NICE CG127: Implementation in Primary care

Dr Terry McCormack, Whitby

Will GPs follow the Guidance?

• NICE CG018 2004

• NICE CG034 2006

• NICE CG127 2011?

Will GPs follow the Guidance?

• NICE CG018 2004

• NICE CG034 2006

• NICE CG127 2011?

Will GPs follow the Guidance?

• NICE CG018 2004

• NICE CG034 2006

• NICE CG127 2011?

• Professionalism?

• Incentives – QOF?

Effect of pay for performance on the management and outcomes of hypertension

in the United Kingdom: interrupted time series study: Serumaga, B et al. BMJ 2011

• THIN database (The Health Improvement Network 358/470,725)

• January 2000 to August 2007• QOF introduced April 2004• Using G20 code x2• Centiles systolic/diastolic BP over time• Number of measurements performed• Blood pressure control• Treatment intensity• Cardiovascular outcomes

BMJ 2011; 342:d108 doi: 10.1136/bmj.d108 (Published 25 January 2011)

Fig 1 Time series of centiles of systolic and diastolic blood pressure in United Kingdom by quarter from January 2001 to July 2007.

Serumaga B et al. BMJ 2011;342:bmj.d108

©2011 by British Medical Journal Publishing Group

Fig 2 Effect of pay for performance on blood pressure control and monitoring in United Kingdom.

©2011 by British Medical Journal Publishing Group

Serumaga B et al. BMJ 2011;342:bmj.d108

Fig 3 Effect of pay for performance on intensity of treatment for hypertension in United Kingdom.

©2011 by British Medical Journal Publishing Group

Serumaga B et al. BMJ 2011;342:bmj.d108

Fig 4 Effect of pay for performance on hypertension related adverse outcomes (myocardial infarction, stroke, renal failure, heart failure) or on all cause mortality in United Kingdom.

©2011 by British Medical Journal Publishing Group

Serumaga B et al. BMJ 2011;342:bmj.d108

Results/Conclusion

•No change in activity

•No change in outcomes

•Pay for performance had no effect

•NICE - CG018 2004 may have influenced GP performance

Limitations

•EMIS practices – sociodemographic population but ?higher performance

GPs•G20 code = those we intend to treat and

try hard (excludes many TOD patients)•Code cleaning was taking place•No measure of exception reporting•Too soon to see change•Short period for outcomes study

Interpretation

• Professionalism won over incentivisation• GPs already applying a better standard?• Influence of NICE guideline 2004? • Many practices will have been trying to get

ahead of the game• For many QOF meant recording what we did,

poorer practices had to change the most• Needs updating

Quality Outcomes Framework

Quality Outcomes Framework

NICE CG127 2011?

• Have we changed and become ruled by QOF?• Treatment algorithm logical and easy to apply• Spironolactone requires a leaflet advising care

when dehydrated or suffering diarrhoea/vomiting• Advice to treat over 80s will challenge some

doctors preconceptions• ABPM is the biggest hurdle

• Capital cost• Logistics• Mindset change from repeat visits/measurements

New QOF hypertension target pilot

•As a result of a letter from BHS Executive•Target remains at 150/90 for those

aged 80 or more•Lower targets remain for CKD, Diabetes

BP Threshold

150/90 90%

140/90 50%