Diabetes: blood pressure (without moderate or severe frailty)

Indicator type

General practice indicator suitable for use in the Quality and Outcomes Framework.

Rationale

Blood pressure (BP) lowering in people with diabetes reduces the risk of developing macrovascular and microvascular complications.

Applying universal BP target levels to all people with diabetes regardless of co-morbidities may inadvertently lead to both under-treatment and overtreatment (Kearney et al. 2017). People with diabetes and less complex care needs may be undertreated, whilst people with more complex care needs may be at risk of overtreatment. This indicator allows for an individualised management approach that adjusts care according to an individual's frailty status. A focus on people without moderate or severe frailty aims to reduce under-treatment and support better control of biomedical targets in people with the greatest capacity to benefit. The General Medical Service (GMS) contract requires practices to use an appropriate tool (such as the electronic frailty index) to identity moderate and severe frailty in patients 65 years and over. It also requires secondary validation.

Blood pressure targets differ between clinic and home settings because blood pressure can be raised in formal settings such as in clinic.

The targets in this indicator differ to those in the NICE guideline for people with type 1 diabetes and a urine albumin:creatinine ratio (ACR) of 70 mg/mmol or more. For the purpose of a pay-for-performance indicator that does not differentiate between type 1 or type 2 diabetes, the targets for type 2 diabetes have been used.

Source guidance

Specification

Numerator: The number of patients in the denominator in whom the last blood pressure reading (measured in the preceding 12 months) is less than 135/85 mmHg if using ambulatory or home monitoring, or less than 140/90 mmHg if measured in clinic.

Denominator: The number of patients on the diabetes register, aged 79 years and under without moderate or severe frailty.

Calculation: Numerator divided by the denominator, multiplied by 100.

Exclusions: Patients under 17 years.

Personalised care adjustments or exception reporting should be considered to account for situations where the patient declines, does not attend or these blood pressure targets are not appropriate.

Expected population size:

Estimates provided by the National Collaborating Centre for Indicator development (see frailty and age stratification, a data analysis paper) show that 11.51% of patients aged 80 and over with no or mild frailty could be at risk of overtreatment. Comparing DM019 QOF data for 2021/22 with ONS population statistics and applying the estimates for those at risk of overtreatment shows that an average practice with 10,000 patients would have around 479 patients with diabetes, aged 79 years and under without moderate or severe frailty. To be suitable for use in QOF, there should be more than 20 patients eligible for inclusion in the denominator, per average practice with 10,000 patients, prior to application of personalised care adjustments.

ISBN: 978-1-4731-5934-1