Good data collection is important in ensuring that audit results are translated into improved care for patients, as Dr Nigel Watson explains


   

Coronary heart disease is a major cause of death in both men and women, resulting in one in four deaths overall. It is the single most common cause of premature death in the UK.1 Each year in the UK approximately 300 000 people suffer a myocardial infarction, of whom around 140 000 die.2 Many of these deaths may be avoidable. Although mortality from CHD is falling in the UK, morbidity is increasing.

The Government, in its Health of the Nation document, establishes the prevention and management of CHD as a major priority.3

The New Forest PCT, in its Primary Care Investment Plan and Health Improvement Plan has also identified CHD as an important priority. In the New Forest PCT, 19 practices look after a population of approximately 190 000. The PCTÍs primary care development group developed proposals for the management of patients with CHD, which largely focused on the National Service Framework for Coronary Heart Disease.1

All 19 practices agreed to develop a management plan for patients with a history of MI, angina pectoris and heart failure. The practices also agreed to audit the care of patients in each group measured against agreed criteria.

Audit of patients with a history of MI

The target population consisted of all patients registered with a New Forest practice aged under 75 years of age with a history of MI.

The audit criteria are shown in Table 1 (below).

Table 1: Criteria for New Forest PCTÍs CHD audit

Criterion
  • Patient review at least annually
  • Blood pressure measurement recorded at least annually
  • Patient should be taking aspirin, unless contraindicated
  • Patient should have been screened for diabetes mellitus in past 5 years
  • Cholesterol measurement annually
  • Smoking status recorded, at least annually if a current smoker and every 5 years for a non-smoker
  • BMI recorded annually

Criteria for follow up

Record BP measurement

Hypertension is an independent risk factor for CHD and there is a progressive increase in MI, angina pectoris and sudden death associated with an increase in blood pressure.

Control of blood pressure should follow British Hypertension Society Guidelines 1999.4 Box 1 (below) shows the targets for blood pressure measured in clinic, while Box 2 (below) shows the targets for mean daytime ambulatory or home blood pressure measurement.

Box 1: Targets for blood pressure measured in clinic

 

Optimum Suboptimum
Non-diabetic <140/85 mmHg <150/90 mmHg
Diabetic <140/80 mmHg <140/85 mmHg
Box 2: Targets mean daytime ambulatory or home blood pressure
  Optimum Suboptimum
Non-diabetic <130/80 mmHg <140/85 mmHg
Diabetic <130/75 mmHg <140/80 mmHg

Check patient is taking aspirin

All patients with CHD should receive aspirin indefinitely, unless there are contraindications.5 Aspirin reduces the absolute risk of vascular events by 3.6%, and also decreases non-fatal MIs, non-fatal strokes, vascular deaths and all-cause mortality. Doses of 75-150mg/day of aspirin are effective.

Test urine or blood for glucose

Diabetes mellitus is an independent risk factor for CHD. There is also an increased incidence of diabetes mellitus in patients with CHD.

Check lipid levels

There is good evidence that all patients with established CHD benefit from a reduction in cholesterol levels.6 The target is to reduce total cholesterol levels to <5 mmol/l (and LDL to <3 mmol/l) or by 30% whichever is the greater.

Dietary advice and modification can reduce cholesterol by 5-10%.1 If drug treatment is required, a statin is the best therapy.7

Record smoking status

Smoking is an independent risk factor for MI, stroke and sudden death. Patients with CHD who stop smoking reduce their risk of death by around 50% over 5 years.8 Advice, guidance and support to help patients stop smoking are therefore of major importance.

Record BMI

BMI >30 is associated with an increased risk of hypertension and diabetes mellitus. It is therefore suggested that the target should be to achieve a BMI <30 and preferably <25. It should be noted that there are no randomised controlled trials to show that a reduction in weight improves the outcome in coronary heart disease.

Audit results

Eighteen of the 19 practices in the New Forest PCT participated in the audit, which covered a population of 153674 aged under 75 years. The audit identified 1884 (1.23%) of this population with a recorded history of MI (Table 2, below).

Table 2: Results of CHD audit in 1884 patients <75 years with a history of MI

Criterion

Average achieved

Standard

Reviewed in past 15 months

81%

90%

Blood pressure measured in past 15 months 77% 90%
Taking aspirin or aspirin contraindicated 78% 90%
Screened for diabetes mellitus in the past 5 years 41% 90%
Cholesterol measurement in past 15 months 61% 90%
Taking a statin 59% 90%
Smoking status recorded in past 5 years if a non-smoker or past 15 months if a current smoker 50% 90%
BMI calculated in past 15 months 35% 90%

The data provide each practice with a standardised comparison with all other practices and with a PCT average. The data depend on the following variables:

  • Quality:
    • amount of information contained in patientsÍ electronic health records (EHRs)
    • accuracy of coded information added
  • Data extraction:
    • the ability of each practice to construct reports to reflect accurately the data in EHRs.

The New Forest PCT is working with PRIMIS9 to ensure improvement in data quality.

The results are not a league table; they do not identify the ïbestÍ and the ïworstÍ practices. They merely enable practices to compare their own performance with that of others.

The results were shown to all the practices to enable them to establish practice-based action plans to improve performance and address specific areas.

