Dr Hamish Dougall and Professor Frank Sullivan describe the Tayside initiative to tackle secondary prevention of CHD
There are many guidelines outlining the recommended approach to secondary prevention of coronary heart disease (CHD). Numerous studies,1,2 however, show that optimal secondary prevention is still not being attained, despite clear and indisputable evidence that it saves lives. Many CHD deaths must therefore be considered preventable.
Although death rates from CHD in Tayside are near the average for Scotland and declining, they are still among the highest in Western Europe, and not declining as rapidly as in many other countries.
In trying to determine how the problem of under-delivery of secondary prevention was being tackled in Tayside it became apparent that there was no single coordinated approach.
Within the region a multitude of initiatives were underway, or being considered, both in primary and secondary care and at local health care cooperative and trust levels.
Many of these initiatives were occurring in isolation and duplicating the work of others, thus failing to benefit from the wider experience available.
Inevitably, too, resources were being used suboptimally as different projects vied for access to the limited resources available. At all levels of political and clinical thinking, CHD has been prioritised within Tayside.
Over the past few years, an innovative and exciting clinical audit & research tool has been developed within the DARTS (Diabetes Audit & Research in Tayside, Scotland) initiative3 (www.diabeteshealthnet.ac.uk). This is progressing to provide real time electronically linked data from a multitude of sources, available at the point of delivery of care via the NHS-net.
In collaboration with MEMO – the Medicines Event Monitoring Organisation (www.dundee.ac.uk/memo) – high quality information linking clinical data with encashed prescription data has been obtained.4 A similar record linkage system may assist in improving the standard of secondary prevention within Tayside.
A small multidisciplinary group from primary and secondary care came together during the autumn of 1999 to try to optimise, rationalise and move forward the agenda of inadequate secondary prevention provision within Tayside. A conference on a regional aproach to secondary prevention of CHD was held in January 2000.
A Consensus Group attempted to distil and represent the views expressed at the conference. There was a firm feeling that there must be equity of delivery of care using a cooperative, integrated, multidisciplinary approach across primary and secondary care.
An open and inclusive Tayside-wide Steering group will be formed to lead the process and develop the framework (www.hearts.org.uk). A suitable database was identified as a key tool in the implementation of effective CHD secondary prevention.
|Home page of the Tayside H.E.A.R.T.S. Initiative website|
Over the coming months the process will be developed under the four main banners:
|Audit & clinical governance.|
Using information from GP records, and integrating it with other available sources and SIGN guideline No. 41,5 which summarises a detailed review of the evidence-based approach to secondary prevention, we plan to give participating surgeries detailed feedback on patients within their practice requiring secondary prevention. It is hoped that the initiative will have a significant impact on the delivery of care in the region.
- The ASPIRE Steering Group. A British Cardiac Society survey of the potential for the secondary prevention of coronary heart disease (Action on Secondary Prevention through Intervention to Reduce Events). Heart 1996;75:334.
- Brady AJB, Pittard JB. Prevalence of coronary heart disease within a population of 901,829 sampled in the United Kingdom, and level of secondary prevention of coronary heart disease among those identified. Eur Heart J 1999;20:472.
- Morris AD, Boyle DI, MacAlpine R et al. The diabetes audit and research in Tayside Scotland (DARTS) study: electronic record linkage to create a diabetes register. DARTS/MEMO Collaboration. Br Med J 1977; 315: 524-88.
- Morris AD, Boyle DI, McMahon AD, Greene SA, MacDonald TM, Newton RW. Adherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus. The DARTS/MEMO Collaboration. Diabetes Audit and Research in Tayside Scotland. Medicines Monitoring Unit. Lancet 1997; 350: 1505-10.
- SIGN. Secondary Prevention of Coronary Heart Disease following Myocardial Infarction. SIGN publication no. 41. Edinburgh: SIGN, 2000