Prevention of coronary heart disease (CHD) is a government priority. The White Paper Saving Lives: Our Healthier Nation1 set a target of reducing the death rate from heart disease, stroke and related conditions by 40% in those aged <75 years by 2010.
CHD is common, frequently fatal and largely preventable. Each year 300 000 people have heart attacks in the UK, and more than 110 000 die as a result of heart disease in England. As well as being the most common cause of premature death, CHD is a major cause of morbidity.
The recently published NHS Plan2 reinforces CHD as a clinical priority and focuses on reducing risk factors for the disease. The plan highlights the importance of the National Service Framework (NSF) for CHD.3
We decided to review all our patients on the cardiac register as the first stage in our practice's implementation of standard 3 of the NSF for CHD (see Figure 1, below). This included patients with the diagnosis of angina, atrial fibrillation or heart failure, and patients who had undergone heart surgery.
|Figure 1: NSF for Coronary Heart Disease Standard 3|
Our project plan included the following recommendations:
- A Saturday morning CHD education day for the public.4
- A designated clinic with half an hour's protected time for review of each patient.
- The introduction of a patient-held record card to ensure that care was personalised, with a contract between the patient and the nurse practitioner to address issues such as lifestyle changes.
- A comprehensive survey of consumers' views and evaluation of the CHD service offered by the practice.
The NSF for CHD focuses on the quality and outcome of healthcare. Patient-held record cards could have an enormous impact on the effectiveness of healthcare, and we thought it was worth exploring this idea.
Patient-held cards were designed by the nurse practitioner in consultation with the GPs. The following information is recorded on the cards:
- Personal and family history
- Basic measurements, i.e. height, weight, BMI, blood pressure, pulse, urine analysis etc.
- Current medication, including those recommended as standard, e.g. beta-blockers and aspirin, contraindications, any additional medication issued through the clinic, and titration of dosage
- Lifestyle parameters, such as diet, smoking status, level of exercise, and feeling of wellbeing (GHQ)
- Cardiovascular limitations and symptoms profile (CLASP) scores, documenting frequency of angina pain, ankle swelling and breathlessness. We use the Canadian classification of angina scoring system to assess limitation of activity due to angina.
- Dietary history.
The aims of the project were to tailor healthcare to the individual patient and to allow patients input into their own management through the patient-held record card.
The objectives were twofold:
- To evaluate the consumers' views of the service provided, and the introduction of a CHD patient-held record card.
- To complete an individual patient-held record card, in consultation with the nurse practitioner, to include the patient's goals regarding modifiable risk factors.
A total of 135 patients on the cardiac register were seen in the designated cardiac clinic. Of these, 95 (70%) were randomised to receive evaluation questionnaires by post.
Patient satisfaction with the service and opinions on the feasibility of introducing a patient-held record card for the clinic were obtained using a questionnaire containing four dimensions: opinion (free text); perceived benefits (Likert scale); improved communication (Likert scale); and additional comments (free text).
The questionnaire elicited a combination of ordinal data (Likert scale ranking from excellent, very good, good, fair, or poor) and qualitative data (free text).
Consent of the participants was gained at the outset by a letter accompanying the postal questionnaire. Confidentiality was ensured by asking participants not to identify themselves on the completed questionnaire.
The project lasted 9 months.
Of the 95 questionnaires sent out, 50 were completed and returned, giving a response rate of 53%. Two were received too late to be included in the analysis.
Question 1: Opinion
Patients' comments were skewed towards excellent and very good.
One patient remarked that he had shown the card to his hospital consultant, who was very impressed with the content.
Two patients commented that they would have liked the card to be a little smaller. One patient commented: "The nurse practitioner's writing in the record cards could have been clearer; difficulty in reading same."
Questions 2 & 3: Perceived benefits and Improved communication
Responses to questions 2 and 3 are shown in chart form in Figures 2 and 3 respectively (see below). The majority of responses fell within the excellent/good categories.
|Figure 2: Summary of the results to question 2|
|Figure 3: Summary of the results to question 3|
Question 4: Comments
Half the respondents requested workshops and group participation to address the issue of lifestyle interventions. The main workshops requested were weight reduction and exercise.
Many respondents experienced difficulty in accessing a dietitian as quickly as they would like, and difficulty in travelling to the nearest hospital.
A few respondents (5%) were concerned about the waiting times to see all hospital staff (including the cardiologist).
Patients generally wanted more facilities in the community, with the core of the workshops held in the health centre.
We hoped that a designated cardiac clinic would enable the practice to achieve its full potential in screening and reviewing its CHD population through a systematic and structured approach.
Patient uptake of the service was excellent: 91% (135 patients) of our cardiac population received a full review and were given patient-held record cards.
Within the patient survey, the following key issues were raised:
- Reduction in patient waiting times for secondary care.
- More clinic visits to our practice along with in-house support groups and lifestyle intervention activities, such as exercise and weight reduction clinics.
The project has benefited the practice in several ways: improved IT development, a structured and systematic approach to patient care, and an opportunity to survey our CHD population and to take forward some of the ideas identified by the patient survey.
In addition, we have set up collaborative educational programmes for weight loss and exercise; these workshops will be held weekly.
We have also struck a deal with our local sports centre to instigate a card scheme that enables our patients to swim for 50% of the normal cost.
We are trying to set up a similar scheme for use of the gym facilities.
- Department of Health. Saving Lives: Our Healthier Nation. London: The Stationery Office, 1999.
- The NHS Plan. London: DoH, 2000.
- National Service Framework for Coronary Heart Disease. London: DoH, 2000.
- Bennett J. CHD patient education morning proves popular. In Reply. Guidelines in Practice 2000; 3 (December): 20.
- Acknowledgement: To Merck, Sharp & Dohme for an educational grant to enable the publication and printing of the record cards.