Eric Rudnick, MD, FACEP EMS Medical Director Best Practices for Pulmonary Hypertension and the Interaction Pulmonary hypertension is a disease process where there is increased resistance to blood flow in the pulmonary arterial circulation. This is occurs as the small pulmonary arteries and capillaries become blocked, narrowed, and/or destroyed. As you recall, the right side of the heart pumps
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Atozhandbooks.co.ukREPLACEMENT INDICATORS (indicator wording amended) continued
AGREED CHANGES TO QOF 2011/12
2009/11 2011/12 2011/12 Indicator wording
With effect from 1 April 2011, 12 QOF indicators have been retired: Indicator Indicator
CH5, CHD7, DM5, DM11, DM16, STR5, MH7, EP7, Information 4, Records The percentage of patients with diabetes in whom the 21, PE7 and PE8. New and replacement indicators are listed below. For last blood pressure is 150/90 or less in the preceding 15 months details, see www.nhsemployers.org > Pay & Contracts > General Medical The percentage of patients with diabetes in whom the Services Contract > Quality and Outcomes Framework last blood pressure is 140/80 or less in the preceding 15 months REPLACEMENT INDICATORS (indicator wording amended)
REPLACEMENT INDICATORS (changed to reflect coding or business logic amendments)
2009/11 2011/12 2011/12 Indicator wording
The practice can produce a register of patients with COPD Indicator Indicator
The percentage of all patients with COPD diagnosed The percentage of patients with a history after 1 April 2011 in whom the diagnosis had been of myocardial infarction (from 1 April 2011) confirmed by post bronchodilator spirometry currently treated with an ACE inhibitor (or ARB The percentage of patients on the register who have a if ACE intolerant), aspirin or an alternative anti- comprehensive care plan documented in the records platelet therapy, beta blocker and statin (unless a agreed between individuals, their family and/or contraindication or side-effects are recorded) For patients with newly diagnosed angina POINTS REDUCED (change only in point value)
(diagnosed after 1 April 2011), the percentage who are referred for specialist assessment 2009/11 2011/12 Indicator wording
2009/10 2010/12 Threshold
In those patients with a new diagnosis of hypertension (excluding those with pre-existing CHD, diabetes, stroke and/or TIA) recorded between the preceding 1 April to 31 March: the percentage of THRESHOLD INCREASED (by 1 percentage point)
patients aged 30 to 74 years who have had a face to face cardiovascular risk assessment at the outset 2009/11 2011/12 Indicator wording
of diagnosis (within 3 months of the initial diagnosis) Indicator Indicator
The percentage of patients with diabetes in whom STROKE6 STROKE6 Unchanged
the last IFCC-HbA1c is 59 mmol/mol (equivalent to HbA1c of 7.5% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 15 months NEW INDICATORS for 2011/12
The percentage of patients with diabetes in whom Indicator Indicator wording
the last IFCC-HbA1c is 64 mmol/mol (equivalent The percentage of women under the age of 55 years who are to HbA1c of 8% in DCCT values) or less (or taking antiepileptic drugs who have a record of information and equivalent test/reference range depending on local counselling about contraception, conception and pregnancy in the The percentage of patients with diabetes in whom Percentage of patients on the Learning Disability register with the last IFCC-HbA1c is 75 mmol/mol (equivalent Down’s Syndrome aged 18 years and over who have a record of to HbA1c of 9% in DCCT values) or less (or blood TSH in the preceding 15 months (excluding those who are on equivalent test/reference range depending on local The percentage of patients with a new diagnosis of dementia from The percentage of patients with diabetes with a April 2011 to have FBC, calcium, glucose, renal and liver function, record of a foot examination and risk classification: thyroid function tests, serum vitamin B12 and folate levels 1) low risk (normal sensation, palpable pulses), recorded 6 months before or after entering on to the register 2) increased risk (neuropathy or absent pulses), QP1–QP5 Indicators QP1–QP5 relate to prescribing.
3) high risk (neuropathy or absent pulses plus This indicator set requires practices to conduct an internal review of their prescribing deformity or skin changes or previous ulcer) or followed by an external peer review that will include an assessment of clinical and 4) ulcerated foot within the preceding 15 months cost effectiveness. Practices will be required to agree three areas in which to make improvements. Agreed for 2011/12 only, may be extended if effective. A to Z Handbook for Nurses in General Practice Montgomery Plester 2011 A to Z Handbook for Nurses in General Practice Montgomery Plester 2011 NEW FROM NICE www.nice.org.uk
CG122 Ovarian cancer (Apr 2011) Recognition and initial management
The National Institute for Health and Clinical Excellence (NICE) is of ovarian cancer Care and early treatment of women with suspected or
an independent organisation that provides national guidance on confirmed ovarian cancer. Updates and replaces recommendation 1.7.4 in promoting good health and preventing and treating ill health.
