Percentage of patients aged 79 or under with hypertension where the last blood pressure reading is ≤140/90 mmHg.
Patients with diabetes and CKD currently treated with an ACE inhibitor or ARB — trajectory-qualifying set surfaces patients the model says are already on this trajectory but not yet coded.
Patients with CHD currently taking a statin. Trajectory-qualifying set surfaces patients whose forward ASCVD risk justifies initiation.
HFrEF patients on guideline-directed four-pillar medical therapy (ARNI/ACEi, beta-blocker, MRA, SGLT2i).
Patients on the COPD register with a review within the preceding 12 months including assessment of symptoms and inhaler technique.
Patients with SMI who have had a comprehensive physical health check in the preceding 12 months.