Discussion

Annual review

An average of 81% of patients aged under 75 years with a history of MI have been reviewed in the past 15 months. The range across practices was 53-100%. Action required:

  • Practices need to establish a call/recall system for all patients with a history of CHD.

Blood pressure

An average of 77% (range 57-93%) of patients in the target group have had their blood pressure recorded in the past 15 months. Action required:

  • Practices need to ensure that all blood pressure recordings are entered into the patientÍs EHR.
  • A review of data added during a routine consultation may also improve both care of the patient and data quality.

Aspirin

An average of 78% (range 49-97%) of patients in the target group are recorded as taking aspirin or aspirin is contraindicated.

The options for recording the information are:

  • Aspirin prescribed by GP
  • Aspirin bought over the counter
  • Aspirin contraindicated either because of a GI bleed or acute allergic reaction
  • Aspirin therapy refused.

Not all practices are recording over-the-counter aspirin.

Action required:

  • At each review patients should be asked whether they are taking aspirin; this should be recorded and the entry coded to allow easy reporting in the future.

Diabetes mellitus screening

An average of 41% (range 13-92%) of patients in the target group are recorded as having been screened for diabetes in the past 5 years. Screening for diabetes mellitus includes a urine test for glucose or a blood glucose result.

The wide range of results is due to the fact that some practices record all results on the patientÍs EHR and some are still storing the results only in the ïLloyd GeorgeÍ notes.

Action required:

  • All practices must ensure that as part of an annual review a screen for diabetes mellitus is performed. By April 2003 all laboratory results should be transmitted to practices electronically and be easily available in the patientÍs EHR.

Cholesterol measurement

An average of 61% (range 34-78%) of patients in the target group have had cholesterol levels measured in the past 15 months. These figures reflect the fact that pathology results are not routinely sent electronically and some data are not available on patientsÍ EHRs.

For the first year it was felt important to ensure that all patients had an annual cholesterol measurement. The targets for cholesterol levels were left to a future audit.

Action required:

  • To ensure that all patients are reviewed at least annually.
  • To ensure that as part of the annual review cholesterol levels are measured, results discussed and appropriate action taken.
  • Target levels of a total cholesterol of less than 5mmol/l (and LDL of less than 3mmol/l) or a reduction of 30% need to be achieved.

Statins

An average of 59% (range 53-100%) of patients in the target group are currently prescribed a statin.

Practices are not recording those patients who have had side-effects to statins, where statins are not clinically indicated, for example in terminally ill patients or those who have refused treatment.

There remains a small core of patients who had an MI before the widespread use of statins who are unwilling to start statin therapy now.

Action required:

  • Review all patients not currently being prescribed a statin to see whether this is clinically appropriate. A review of medication should form the cornerstone of an annual review for all patients with CHD.
  • Record those who refuse statin treatment and those for whom statins are not appropriate or are contraindicated.

Smoking

It was agreed that smokers should have their smoking status updated annually while that of non-smokers should be updated every 5 years.

The results showed a PCT average of 50% (range 7-100%). The data are incomplete because some practices have only just started to record smoking status and some may have had difficulty in extracting the data.

Action required:

  • To ensure that smoking status is recorded annually if appropriate.
  • To assist practices with data extraction where needed.

Body mass index

An average of 35% (range 16-66%) of patients in the target group had BMI recorded. Some practices are recording weights but not BMI -some question the value of measuring BMI.

As there is an association between BMI, diabetes mellitus and CHD, practices should be encouraged to measure and record BMI annually.

Conclusion

Mortality from CHD is falling locally as well as nationally, as Figure 1 (below) shows.10

Figure 1: Trends in CHD mortality between 1995 and 2000

All practices in the New Forest PCT have set up systems to manage patients with established CHD. They should now review their audit results and compare them with those of other practices. The results should be shared with all members of the primary healthcare team and action plans agreed and established.

Improved care brings rewards in terms of decreasing both morbidity and mortality from CHD.

References

  1. Department of Health. National Service Framework for Coronary Heart Disease. London: DoH, 2000.
  2. Department of Health. The Health of the Nation: A strategy for health in England. London: DoH, 1998.
  3. Petersen S, Mockford C, Rayner M. Coronary Heart Disease Statistics. London: British Heart Foundation Statistics Database, 1999.
  4. Ramsay LE, Williams B, Johnston GD et al. British Hypertension Society. Guidelines for hypertension management 1999: summary. Br Med J 1999; 319: 630-5.
  5. Antiplatelet TrialistsÍ Collaboration (APT). Collaborative overview of randomised trials of antiplatelet therapy-I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories. Br Med J 1994; 308: 81-106.
  6. Sacks FM, Pfeffer MA, Moye LA et al for the Cholesterol and Recurrent Events Trial Investigators (CARE). The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996; 335: 1001-9.
  7. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360: 7-22.
  8. Secondary prevention of myocardial infarction. MeReC Bulletin 1999; 10(2).
  9. Watson N. PRIMIS will ensure the effective use of practice computers. Guidelines in Practice 2001; 4(7): 76-8.
  10. Department of Health. Compendium of clinical and health indicators. London: DoH, 2002.

Guidelines in Practice, December 2002, Volume 5(12)
© 2002 MGP Ltd
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