Referral guidelines for suspected cancer (CG27, 2005)
• Clinical guidelines (CG) offer evidence-based Cardiovascular disease
• Public health guidance (PH) recommends CG126 Stable angina (Jul 2011) The management of stable angina
activities, policies and strategies to help prevent Care and treatment of adults with stable angina, usually caused by disease or improve health in populations and individuals. It may focus on a particular topic (eg, smoking), CG127 Hypertension (Aug 2011 - updates and replaces CG34). Clinical
population (eg, schoolchildren) or setting (eg, the workplace).
management of primary hypertension in adults Care and treatment of
• Technology appraisals (TA) are recommendations on the use primary hypertension, with new and updated advice on diagnosis, drug of new and existing: medicines; medical devices (eg, hearing aids or inhalers); diagnostic techniques; surgical procedures (eg, hernia repair); and health promotion activities Diabetes prevention
PH35 Type 2 diabetes (May 2011) Preventing type 2 diabetes:
Alcohol dependence and harmful alcohol use
population and community-level interventions in high-risk groups
CG115 (Feb 2011) Alcohol-use disorders: diagnosis, assessment
and the general population Aimed at those working in national and local
and management of harmful drinking and alcohol dependence
public health services, including GPs, practice nurses and dietitians, or Advice on alcohol-use disorders in adults and in young people aged involved in physical activity interventions and community engagement.
10–17 years. Read CG115 along with the below earlier guidance: Risk factors include being overweight or obese, and lack of physical PH24 (2010) Alcohol-use disorders: preventing the development
activity, and certain ethnic communities and people from lower of hazardous and harmful drinking Includes advice on how best to
socioeconomic groups are particularly at risk.
detect alcohol misuse, and on brief interventions to manage it, in the • integrating national strategy on type 2 diabetes with national CG100 (2010) Alcohol-use disorders: physical complications
activities to prevent other non-communicable diseases (such as Covers acute unplanned alcohol withdrawal, including delirium cardiovascular disease and certain cancers). tremens, alcohol-related liver damage and pancreatitis, and • national action to promote a healthy diet and physical activity. management of Wernicke’s encephalopathy. • local needs assessments and strategies, including local action to promote a healthy diet and physical Anaemia in patients with CKD
activity among communities at high risk. CG114 (Feb 2011 - updates & replaces CG39) Anaemia management
• training for those involved in helping to spread awareness in people with chronic kidney disease Covers: detecting and
of the risks and how to prevent the condition. diagnosing and managing anaemia of chronic kidney disease (CKD) and other health problems or treatments that may affect it Food allergy in children and young people
CG116 (Feb 2011) Diagnosis and assessment of food allergy
in children and young people in primary care and community setting
CG121 Lung cancer (Apr 2011 - updates CG24) Diagnosis and
Covers children and young people up to their 19th birthday who: treatment of lung cancer Care and treatment of people with
• have symptoms or signs that could suggest food allergy. lung cancer. Includes new and updated advice on communication, • are at greater risk of developing a food allergy, eg, already have diagnosis and staging; follow-up and patient perspectives.
asthma, atopic eczema or allergic rhinitis, or have a parent or sibling with a food allergy. A to Z Handbook for Nurses in General Practice Montgomery Plester 2011 A to Z Handbook for Nurses in General Practice Montgomery Plester 2011 CG116 does not specifically look at individuals who have a reaction to a food, eg, lactose intolerance, not caused by the immune system Mental health: anxiety & other common disorders
CG123 (May 2011) Common mental health disorders: identification
and pathways to care Advice on the care and treatment common
mental health disorders, with a focus on primary care. New recommendations on: access to care; assessment; and developing local care pathways for common mental health disorders (depression, generalised anxiety disorder, panic disorder, obsessive-compulsive disorder, post traumatic stress disorder and social anxiety disorder).
CG113 Anxiety (Jan 2011 - updates and replaces CG22)
Generalised anxiety disorder and panic disorder (with or without
agoraphobia) in adults New and updated advice on managing
‘DO NOT DO’ ADVICE www.nice.org.uk/usingguidance/
To access NICE’s database of ‘Do not do’ recommendations, from the home page > Putting Guidance into Practice > left-hand menu, and click on ‘Do Skin cancer
PH32 (Jan 2011) Skin cancer prevention: information, resources,
For example: type ‘primary prevention’ in the ‘Do not do’ recommendations search box to find 10 environmental changes Being out in the sun can benefit health,
recommendations on cardiovascular disease and the following advice on osteoporosis prevention: providing a good source of vitamin D and the opportunity for physical Osteoporosis - primary prevention
activity, but prolonged exposure can significantly increase skin Guidance ID NICE ‘do not do’ recommendation
cancer risk. The guidance encourages a balanced approach, helping Raloxifene is not recommended as a treatment option for the primary Raloxifene to ensure that skin cancer prevention activities do not discourage prevention of osteoporotic fragility fractures in postmenopausal women outdoor physical activity, while encouraging people to use sensible skin protection. NHS Evidence www.evidence.nhs.uk
NICE Pathways access only current NICE guidance. Use NHS Evidence
to find and access high-quality clinical information from both NICE and CG117 Tuberculosis (Mar 2011 - updates and replaces CG33)
Clinical diagnosis and management of tuberculosis, and
measures for its prevention and control Covers diagnosis and
treatment of active and latent tuberculosis (TB) in adults and children,
NEW FROM SIGN www.sign.ac.uk
and on preventing the spread of TB, eg by offering tests to people at The Scottish Intercollegiate Guidelines Network (SIGN) develops evidence- based clinical practice guidelines for the National Health Service (NHS) in Scotland.
