Montrose GP Dr John Griffith, winner of the Guidelines in Practice Awards 2002, describes his team's project to improve primary and secondary prevention
The Government White Paper Towards a Healthier Scotland identifies the prevention of coronary heart disease as a national priority.
CARDIA, a computer program developed for Angus Local Health Care Cooperative by a team from Townhead Surgery, Montrose, Finix (the IT Directorate of Tayside Health Board) and Saragon Ltd, has been created to facilitate the provision of effective evidence based care to patients with existing CHD or those at significant risk of developing it.
CARDIA incorporates SIGN Guidelines 40 and 41, the British Hypertension SocietyÍs management guidelines for hypertension and the Tayside Diabetes Handbook based on SIGN Guideline 55.
CARDIA uses the Tayside electronic health record which is held on a central server outside the practice, at Tayside Health Board. Data are collated from practice systems (GPASS), laboratory systems and hospital discharges as well as from direct entry into CARDIA itself.
The fundamental aim for managing data has been to ïcollect onceÍ and ïuse oftenÍ. Access to the system is via a closed secure intranet site using a standard web browser. The electronic health record is based on the area community health index number that is a unique patient identifier.
CARDIA collates all the electronic data held for each individual patient. The system prompts the entry of missing data and determines if a patient requires primary or secondary CHD prevention (Figure 1, below).
For patients not identified as having existing CHD, CARDIA calculates risk using the Framingham equation (Figure 2, below).
|Figure 1:The CARDIA summary screen|
|Figure 2:The CARDIA primary risk assessment screen|
For both primary and secondary prevention, CARDIA gives detailed advice in terms of managing:
- Preventive medication
- Lipid lowering
CARDIA can be used to search for patients under all data headings and also has an audit facility allowing individual practices to be compared.
Why implement CHD guidelines?
Incidence and trends in CHD in Angus reflect those nationwide. Shortly after the Angus LHCC and its sister organisation in Arbroath and Froickheim were established in 1999, a group was formed to tackle CHD prevention. Although a considerable amount of work was going on in Angus practices to achieve a reduction in CHD, the level of commitment and the effectiveness of interventions showed a wide variation.
There were problems in identifying those patients who required interventions and in standardising the interventions using evidence-based guidelines. There was a need to develop a system that:
- Maximised outcome
- Simplified the process
- Co-ordinated the process
- Facilitated monitoring and audit
- Improved outcomes.
Most importantly, a patient centred approach was required that looked at managing patients with existing CHD and those at risk rather than a disease centred process that managed hypertension, diabetes, lipid lowering and lifestyle as separate and unconnected conditions.
How did we implement guidance?
In implementing CHD guidance we studied:
- SIGN Guideline 40: Lipids and the Primary Prevention of Coronary Heart Disease.1
- SIGN Guideline 41: Secondary Prevention of Coronary Heart Disease following Myocardial Infarction.2
- British Hypertension Society Guidelines for the Management of Hypertension.3
- The Tayside Diabetes Handbook.4,5
In consultation with other Angus practices and in particular practice pharmacists, we identified quality markers (prescribing of aspirin, statins, ACE inhibitors and beta-blockers) that could be used to audit existing CHD prevention activity and then monitor future progress.
We looked at clinical processes, particularly those that involved recording clinical measurements (weight, blood pressure, biochemistry) lifestyle data (smoking, exercise, alcohol consumption) and summarising clinical data (CHD, hypertension, stroke, family history) to develop a system that required single data entry. This mixture of paper based and electronic systems allowed benchmark comparisons to be made of quality indicators across the LHCC practices.
Pulling together clinical processes in this way led to a patient centred approach that became a stepping stone to the electronic method that has evolved through CARDIA.
CARDIA was funded through a Primary Care Development Fund grant. Development involved extracting the algorithms presented in the reference works, linking them together where links exist and translating these algorithms into a form that could be programmed electronically.
How has evidence-based practice been improved?
The improvement has been in two areas:
- Process: this has involved focusing on those patients requiring greatest clinical input, recalling them at the right time and identifying those who are defaulting from clinical review.
- Clinical management: CARDIA has allowed us to identify quickly those patients requiring secondary and primary prevention and to tailor our approach in these areas. In particular it has allowed us to optimise the management of those requiring medication, to identify those patients who are not receiving medication, and to avoid unnecessary medication.
- Hypertension: CARDIA allows us to identify patients whose blood pressure is not being maintained within recommended ranges and to reduce some of the confusion around different target levels for those with or without diabetes and those with evidence of diabetic nephropathy.
- Lipid management: CARDIA removes confusion around who to treat based on risk. For patients who are receiving treatment, it prompts the user to strive for an adequate reduction in lipid levels.
- Diabetes: CARDIA prompts the user to exclude diabetes in every patient who is at primary or secondary risk. In patients with diabetes, it prompts the clinician to try to maintain adequate glycaemic control and cardiovascular disease prevention.
- Lifestyle: CARDIA prompts the calculation of BMI and prompts the user to assess adequately and manage patients with weight problems as well as record and give advice about smoking, alcohol consumption, exercise and diet.
What tangible benefits have been achieved?
Between 2000 and 2001 there was a general improvement in most practicesÍ outcomes even before CARDIA had been released (Figures 3, 4, 5 and 6 below). This yearÍs data will soon be available.
|Figure 3: Post-MI patients taking aspirin, clopidogrel or warfarin (%)|
|Figure 4: Patients under 75 years with total cholesterol <5.0mmol/l (%)|
|Figure 5: Patients under 75 years taking a beta-blocker (%)|
|Figure 6: Patients under 75 years taking an ACE inhibitor (%)|
There has been a subjective improvement in awareness of CHD prevention by clinical and clerical staff.
The new electronic system allows a more structured approach to patient management and is a significant improvement over previous paper based and uncoordinated systems.It ensures that clinicians give patients consistent advice and that patients do not have to attend several different disease based clinics.Instant audit is available as part of the routine clinical process, thus streamlining the benchmarking process.
Rolling out CARDIA
CARDIA is pushing back the boundaries of clinical database linking and is now being rolled out to all practices in the Angus LHCC. It comes as part of a suite of programs that facilitate investigation reporting, electronic ordering of investigations, electronic referrals and discharge and rheumatology monitoring.
We await with anticipation the development of its full potential as a tool for implementing CHD prevention guidelines and the automatic monitoring of that process.
- SIGN Guideline 40: Lipids and the Primary Prevention of Coronary Heart Disease. Edinburgh: Scottish Intercollegiate Guidelines Network, 1999.
- SIGN Guideline 41: Secondary Prevention of Coronary Heart Disease following Myocardial Infarction. Edinburgh: Scottish Intercollegiate Guidelines Network, 2000.
- Ramsay LE, Williams B, Johnston GD et al. British Hypertension Society Guidelines for the Management of Hypertension: report of the third working party of the British Hypertension Society. J Hum Hypertens 1999; 13: 569-92.
- Brennan G, Silburn J, Connacher A, Young A. Tayside Diabetes Handbook. Tayside Regional Diabetes, 2000. www.diabetes-healthnet.ac.uk
- SIGN Guideline 55: Management of Diabetes. Edinburgh: Scottish Intercollegiate Guidelines Network, 2001.