AF001

The contractor establishes and maintains a register of patients with atrial fibrillation

CHD001

The contractor establishes and maintains a register of patients with coronary heart disease

HF001

The contractor establishes and maintains a register of patients with heart failure

HYP001

The contractor establishes and maintains a register of patients with established hypertension

STIA001

The contractor establishes and maintains a register of patients with stroke or TIA

DM001

The contractor establishes and maintains a register of all patients aged 17 or over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed

AST001

The contractor establishes and maintains a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months

COPD001

The contractor establishes and maintains a register of patients with COPD

DEM001

The contractor establishes and maintains a register of patients diagnosed with dementia

MH001

The contractor establishes and maintains a register of patients with schizophrenia, bipolar affective disorder and other psychoses and other patients on lithium therapy

CAN001

The contractor establishes and maintains a register of all cancer patients defined as a ‘register of patients with a diagnosis of cancer excluding non-melanotic skin cancers diagnosed on or after 1 April 2003’

EP001

The contractor establishes and maintains a register of patients aged 18 or over receiving drug treatment for epilepsy

LD001

The contractor establishes and maintains a register of patients with learning disabilities

OST001

The contractor establishes and maintains a register of patients—

1. Aged 50 or over and who have not attained the age of 75 with a record of a fragility fracture on or after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan, and

2. Aged 75 or over with a record of a fragility fracture on or after 1 April 2012

RA001

The contractor establishes and maintains a register of patients aged 16 or over with rheumatoid arthritis

PC001

The contractor establishes and maintains a register of all patients in need of palliative care/support irrespective of age

OB001

The contractor establishes and maintains a register of patients aged 16 or over with a BMI of 30 in the preceding 15 months.

AF006

The percentage of patient with atrial fibrillation in whom stroke risk has been assessed using CHA2DS2-VASx score risk stratification scoring system in the preceding 3 years (excluding those patients with a previous CHADS2 or CHA2DS2-VASc score of 2 or more) and a record of counselling regarding the risks and benefits of anticoagulation therapy has been made

AF007

In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated with anticoagulation drug therapy

DM002

The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 15 months) is 150/90 mmHg or less

DM003

The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 15 months) is 140/80 mmHg or less

DM007

The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 15 months

DM012

The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification; 1) low risk (normal sensation, palpable pulse), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 15 months

DM014

The percentage of patients newly F1diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register

COPD003

The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 15 months

MH011W

The percentage of patients with Schizophrenia, Bipolar affective disorder and other psychoses who have a record of blood pressure, BMI, smoking status and alcohol consumption in the preceding 15 months and in addition to those aged 40 or over, a record of blood glucose or HbA1c in the preceding 15 months

PC002W

The contractor has regular (at least 2 monthly) multi-disciplinary case review meetings where all patients on the palliative care register are discussed

FLU001W

The percentage of the registered population aged 65 years or more who have had influenza immunisation in the preceding 1 August to 31 March

FLU002W

The percentage of patients aged under 65 years included in (any of) the registers for CHD, COPD, Diabetes or Stroke who have had influenza immunisation in the preceding 1 August to 31 March