 20%.
2. The patients do not fall within the criteria of 30yrs – 75 yrs with no pre-existing CHD, Diabetes, Stroke and/or TIA.
3. Not all the patients have a QRISK2 score saved to their records. This would mean you have not identified those patients with a risk =>20%. This can be done through reviewing of the patients notes. It does not have to be a face to face consultation to record the score but you will need to call the patient in to discuss the results if appropriate. Many clinicians also open the clinical tool but forget to press the save button especially on SystmOne as the button is not obvious!

I would suggest you score a new QRISK2 in the patients record to assess if their risk has changed. This potentially could identify a patient who requires a statin.

I would recommend the following audits:

First check that all the newly diagnosed Hypertensive patients have an episode type of ’New’ or ‘First’ otherwise they will not be included in the denominator.

You will need to exclude all those patients who have a pre-existing co-morbidity as these are excluded from this indicator.

Remember this indicator is only looking at the newly diagnosed Hypertensive who has a risk of =>20 in the preceding 12 months who have been prescribed  Statins

One suggestion is the QRISK tool is added to the Hypertension Template to ensure it is not missed as many clinicians will open the tool, view the results but not save it to the records.

Yes, the QRISK2 looks at clinical information within the patients records and can be saved to the patients journal without a consultation but all patients with a risk score of ≥20% who are currently not treated with a statin or have a contraindication/allergy/intolerance  recorded should be invited in for a further review. The list of the remainder patients should have their records reviewed by a clinician to ensure there is no further action (this can be completed by either a GP, Nurse Practitioner or Practice Nurse)

The patient may have a second entry of Hypertension in their clinical record. There should only be one entry of the diagnosis with a ‘New Episode’ attached to the Read code, if a duplicate entry is made again this will reactivate the reminders for the newly diagnosed Hypertensives

No, the guidance clearly states that it is a primary care face to face review. The review is about the patients wellbeing looking at the:

Discussing DMARS, if relevant

Need for referral for surgery, if relevant

Effects the disease is having on their life, for example work and education

The need to organise appropriate cross-referral within the MDT