CHOL003 - Patients on a statin or other lipid lowering drug

The codes referenced in this article are taken from the NHS Technology Reference Update Distribution (TRUD).  Not all of these may be present or selectable in all clinical systems.

The information contained within this article is from version 50 of the Business Rules for Quality and Outcomes Framework (QOF).                                                                                  

This indicator was updated in version 50 for the contract year 2025/26 to remove icosapent ethyl medication from counting towards the indicator                                                        

Indicator definition

Indicator ID	Description
CHOL003	Percentage of patients on the QOF Coronary Heart Disease (CHD), Peripheral Arterial Disease (PAD), Stroke/Transient Ischaemic Attack (TIA) or Chronic Kidney Disease (CKD) Register who are currently prescribed a statin, or where a statin is declined or clinically unsuitable, another lipid-lowering therapy.

What do the business rules mean?

What makes a patient eligible?

Patients are eligible for the CHOL003 denominator if:

1. they have a diagnosis at least one of:
   
1. coronary heart disease (CHD)
   
2. peripheral arterial disease (PAD)
3. stroke or TIA
4. chronic kidney disease (CKD) 3-5 diagnosis, as well as being aged at least 18 years old and there is no subsequent CKD resolved or CKD stage 1 or 2 code
   
2. and they do not have a history of haemorrhagic stroke
   
3. and they do not have an unresolved diagnosis of diabetes

How to achieve the indicator

To meet the criteria for CHOL003, eligible patients must have:

1. been issued a statin in the last 6 months of the contract year
   
2. any of the criteria in Group 1 and be prescribed a drug from Group 2 in the last 6 months of the contract year
   Group 1:
1. Patient has a statin intolerance code recorded ever (or)
   
2. Patient has chosen not to receive a statin during the contract year (or)
3. Patient has a persisting statin contraindication recorded ever (or)
4. Patient has an expiring statin contraindication recorded during the contract year

           Group 2 (drugs):

1. Bempedoic acid
   
2. Ezetimibe
   
3. Inclisiran
   

4. PCSK9 inhibitor
   

What will remove patients from eligibility?

1. Patients on the palliative care register (without a more recent code of Palliative care not indicated)
2. Patients who have maximal tolerated cholesterol lowering therapy in the contract year
   
3. Patients who have allergies (ever), adverse reactions (ever), contraindications (in contract year), declined (in contract year) or not indicated (contract year) to each of the lipid lowering therapies: bempedoic acid, ezetimibe, inclisiran and PCSK9 inhibitor
   
4. Patients who have had a lipid lowering adverse reaction ever
   
5. Patients who have a lipid lowering therapy contraindication code (ever) OR a lipid lowering therapy not indicated code in the contract year
6. Patients who chose not to receive lipid lowering therapy in the contract year
7. Patients who have been invited twice (at least 7 days apart) for review
8. Patients who were newly registered with the practice in the last 3 months of the contract year

If a patient achieves the indicator at any point during the year, any exclusions that have also been added are ignored.

What are the common pitfalls/what do I need to watch out for?

If a patient does not want any lipid lowering medication, there are two approaches to excluding the patient:

1. The short approach is to code Lipid lowering therapy declined and nothing else
   
2. The long approach would be to first code Statin declined, then a declined code for each of the 4 alternative drug groups - a total of 5 codes
   

In approach 2, Statin declined is not strictly necessary, but would be good coding practice to use it.

SNOMED codes used in this indicator

The codes referenced in this article are taken from the NHS Technology Reference Update Distribution (TRUD).  Not all of these may be present or selectable in all clinical systems.

Codes indicating the patient is on maximal tolerated cholesterol lowering treatment (CHOLMAX_COD)

SNOMED code	SNOMED code description
407568002	Patient on maximal tolerated lipid lowering therapy

Codes indicating allergy to bempedoic acid (BEMPACIDALL_COD)

SNOMED code	SNOMED code description
1326571000000106	Allergy to bempedoic acid

Codes indicating adverse reaction to bempedoic acid (BEMPACIDADV_COD)

SNOMED code	SNOMED code description
1326581000000108	Adverse reaction to bempedoic acid

Bempedoic acid contraindicated codes (BEMPACIDCON_COD)

SNOMED code	SNOMED code description
1326611000000102	Bempedoic acid contraindicated

Bempedoic acid not indicated codes (BEMPACIDNIND_COD)

SNOMED code	SNOMED code description
1326601000000104	Bempedoic acid not indicated

Codes indicating the patient has chosen not to receive bempedoic acid (BEMPACIDDEC_COD)

SNOMED code	SNOMED code description
1326631000000105	Bempedoic acid refused

Codes indicating allergy to ezetimibe (EZETIMIBEALL_COD)

SNOMED code	SNOMED code description
1326121000000101	Allergy to ezetimibe

Codes indicating adverse reaction to ezetimibe (EZETIMIBEADV_COD)

SNOMED code	SNOMED code description
1326131000000104	Adverse reaction to ezetimibe

