KISS: QoF 2024-25 Clinical Domains

NO

PHARMACEUTICAL INFLUENCE

NO PHARMACEUTICAL INFLUENCE

QoF 2024/25 March 2024

Unless otherwise stated indicators refer to those patients as defined in the register and data/targets should be recorded/performed within the preceding 12 months.
Light Blue field indicators are income protected.

Domain	Indicator	Points	Thresholds
AF	AF 001 - AF register	5	N/A
	AF006 - % pts who have had stroke risk assessment with CHA2DS2VASc score	12	40-90%
	AF008 - % pts with CHA2DS2VASc score ≥2 on DOAC or Vit K antagonist	12	70-95%
CHD	CHD001 - register of pts with CHD	4	N/A
	CHD005 - % pts on aspirin or alternative antiplatelet, or anticoagulant	7	56-96%
	CHD015 - % pts aged ≤79 yrs with BP ≤140/90 (or equivalent HBPM)	12	40-77%
	CHD016 - % pts aged ≥80 yrs with BP ≤150/90 (or equivalent HBPM)	5	46-86%
Heart Failure	HF001 - register of pts with heart failure	4	N/A
	HF008 - % pts with HF diagnosed after 1/4/23 confirmed by echo or specialist assessment within 6 months before entry onto register	6	50-90%
	HF003 - % pts with HFrEF (or HF with LVSD) on ACEI or ARB	6	60-92%
	HF006 - % pts with HFrEF (or HF with LVSD) on beta blocker	6	60-92%
	HF007 - % pts with HF who have had annual review inc. functional capacity & medication review to ensure meds at max tolerated doses	7	50-90%
Hypertension	HYP001 - register of pts with hypertension	6	N/A
	HYP008 - % pts aged ≤79 yrs with BP ≤140/90 (or equivalent HBPM)	14	40-77%
	HYP009 - % pts aged ≥80 yrs with BP ≤150/90 (or equivalent HBPM)	5	40-80%
PAD	PAD001 - register of pts with peripheral arterial disease	2	N/A
Stroke/TIA	STIA001 - register of pts with stroke or TIA	2	N/A
	STIA007 - % pts with non-haemorrhagic stroke/TIA on antiplatelet/anticoagulant	4	57-97%
	STIA014 - % pts aged ≤79 yrs with BP ≤140/90 (or equivalent HBPM)	3	40-74%
	STIA015 - % pts aged ≥80 yrs with BP ≤150/90 (or equivalent HBPM)	2	46-86%
Cholesterol	CHOL003 - % pts with CHD, PAD, stroke/TIA or CKD on statin (or alternative lipid lowering therapy)	14	70-95%
	CHOL004 - % pts with CHD, PAD or stroke/TIA with LDL ≤2.0 mmol/L (or if LDL not recorded non-HDL ≤2.6 mmol/L)	16	20-35%
Diabetes	DM017 - register of pts aged ≥17 yrs with diabetes and type confirmed	6	N/A
	DM006 - % pts with nephropathy or micro-albuminuria on ACEI (or ARB)	3	57-97%
	DM012 - % pts with recorded foot exam and risk classification	4	50-90%
	DM014 - % pts newly diagnosed referred to structured education programme within 9 months of addition to the register	11	40-90%
	DM020 - % pts without moderate/severe frailty with HbA1c ≤ 58 mmol/mol	17	35-75%
	DM021 - % pts with moderate/severe frailty with HbA1c ≤ 75 mmol/mol	10	52-92%
	DM022 - % pts aged ≥40 yrs (without moderate/severe frailty or known CVD) with CVD risk score ≥10% on statin	4	50-90%
	DM023 - % pts with known CVD (not haemorrhagic stroke) on statin	2	50-90%
	DM033 - % pts without mod/severe frailty with BP ≤140/90 (or equivalent HBPM)	10	38-78%
Asthma	AST005 - register of pts aged ≥ 6 yrs with asthma (excludes those who have been prescribed no asthma drugs in the preceding 12 months)	4	N/A
	AST011 - % pts with asthma diagnosis (after 1/4/23) with spirometry and one other objective test (FeNO, bronchodilator reversibility, peak flow variability) between 3m before to 6m after diagnosis	15	45-80%
	AST007 - % pts with annual review inc. asthma control, no. exacerbations, inhaler technique & personalised action plan	20	45-70%
	AST008 - % pts aged ≤19 yrs with smoking record or 2nd hand smoke exposure	6	45-80%
COPD	COPD015 - register of pts with COPD (if after 1/4/23 diagnosis confirmed with post-bronchodilator spirometry FEV1/FVC ratio <0.7, between 3 months before to 6 months after diagnosis)	8	N/A
	COPD010 - % pts with annual review inc. no. exacerbations & MRC breathlessness score	9	50-90%
	COPD014 - % pts with MRC score ≥3 referred to pulmonary rehab	2	40-90%
Dementia	DEM001 - register of pts with dementia	5	N/A
	DEM004 - % pts with annual review of care plan	14	35-70%
Depression	DEP004 - % pts aged ≥18 yrs with new diagnosis reviewed 10-56 days after diagnosis	10	45-80%
Mental Health	MH001 - register of pts with schizophrenia/psychosis, bipolar disorder or on lithium	4	N/A
	MH002 - % pts with annual care plan agreed between individuals, family and/or carers	5	40-90%
	MH003 - % pts with BP recorded	3	50-90%
	MH006 - % pts with BMI recorded	3	50-90%
	MH007 - % pts with alcohol consumption recorded	3	50-90%
	MH011 - % pts with lipid profile recorded (NB for some lower risk pts can be within 24 months rather than 12 months)	7	50-90%
	MH012 - % pts with HbA1c or blood glucose recorded	7	50-90%
	MH021 - % pts who have received all 6 elements of SMI check	6	50-80%
Cancer	CAN001 - register of pts with cancer (excluding non-melanotic skin cancer) after 1/4/03	5	N/A
	CAN004 - % pts with cancer diagnosed in last 24 months with cancer care review	6	50-90%
	CAN005 - % pts with cancer that have had discussion and support from 1⁰ care within 3 months of diagnosis	2	70-90%
CKD	CKD005 - register of pts aged ≥18 yrs with CKD stages G3a-G5	6	N/A
Epilepsy	EP001 - register of pts aged ≥18 yrs receiving drug therapy for epilepsy	1	N/A
LD	LD004 - register of pts with learning disability	4	N/A
Osteoporosis	OST004 - register of pts aged ≥50 yrs with fragility fracture and diagnosis confirmed on DEXA scan (those aged ≥75 yrs do not require DEXA for diagnosis)	3	N/A
RA	RA001 - register pf pts aged ≥16 yrs with rheumatoid arthritis	1	N/A
Pall care	PC001 - register of pts in need of palliative care	3	N/A
NDH	NDH002 - % pts with non-diabetic hyperglycaemia with HbA1c or fasting glucose	18	50-90%