. 2019 Jul 4;9(7):e025705. doi: 10.1136/bmjopen-2018-025705

Table 1.

Indicators, their numerators and denominators and questions the indicators answer

CVD, cardiovascular disease; DM, diabetes mellitus; HbA1c, glycated haemoglobin; LDL, low-density lipoprotein; SCORE, Systematic COronary Risk Evaluation.

Question	Indicator	Numerator	Denominator
Are risk factors being measured?	Proportion of eligible patients who have all risk factor values recorded as required for calculation of risk score.	Patients aged 40 years or older who have visited in the last 12 months who have all measurements required for calculation of risk score within 12 months of the most recent date of visit.	Patients aged 40 years or older who have visited in the last 12 months.
Are risk factor measurements being converted to a total risk score?	Proportion of patients aged 40 years or older who have visited in the last 12 months who have all measurements required for calculation of risk score within 12 months of the most recent date of visit, which have a documented risk score.	Patients aged 40 years or older who have visited in the last 12 months who have all measurements required for calculation of risk score within 12 months of the most recent date of visit, which have a documented risk score.	Patients aged 40 years or older who have visited in the last 12 months who have all measurements required for calculation of risk score within 12 months of the most recent date of visit.
Are risk scores calculated correctly?	Proportion of patients aged 40 years or older who have visited in the last 12 months who have all measurements required for calculation of risk score within 12 months of the most recent date of visit, which have a documented risk score that is correct.	Patients aged 40 or older who have visited in the last 12 months who have all measurements required for calculation of risk score within 12 months of the most recent date of visit, which have a documented risk score that is correct.	Patients aged 40 or older who have visited in the last 12 months who have all measurements required for calculation of risk score within 12 months of the most recent date of visit, which have a documented risk score.
Are patients being risk scored?	Proportion of eligible patients with a documented risk score.	Patients aged 40 years or older who have visited in the last 12 months with a documented risk score.	Patients aged 40 years or older who have visited in the last 12 months.
Are risk scores calculated correctly?	Proportion of eligible patients with a documented risk score that is correct.	Patients aged 40 years or older who have visited in the last 12 months with a documented risk score that is correct.	Patients aged 40 years or older who have visited in the last 12 months with a documented risk score.
Are statins prescribed to the correct patients?	Proportion of eligible patients prescribed a statin.	Patients with existing CVD, patients with diabetes aged 40 years or older with high LDL values (as defined based on total CVD risk of SCORE 10%–14% in LDL≥2.6 mmol/L; with very high risk SCORE≥15% in LDL≥1.8 mmol/L), or patients with a SCORE of ≤9% and LDL≥2.6 or total cholesterol≥7.2, or patients with a SCORE of 10%–14% and LDL≥1.8 or total cholesterol≥7.2 mmol/L, or patients with a SCORE of ≥15%, prescribed a statin.	Patients with existing CVD, patients with diabetes aged 40 years or older with high LDL values (as defined based on total CVD risk of SCORE 10%–14% in LDL≥2.6 mmol/L; with very high risk SCORE≥15% in LDL≥1.8 mmol/L), or patients with a SCORE of ≤9% and LDL≥2.6 or total cholesterol≥7.2, or patients with a SCORE of 10%–14% and a LDL≥1.8 or total cholesterol≥7.2 mmol/L, or patients with a SCORE of ≥15%.
Are statins prescribed correctly based on documented risk score?	Proportion of patients eligible based on documented risk score prescribed a statin.	Patients with a documented risk score as very high risk SCORE≥15% prescribed a statin.	Patients with a documented risk score as very high risk SCORE≥15%.
Are patients with existing disease, who do not require the calculation of a risk score to prescribe satins, prescribed statins?	Proportion of patients with existing CVD prescribed a statin.	Patients with existing CVD prescribed a statin.	Patients with existing CVD.
Is the blood pressure of high-risk patients controlled?	Proportion of high-risk patients (SCORE≥15% or DM and age over 40 years) whose last two recorded blood pressure measurements were <130/80 mm Hg.	Patients with a true risk score indicating a very high risk (SCORE≥15%) or DM and age over 40 years whose last two documented blood pressure readings were <130/80 mm Hg.	Patients with a true risk score indicating a very high risk (SCORE≥15%) or DM and age over 40 years.
Is the blood pressure of low-risk patients controlled?	Proportion of low-risk patients (SCORE<15%) whose last two recorded blood pressure measurements were <140/90 mm Hg.	Patients with a true risk score indicating <15% whose last two documented blood pressure readings were <140/90 mm Hg.	Patients with a true risk score indicating <15%.
Are patients with existing CVD prescribed basic medications to reduce risk?	Proportion of patients with existing CVD prescribed a statin and aspirin and blood pressure-lowering treatment.	Patients with existing CVD prescribed a statin and aspirin and blood pressure-lowering treatment.	Patients with existing CVD.
Is the blood glucose of patients with diabetes controlled?	Proportion of patients with diabetes with glycaemic control as defined by last two HbA1c measurements.	Patients with type 2 diabetes whose last two HbA1c measurements were below personal target as defined by MDA-adapted WHO PEN protocol 1.	Patients with type 2 diabetes.
Is the blood pressure of patients with hypertension controlled?	Proportion of patients with confirmed hypertension whose systolic blood pressure is <140/90 mm Hg at last two visits.	Patients with confirmed hypertension whose last two blood pressure readings were <140/90 mm Hg.	Patients with confirmed hypertension.
What is the prevalence of high blood pressure?	Proportion of people whose last two systolic blood pressure reading are 140 mm Hg or above.	Patients whose last two systolic blood pressure readings were ≥140 mm Hg.	All patients aged over 18 years.