The team from Harrow PCT who were joint runners up in the Guidelines in Practice Awards 2003 describe how their project improved CHD care in their area

Harrow, in north-west London is a diverse area. While there is a generally high level of owner-occupancy, some wards are among the most deprived in the country.

Trends for mortality from all circulatory diseases in individuals under 75 years and from coronary heart disease in those aged 65-74 years show a decline in Harrow, in line with rates for London and nationally, nevertheless they remain high. The area has a large Asian population who are at high risk of CHD.

A preliminary audit undertaken in one of the Harrow primary care groups in 2000 showed that, across the 24 practices, standards of care for CHD and heart failure varied and were not universally applied.

The inception of Harrow PCT in 2002, which now includes 40 practices, has provided a big impetus to improving the quality of CHD care in the area.

Drawing up local guidelines

A collaboration between Harrow PCT, North West London Hospitals NHS Trust and Brent Primary Care Trust with the support of the North West London CHD Collaborative was set up in 2002. The aim was to improve CHD and heart failure care by ensuring that it was standardised and evidence-based, through implementing national guidelines (Box 1, below).

Box 1: National guidelines for CHD and heart failure implemented in Harrow PCT
Coronary heart disease
  • National Service Framework for Coronary Heart Disease 1
  • SIGN 41. Secondary prevention of coronary heart disease following myocardial infarction 2
  • British Hypertension Society. Guidelines for the Management of Hypertension 3
  • Joint British recommendations on prevention of coronary heart disease in clinical practice. British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society, British Diabetic Association 4
  • SIGN 40. Lipids and the primary prevention of coronary heart disease 5
  • NICE guideline on prophylaxis for patients who have experienced a myocardial infarction 6
Heart failure
  • National Service Framework for Coronary Heart Disease (Chapter 6, Heart Failure) 1
  • SIGN 35. Diagnosis and treatment of heart failure due to left ventricular systolic dysfunction 7
  • PRODIGY guidance - heart failure 8
  • The Treatment of Heart Failure.The Task Force of the Working Group on Heart Failure of the European Society of Cardiology 9

A steering group was set up, consisting of GPs, cardiologists, CHD primary and secondary care specialist nurses, pharmacists, endocrinologists and a project manager from North West London CHD Collaborative.

The group met regularly to review and critically appraise current evidence and guidelines. The group formulated local plans and developed a strategy for implementing the National Service Framework for Coronary Heart Disease.1 Local evidence-based guidelines for the management of CHD and heart failure were then produced.

In conjunction with developing new CHD and heart failure guidelines, it was essential to ensure that all cardiovascular disease registers, including those for CHD, heart failure, peripheral vascular disease, cerebrovascular accident and atrial fibrillation, were accurate.

This involved verifying that all patients already on the registers were correctly diagnosed and tracking down other patients with cardiovascular disease and adding them to the appropriate register with the correct Read code. Further guidelines were developed to assist practice staff in completing the registers.

Drafts of the local CHD and heart failure guidelines were circulated to healthcare professionals for their feedback. Final changes were incorporated before the guidelines were launched at meetings of GPs and practice and community nurses, in May 2002.

The guidelines were then distributed to all clinicians in general practice by mail and email. CHD nurses and pharmacists visited practices to promote and encourage use of the guidelines.

A condensed, more ‘user friendly’, version of the heart failure guideline was disseminated to encourage uptake.

Complementing the guidelines

A standardised Harrow CHD computer template was introduced to all practices for GPs’ and practice nurses’ use to support systematic and evidence-based CHD care. A range of recall systems were put in place to ensure that patients were monitored at least annually, as recommended by the National Service Framework for CHD.

An introduction to cardiac care course was established to facilitate practice nurses in setting up nurseled clinics. Guidelines on running clinics were also produced.

Incentivised targets for the year 2002/3 were formulated by the PCT and distributed to all practices. Nine targets were defined (Table 1, below), and there was a sliding scale of payment for achieving targets, as follows:

  • Three out of nine = 20%
  • Five out of nine = 50%
  • Seven out of nine = 100% (need to have three of the five asterisked).

Measuring our success

In May 2003, we carried out an audit of CHD care across the whole PCT. We then compared data from a CHD audit carried out in 2002 in one of the PCGs and extracted using MIQUEST, with data for the same 20 practices taken from the 2003 audit (Table 2, below).

