Support to achieve QOF lipid targets: Primary care lipid optimisation in secondary prevention

27th September 2023

In this blog, GPSI of Cardiology, Professor Ahmet Fuat, takes us through the 23/24 QOF lipid targets and provides practical advice about how GP practices can achieve them.

This year World Heart Day falls on Friday, 29th September with a theme of “use heart”, a reminder for people around the world to take care of their hearts.  

Cardiovascular disease (CVD) continues to be the biggest cause of premature death in England accountable for, or a contributing factor, in 27% of all deaths. The disease is also the biggest driver of health inequalities and those who live in the most deprived areas of England are 4 times more likely to die early from CVD compared to those living in the least deprived areas[1],[2].

7.1% of all UK deaths are due to high cholesterol1  and the new 2023/24 quality and outcomes framework (QOF) guidance[3] gives a strong and clear statement that primary care should be focusing on lowering cholesterol in high-risk patients with a view to reducing preventable cardiovascular events including heart attack and stroke.

The new QOF cholesterol indicators[3] reflect the strong evidence base that lowering low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (HDL-C) can significantly reduce cardiovascular events[4].

 

QOF indicators

Indicator Thresholds
CHOL0001.  Percentage of patients on the QOF Coronary Heart Disease, Peripheral Arterial Disease, Stroke/TIA or Chronic Kidney Disease Register who are currently prescribed a statin, or where a statin is declined or clinically unsuitable, another lipid-lowering therapy. 70-95%
CHOL002.  Percentage of patients on the QOF Coronary Heart Disease, Peripheral Arterial Disease, or Stroke/TIA Register, who have a recording of non-HDL cholesterol in the preceding 12 months that is lower than 2.5mmol/L, or where non-HDL cholesterol is not recorded, a recording of LDL-cholesterol in the preceding 12 months that is lower than 1.8mmol/L. 20-35%

Context of QOF indicators

The National CVDPrevent audit data shows us that around 20% of people with established cardiovascular disease are not on lipid lowering therapy (LLT) and only around 25% have an LDL-C <1.8mmol/L or non-HDL cholesterol <2.5mmol/l [5].  Furthermore, the European Society of Cardiology guidelines advise even lower levels with an LDL-C <1.4mmol/L and a reduction in LDL-C of over 50% from baseline for these high-risk secondary prevention patients[6]. These are targets I personally aim for in patients at high risk including those who have had more than one cardiovascular event.

 

Tools to support practice to achieve targets

  • Guidelines – The local NEELI guidelines have been developed to support the medical management of secondary prevention in primary care with high intensity statins advocated within NICE lipid modification guidelines. NICE lipid modification guidelines are currently being updated.
  • Patient searches – I would advise clinicians to use whichever patient search tools are available or that they are comfortable with in monitoring their progress. Once QOF indicators have been updated in IT systems, those can be used. We also have very good CDRC searches in the North East and North Cumbria and UCLPartners also provide a free to use search tool that clinicians can use to monitor their progress. In my own practice we have run the CDRC contracting QOF searches and started to call in patients for blood tests to check their lipid profile alongside other tests if required according to their co-morbidities. We would then review these with a view to optimising therapy if targets have not been reached.
  • Lipid lowering therapies –
    • Clinicians should be starting all patients with coronary heart disease, peripheral arterial disease, stroke/TIA or chronic kidney disease on a statin. Where a statin is declined or clinically unsuitable, another lipid lowering therapy should be used (CHOL001 QOF indicator).
    • Clinicians should then be aiming for target levels of either a non-HDL cholesterol of <2.5mmol/L or and LDL cholesterol of <1.8 mmol/L in the preceding 12 months to qualify for (CHOL002 QOF indicator).
    • Therapy can be optimised by either doubling the dose of statin and we should be using high intensity statins such as atorvastatin or rosuvastatin. Clinicians should be aware that doubling the dose of a statin only increases cholesterol lowering by 6% whereas the addition of an alternative therapy such as Ezetimibe can reduce LDL cholesterol by 15 to 20% on top of a statin[7],[8] .
    • Newer agents such as Bempedoic acid with or without Ezetimibe and Inclisiran are both licensed to be used in primary care and must be done so in line with NICE guidelines[9] .
  • Utilising the wider workforce – We need to involve all health care professionals within a practice including health care assistants, nurses, nurse practitioners, clinical pharmacists as well as GPs. By ultilising and training the entire workforce we can raise awareness of the benefits of lipid lowering in secondary prevention in our communities.
  • Patient education – Patient education and awareness are hugely important and often need to be reinforced on a background of sometimes adverse media coverage of the use of statins.

I am delighted that QOF has recognised the need for clear targets in managing lipid optimisation in secondary care and hopefully this will lead to improvements in target attainment with subsequent reductions in cardiovascular events in this high-risk population.

 

More information and support

The AHSN NENC has created a number of educational resources for healthcare professionals working in primary care which you can download here.

 

References