Cholesterol control and lipid management (CHOL) - QOF indicator

Cholesterol control and lipid management (CHOL)

This QOF area covers lipid-lowering prescribing for patients with established cardiovascular disease or chronic kidney disease, alongside cholesterol outcomes for those with established cardiovascular disease. Notable features of the 2026/27 guidance include separate prescribing and outcome indicators, with LDL taking precedence when both LDL and non-HDL results are recorded on the latest measurement date.

Indicators

Ongoing management

Why cholesterol control is included

• Raised cholesterol makes a major contribution to cardiovascular disease (CVD). Worldwide, it accounts for a third of ischaemic heart disease; estimates for England attribute 7.1% of deaths and 3.7% of disability-adjusted life years (DALYS) to high cholesterol.

CHOL003: lipid-lowering prescribing

CHOL003 draws on NICE IND230.

Rationale

• The indicator seeks to support NICE-recommended cholesterol reduction in everyone with established CVD — coronary heart disease, peripheral arterial disease or stroke/TIA — and in those with chronic kidney disease. National lipid management guidance takes the same approach.

• For secondary prevention of CVD, the recommended starting treatment is a high intensity statin. NICE advises ezetimibe when this is declined or cannot be used because of contraindications or intolerance. If ezetimibe alone does not achieve the secondary prevention lipid target, further options to consider, subject to eligibility criteria, include bempedoic acid and the injectable treatments alirocumab (TA393, June 2016), evolocumab (TA394, June 2016) or inclisiran (TA733, October 2021).

• These alternatives count towards achievement of the indicator when a high intensity statin has been declined or is clinically unsuitable because of contraindications or intolerance.

Reporting and verification

• Use the CHOL003 definition in the table to determine the requirements for achievement.

CHOL004: cholesterol outcomes

CHOL004 draws on NICE IND278.

Rationale

• This indicator provides an interim measure of outcomes from the lipid-lowering treatments covered by CHOL003 for people with established CVD. It is intended to prompt consideration of more intensive treatment for patients with coronary heart disease, peripheral arterial disease or stroke/TIA whose initial therapy — generally a high intensity statin — has not reduced cholesterol sufficiently.

• The targets of LDL cholesterol at 2.0 mmol/L or below, or non-HDL cholesterol at 2.6 mmol/L or below, follow NICE guideline NG238, which addresses cardiovascular risk assessment and reduction, including lipid modification.

• If cholesterol reduction remains inadequate, increase treatment intensity according to NICE guidance.

• Adding ezetimibe or an injectable treatment may be appropriate, provided the patient meets the relevant NICE eligibility criteria. For example, inclisiran requires LDL≥ 2.6mmol/L, while PCSK9i (monoclonal antibodies) require LDL cholesterol > 3.5 or 4mmol/L according to the patient's risk profile. For patients who cannot tolerate statins and do not respond adequately to ezetimibe alone, consider adding bempedoic acid in accordance with the statin intolerance pathway.

Reporting and verification

• Use the CHOL004 definition in the table to determine the requirements for achievement.