Table 1: Harrow PCT audit results for coronary heart disease, 2003a
Target Achieved
  • Patients with hypertension (who do not have existing CHD, stroke/TIA, peripheral vascular disease)b should have a Framingham risk assessment in the past 18 months
20% 62%
  • Patients with a diagnosis of heart failure on computer should be taking an ACE inhibitor or A2 antagonist, or recorded as contraindicated (Read code 8128)
30% 60%
  • CHD patients should have smoking status recorded and
    CHD patients who smoke should have smoking level recorded in the past 18 months and have been offered support to stop*

90%
75%

99%
78%
  • CHD patients should have blood pressure measured in the past 18 months*
75% 92%
  • CHD patients should have blood pressure of <=140/85 mmHg measured in the past 18 months*
50% 52%
  • CHD patients should have cholesterol measured in the past 18 months
 75% 78%
  • CHD patients should have cholesterol <5.0 mmol/l measured in the past 18 months or be prescribed lipid lowering treatment in the past 4 months*
60% 76%
  • CHD patients should have warfarin, phenindione, aspirin or clopidogrel prescribed in the past 4 months or OTC aspirin recorded in the past 18 months*
80% 82%
  • Patients over 60 years with a history of atrial fibrillation should have had warfarin, phenindione, aspirin or clopidogrel prescribed in the past 4 months or OTC aspirin recorded in the past 18 months
50% 80%
a,Age range 18-74 years unless otherwise specified; b,These patients should receive usual secondary prevention therapy
* Three of the asterisked targets are required to claim 100% payment

Some of the parameters examined differed from the 2003 audit, so a direct comparison between the years 2002 and 2003 was not possible. However, where parameters coincided, the second audit showed a dramatic improvement in evidence-based care, as all practices achieved their targets.

In 2003, preliminary audit results were obtained across the whole PCT (Table 1, above), which showed that 70% of practices achieved seven out of nine targets, qualifying for the maximum payment on the sliding scale. The audit results were distributed to the practices enabling them to see which areas they needed to target for improvement.

Table 2: Comparison of 2002 CHD audit in one Harrow PCG with data for same 20 practices taken from 2003 PCT-wide CHD audit



2002
 2003
Target Achieved Target Achieved
  • Smoking status recorded

90%

93%

90%

94%
  • Smoking level recorded in past 18 months and support offered to stop
 75% 56% 75% 77%
  • Blood pressure recorded in past 18 months
 75% 85% 75% 94%
  • Cholesterol <5.0 mmol/l in past 18 months or on lipid lowering therapy
 60% 54% 60% 75%
  • Taking aspirin
80% 78% 80% 85%

Our initiative has resulted in the following tangible benefits to patients:

  • We have identified individuals who have no clinical evidence of CHD but whose risk of a cardiovascular event is >30% in 10 years.
  • Heart failure patients receive an ACE inhibitor unless contraindicated.
  • CHD patients who smoke are identified, reviewed and offered support to stop smoking.
  • CHD patients’ blood pressure is recorded annually.
  • CHD patients’ blood pressure is controlled to <=140/85 mmHg.
  • CHD patients’ total cholesterol is measured every 18 months.
  • Patients with a cholesterol level of >5 mmol/l receive lipid lowering treatment.
  • CHD patients receive anticoagulant or antiplatelet treatment.
  • Patients over 60 years of age with a history of atrial fibrillation receive anticoagulation or antiplatelet treatment.

By ensuring that all patients receive evidence-based care, our project should reduce mortality from CHD.

Rolling out the programme

The North West London CHD Collaborative has worked to share the guidelines for setting up registers and the CHD and heart failure guidelines with other PCTs, both locally and nationally.

References

  1. Department of Health. National Service Framework for Coronary Heart Disease. London: DoH, 1999.
  2. Scottish Intercollegiate Guidelines Network. SIGN 41. Secondary prevention of coronary heart disease following myocardial infarction. Edinburgh: SIGN, 2000.
  3. Ramsay LE,Williams B, Johnston GD et al. for the British Hypertension Society. Guidelines for management of hypertension: report of the third working party of the British Hypertension Society. J Hum Hypertens 1999; 13: 569-92.
  4. British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society, British Diabetic Association. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998; 80(Suppl 2): S1-S29.
  5. Scottish Intercollegiate Guidelines Network. SIGN 40. Lipids and the primary prevention of coronary heart disease. Edinburgh: SIGN, 1999.
  6. National Institute for Clinical Excellence. NICE guideline on prophylaxis for patients who have experienced a myocardial infarction (Guideline A). London: NICE, 2001.
  7. Scottish Intercollegiate Guidelines Network. SIGN 35. Diagnosis and treatment of heart failure due to left ventricular systolic dysfunction. Edinburgh: SIGN, 1999.
  8. PRODIGY Guidance - heart failure.www.prodigy.nhs.uk/guidance.asp?gt=HeartFailure
  9. The Task Force of the Working Group on Heart Failure of the European Society of Cardiology.The treatment of heart failure. Eur Heart J 1997; 18: 736-53

Guidelines in Practice, December 2003, Volume 6(12)
© 2003 MGP Ltd
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