Ezetimibe contraindicated codes (EZETIMIBECON_COD)

SNOMED code	SNOMED code description
1326711000000108	Ezetimibe contraindicated

Ezetimibe not indicated codes (EZETIMIBENIND_COD)

SNOMED code	SNOMED code description
1326701000000106	Ezetimibe not indicated

Codes indicating the patient has chosen not to receive ezetimibe (EZETIMIBEDEC_COD)

SNOMED code	SNOMED code description
1326721000000102	Ezetimibe refused

Codes indicating allergy to inclisiran (INCLISIRANALL_COD)

SNOMED code	SNOMED code description
1362871000000100	Allergy to inclisiran

Codes indicating adverse reaction to inclisiran (INCLISIRANADV_COD)

SNOMED code	SNOMED code description
1362881000000103	Adverse reaction to inclisiran

Inclisiran contraindicated codes (INCLISIRANCON_COD)

SNOMED code	SNOMED code description
1362051000000103	Inclisiran contraindicated

Inclisiran not indicated codes (INCLISIRANNIND_COD)

SNOMED code	SNOMED code description
1362041000000101	Inclisiran not indicated

Codes indicating the patient has chosen not to receive inclisiran (INCLISIRANDEC_COD)

SNOMED code	SNOMED code description
1362061000000100	Inclisiran refused

Codes indicating allergy to PCSK9 inhibitors (PCSK9IALL_COD)

SNOMED code	SNOMED code description
1326141000000108	Allergy to proprotein convertase subtilisin/kexin type 9 inhibitor
1365331000000104	Allergy to evolocumab
1365431000000106	Allergy to alirocumab

Codes indicating adverse reaction to PCSK9 inhibitors (PCSK9IADV_COD)

SNOMED code	SNOMED code description
1326151000000106	Adverse reaction to proprotein convertase subtilisin/kexin type 9 inhibitor
1365341000000108	Adverse reaction to evolocumab
1365441000000102	Adverse reaction to alirocumab

PCSK9 inhibitors contraindicated codes (PCSK9ICON_COD)

SNOMED code	SNOMED code description
1326751000000107	Proprotein convertase subtilisin/kexin type 9 inhibitor contraindicat800ed
1365371000000102	Evolocumab contraindicated
1365411000000103	Alirocumab contraindicated

PCSK9 inhibitors not indicated codes (PCSK9ININD_COD)

SNOMED code	SNOMED code description
1326741000000109	Proprotein convertase subtilisin/kexin type 9 inhibitor not indicated
1365361000000109	Evolocumab not indicated
1365401000000100	Alirocumab not indicated

Codes indicating the patient has chosen not to receive PCSK9 inhibitors (PCSK9IDEC_COD)

SNOMED code	SNOMED code description
1326761000000105	Proprotein convertase subtilisin/kexin type 9 inhibitor refused
1365381000000100	Evolocumab declined
1365421000000109	Alirocumab declined

Adverse reaction to lipid lowering drug codes (LIPIDTHERADV_COD)

SNOMED code	SNOMED code description
293417004	Lipid-lowering drug adverse reaction

Lipid therapy contraindicated codes (LIPIDTHERCON_COD)

SNOMED code	SNOMED code description
135822005	Lipid lowering therapy contraindicated

Lipid therapy not indicated codes (LIPIDTHERNIND_COD)

SNOMED code	SNOMED code description
135807000	Lipid lowering therapy not indicated

Lipid therapy declined codes (LIPIDTHERDEC_COD)

SNOMED code	SNOMED code description
135826008	Lipid lowering therapy declined

Cholesterol invite codes (CHOLINVITE_COD)

SNOMED code	SNOMED code description
1109921000000100	Quality and Outcomes Framework quality indicator-related care invitation
310879007	Cholesterol reduction program - invited
711471000000106	Lipid disorder monitoring invitation
716001000000100	Lipid disorder monitoring first letter
716461000000106	Lipid disorder monitoring verbal invitation
716741000000100	Lipid disorder monitoring telephone invitation
716751000000102	Lipid disorder monitoring second letter

Codes for intolerance to statins (STATININTOL_COD)

SNOMED code	SNOMED code description

Codes indicating the patient has chosen not to receive a statin prescription (STATINDEC_COD)

SNOMED code	SNOMED code description
134396000	Statin declined

Statin contraindications (persisting) (XSTAT_COD)

SNOMED code	SNOMED code description
16524331000119104	History of rhabdomyolysis due to statin
293432006	3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitor adverse reaction
293433001	Adverse reaction caused by simvastatin
293434007	Adverse reaction caused by fluvastatin
293435008	Adverse reaction caused by pravastatin
294970008	Allergy to 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor
294971007	Allergy to simvastatin
294972000	Allergy to fluvastatin
294973005	Allergy to pravastatin
787206005	Rhabdomyolysis due to statin

Statin contraindications (expiring) (TXSTAT_COD)

SNOMED code	SNOMED code description
134391005	Statin not indicated
315363002	Statins contraindicated
413174003	Statin not tolerated

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