The winning project in the CHD category in the 2004 Guidelines in Practice Awards was an initiative to improve patient care in a deprived inner city area. Dr John Robson describes its success
The National Service Framework for Coronary Heart Disease and the nGMS contract have made management of cardiovascular disease a priority for primary care.1,2
Implementing CHD guidance is particularly important in deprived areas with a population from a range of ethnic backgrounds, where the decline in coronary heart disease mortality rates has been slower than in more affluent areas.
Between 1979 and 1999, mortality from cardiovascular disease declined by 21% in the inner east London Boroughs of Hackney, Newham and Tower Hamlets compared with a decline of 36% in England and Wales. Between 1979 and 1995, the standardised mortality rate for cardiovascular disease in Newham increased from 4% above to 37% above the national average rate.3
In 1998-9, prescribing for secondary prevention of CHD in east London, in common with other inner city areas, was well below the national average.4
Clinical Effectiveness Group
In 1998, the east London Clinical Effectiveness Group, based in the Centre for General Practice and Primary Care at Queen Mary, University of London, set up the current programme for the primary care management of chronic diseases including cardiovascular disease.
As part of the programme, the group develops local guidelines based on national guidance. The group has published guidelines on heart failure, stroke, atrial fibrillation, diabetes, cancer referral, severe mental illness and depression as well as cardiovascular disease.
The programme covered practices in Hackney, Newham and Tower Hamlets. In 2002, the area had a population of 774 876 registered patients, of whom 50% were white and 26% were from south Asian ethnic groups.
The remaining 24% were from other ethnic minorities or their ethnic origin was not specified.
The Clinical Effectiveness Group works in collaboration with local stakeholders, which generally includes PCTs, hospital consultants, community sector providers and patient group representatives.
Developing local guidance
In 2000, the Clinical Effectiveness Group produced guidelines covering CHD, raised blood pressure and absolute risk, based on the NSF for CHD and SIGN guidelines.2,5,6 Copies of each local guideline were disseminated to all clinicians, including GP registrars and locums, across the three boroughs. The guidelines were updated in 2004 (Figure 1, below).
|Figure 1: Extract from the updated East London Summary Guidelines for Coronary Heart Disease|
The facilitator’s role
The summary guidelines were promoted in local general practices by three trained facilitators, one working in each borough. The facilitators’ brief was to provide continuing support for the practices in implementing the guidelines. The aim was to achieve better patient care by focusing on evidence-based practice and improving the quality of data collected.
The facilitators developed educational sessions on implementing the guidelines. Sessions were held in each practice and aimed at all healthcare professionals involved in the treatment of CHD patients.
Establishing a disease register
At the start of the programme, an important priority was for the facilitators to work with each practice to establish an accurate register of CHD patients.
Improving data collection
A Clinical Effectiveness Group initiative, Sharing Quality in Data (SQUID) was set up to promote computerised disease registers and electronic data collection.
Each year since 1998, an electronic audit of all registered patients and a manual audit on a sample of patients on practice disease registers has been completed. The data gathered by these means were used to compile a locality register and form a clinical dataset that encompassed NSF standards and the local guidelines. Standard data entry templates for the dataset were installed on practice computers.
The strong drive towards establishing computerised registers and electronic audit across the area culminated in all audit data being collected directly from clinical computer systems in 2004.
A report is now generated for each practice and, based on this, the facilitators give feedback annually to each practice on how well they are implementing the guidelines.
Tables and bar charts illustrate each practice’s position in relation to its anonymised peers and the average across the locality, and the report informs changes in clinical practice.
Improving evidence-based practice
By 2004, 147 out of 154 local practices (95%) were carrying out electronic audits, and there were 15 324 patients on the CHD register.
Facilitators visited practices to support them in the construction and maintenance of their CHD registers. Where practices had particularly low performance or prescribing levels these were addressed in a multidisciplinary practice meeting; non-recording was often due to failure to use appropriate templates or misunderstandings over coding.
Benefits to patients
Disseminating evidence-based guidelines that follow national standards but are also seen as being locally owned and supported has encouraged a high level of concordance in the local practices, and this has helped ensure that patient care is effective. As Tables 1 and 2 (below) show, there has been a consistent improvement in appropriate prescribing for patients with CHD. Once well below the national average, prescribing for this group of patients is now only slightly below the average.
|Table 1: Participating practices, type of audit and number of patients on CHD register, 1998-2004|
|Year||Practices participating||Manual audits||Computer audits||No audit data||Practice list size||CHD register||No on register* per 1000 list size|
|* unstandardised rates (inter-quartile range)|
|Table 2: Patients with CHD receiving secondary prevention therapy, 1998-2004|
|Year||No. on CHD register||Beta-blocker||Statin||Aspirin|
|1998||3881||Not available||Not available||1312 (33.8%)|
|1999||8154||1209 (14.8%)||2013 (24.7%)||2772 (34.0%)|
|2000||12507||2318 (18.5%)||4177 (33.4%)||7909 (63.2%)|
|2001||12694||4500 (35.4%)||5685 (44.8%)||7514 (59.2%)|
|2002||14541||5861 (40.3%)||7527 (51.8%)||10847 (74.6%)|
|2003||14715||6421 (43.6%)||8668 (58.9%)||10958 (74.5%)|
|2004||15324||7128 (46.5%)||9755 (63.6%)||11452 (74.7%)|
Establishing accurate computerised disease registers ensures that disease management is efficient by supporting call and recall systems, identifying patients whose clinical care was incomplete and flagging risk factors to prompt early intervention.
Practice-based support with implementing the guidelines and feedback from audits has also ensured that patient care is thorough and includes lifestyle advice, social support and access to other services.
Rolling out the project
The guidelines were updated in 2004 and endorsed by the North East Sector Health Authority; they are available for PCTs that wish to use them. The routine use of standard electronic templates has given local practices a head start in implementing the nGMS contract, and the programme has been adapted to meet and support its requirements.
CEG guidance is available from the Centre for General Practice and Primary Care, Queen Mary, University of London, Mile End Road, London E1 4NS.
- General Practitioners Committee. New GMS contract 2003. Supporting documentation. British Medical Association and The NHS Confederation. London, 2003.
- Department of Health. National Service Framework for Coronary Heart Disease. London: DoH, 2000.
- Office of National Statistics/Office of Population Censuses and Surveys mortality statistics for boroughs/local authorities 1979-1999.
- Unpublished PACT data.
- Scottish Intercollegiate Guidelines Network. SIGN 40. Lipids and the primary prevention of coronary heart disease. Edinburgh: SIGN, 1999.
- Scottish Intercollegiate Guidelines Network. SIGN 41. Secondary prevention of coronary heart disease following myocardial infarction. Edinburgh: SIGN, 2000.