NICE PATHWAYS http://pathways.nice.org.uk/
Use NICE Pathways, a new on-line tool, for quick and easy access to
SIGN app for Apple & Android devices
all the NICE advice on a specific topic. Related pathways link up with Visit the SIGN website to download the SIGN Guidelines app. The app one another, eg, those for diet and physical activity, and those for includes the 2011 edition of The British Guideline on the Management of Asthma SIGN 101, with a new section on asthma in adolescents Listed overleaf are the first 20 pathways developed. www.sign.ac.uk/pdf/qrg101.pdf, and Quick Reference Guides (QRGs) of recently published SIGN guidelines, including: A to Z Handbook for Nurses in General Practice Montgomery Plester 2011 A to Z Handbook for Nurses in General Practice Montgomery Plester 2011 • Management of atopic eczema in primary care SIGN 125 NEW FROM NHS Diabetes www.diabetes.nhs.uk
NHS Diabetes is a service improvement team that works to improve care for people with diabetes. Use the website to source guidance, resources, • Psoriasis and psoriatic arthritis in adults SIGN 121 diabetes information data and support, and contact the team with your questions through the ‘Ask a question?’ button on each page. • Management of sore throat and indications for tonsillectomy SIGN 117• Management of diabetes SIGN 116 Improving the diagnosis, classification and coding of diabetes
Diagnosing, classifying and coding diabetes can be complex, and getting it • Non-pharmaceutical management of depression SIGN 114 right is essential for correct patient management. • Diagnosis and pharmacological management of Parkinson’s disease SIGN 113 A new report and fact sheet, produced by NHS Getting it right: Improving the
Diabetes with the RCGP, offer practical advice classification, diagnosis and coding
of diabetes: report and fact sheet
NEW FROM THE DEPARTMENT OF HEALTH www.dh.gov.uk
You can browse and search the DH’s updated site, subscribe to email Diabetes information guides
alerts or RSS feeds, or view it on your mobile phone. You can also follow New reports in the Knowledge and Information Repository summarise DH on Twitter, and order publications on line latest guidance and evidence in key areas, including: structured education; New items are highlighted on the homepage, and the news and publications emotional and psychological support; prevention; and care planning. pages. The ‘Policy’ pages (the NHS, public health, and social care) aggregate Access them at www.diabetes.nhs.uk →> Areas of care content at the top level. If you are interested in, for example, nutrition, you can bookmark or subscribe to the nutrition page.
NEW FROM THE NPC www.npc.nhs.uk
National Prescribing Centre’s work is now integrated into NICE – note Bowel cancer In England, bowel cancer is the
the above new web address. Visit the site for guidance and resources to third most common type of cancer (in men, NHS Choices information: www.nhs.uk/conditions/Cancer- the third most common after prostate and lung cancer; in women, the second most common after breast cancer). Following the success of regional pilots, a national ‘Be Constipation advice
Clear on Cancer’ campaign to increase awareness of bowel cancer starts Topics in a new bulletin include: when to use non-pharmacological treatments in adults; when to use laxatives; the The management of constipation
“If you’ve had blood in your poo or looser poo for 3 weeks, your evidence for different laxatives; when to review laxative treatment; new treatment options. Lung cancer October 2011 saw the launch of a regional campaign
across the East and West Midlands to highlight signs
and symptoms of lung cancer; local TV and radio ads Find advice on avoiding medication errors in primary care in an article by prompt people with a persistent cough for more than Tony Avery, Professor of Primary Health Care, University of Nottingham Medical School, Strategies for safer prescribing: 10 Top tips. Strategies for safer prescribing:
10 Top tips
www.npc.nhs.uk/publications_resources.php An estimated 750,000+ people in the UK have dementia. Numbers are expected to double in the next 30 years. A significant number (currently c. 15,000) develop dementia relatively early in life.
A to Z Handbook for Nurses in General Practice Montgomery Plester 2011 A to Z Handbook for Nurses in General Practice Montgomery Plester 2011
David Andorsky Harvard Medical School Mario Tristan IHCAI Foundation 25 March 2002 Screening for malnutrition and vaccination status among the children of migrant Nicaraguan workers in Grecia, Costa Rica Introduction Nicaraguans form a large immigrant community in Costa Rica, consisting of approximately 315,000 individuals out of the country’s total population of 3 million.