Dr Zaid Albrefkany’s winning team in the 2007 Guidelines in Practice Cardiovascular Disease Award set up an audit of CVD risk recording, which led to targeted treatment of high-risk patients
The winning initiative in the Guidelines in Practice Cardiovascular Disease Award 2007 integrated measuring and recording cardiovascular disease (CVD) risk into routine practice. A simple audit method was undertaken, which demonstrated significant benefits to patients and has plenty of scope for development. The winning team from the Bermondsey and Lansdowne Medical Mission in South London was led by Dr Zaid Albrefkany, GP. The other team members were Dr Kathryn McAdam-Freud, GP; Dr Rebecca Torry, GP; and nurses Dahlia Manners and Catherine Power.
Various national guidelines promote and endorse carrying out a holistic CVD risk assessment on specific groups of people. These are:
- patients with high blood pressure and no established CVD—NICE guideline on Management of hypertension in adults in primary care1
- patients over the age of 40 years with asymptomatic hypertension, who are therefore at high risk of developing CVD, and those under 40 years of age with a family history of premature CVD—JBS 2 guideline on prevention of CVD in clinical practice2
- all patients who are at significant risk of CVD—National Service Framework for coronary heart disease.3
Southwark PCT suggests that all patients over 40 years of age who have no history of CVD or diabetes should have a CVD risk score calculated every 5 years.4 The PCT recommends starting by calculating CVD risk scores for all adults with hypertension who are between 40 and 70 years of age.4
Although no points are awarded for recording CVD risk in the current quality and outcomes framework, it is a major health priority. Identifying and managing all patients with a significant CVD risk is the most important way of reducing and preventing future cardiovascular events. It is also a long-term way of reducing the social, economic, and lifestyle burdens that the condition imposes.
The team wanted to emphasise the importance of assessing and recording overall CVD risk within specific groups of patients. The project aimed to:
- clarify the individual’s change in CVD risk with increasing age, along with other variables, e.g. blood pressure, lipid levels, smoking status
- encourage practice staff to ask ‘What is this person’s CVD risk?’ rather than ‘Does this person have hypertension or hypercholesterolaemia?’
- evaluate whether there was any area of CVD risk assessing and recording, which, if changed, would improve the quality of care for those patients who have risk factors for CVD.
A clinical meeting was set up and all members of the healthcare team attended. This included:
- healthcare assistants
At the meeting, a protocol for managing hypertension and conducting CVD risk assessments was agreed. It was decided that the Framingham calculator,5 which is within the practice software (Vision 3), would be used for assessments, and results would be recorded in the patient’s notes. The criteria for the audit population were then chosen — all patients must be on the hypertension register, be without established atherosclerotic CVD or diabetes mellitus, and they should have had their 10-year CVD risk assessment recorded within the past 15 months. A timeline was set for the two rounds of data collection.
There were various reasons that justified why this audit population was chosen.These are:
- all hypertension guidelines tend to emphasise the importance of an overall CVD risk assessment1,2,3
- within a 15-month time period an individual’s CVD risk will change because of increasing age and other clinical parameters. Assessments should not, therefore, be carried out only once, but should happen on a continuous basis. The GMS contract hypertension indicators include BP 4, which requires the practice to record blood pressure every 9 months;6 these patients should also have annual check-ups, and so setting 15 months as a time period ensures the targeted population will have their CVD risk assessed
- patients with established atherosclerotic CVD or diabetes mellitus do not need their risk assessed. They are known to be at high risk and, as such, automatically fulfil secondary prevention criteria.
Hypertension is a significant risk factor for CVD. The practice has many patients with hypertension and this meant that a subpopulation had to be chosen. The criteria for the sample group were:
- aged 50–59 years
- not on any of the following disease registers — diabetes mellitus, ischaemic heart disease, cerebro-vascular accident, peripheral arterial disease.
These criteria were chosen because: after the age of 50, CVD risk rate rises steeply; men in this age group have a higher CVD risk than females of the same age; these people do not appear on any other disease register, which means they are a ‘forgotten group’ who would not normally be targeted and so would not be diagnosed—typically middle-aged men who work during normal GP opening hours and so do not attend the surgery frequently.
The team decided that a fair, achievable, minimum goal of 80% of the targeted group of patients undergoing CVD risk assessment should be set.
Cycle 1: data and findings
In March 2006, a total of 46 patients were eligible for the study. At this time only 27 patients (58.7%) had their CVD risk recorded in their notes.
The team presented their findings at the monthly clinical meeting in May 2006. It was acknowledged that the practice was, at that time, failing the set audit standard (i.e. 58.7% vs 80%).
The practice discussed reasons why they failed to meet the 80% level:
- the clinical software does not automatically Read code and record CVD risk scores when accessing and viewing the risk screen, and needs manual recording (i.e. data transfer)
- the hypertension clinical template does not include CVD risk assessments.
With simplicity in mind, some changes were agreed that, it was hoped, would improve the care of patients. Along with raising awareness about assessing CVD risk in certain patients, the practice tried to:
- emphasise the importance of manual recordings
- add CVD risk assessment to the hypertension template
- reconsider CVD risk at annual hypertension check-ups
- manually flag-up patients’ notes with visual reminders, so that they would be picked up every time the notes were accessed.
The team agreed to implement these changes and then re-audit the relevant patients after 7 months.
Cycle 2: data and findings
The second cycle of data collection was conducted in December 2006. Fifty patients were eligible for the audit this time around, and 48 patients (96%) met the criteria. These results were presented at the practice clinical meeting in January 2007, where the overall achievements and ideas for the future were discussed.
Over the 7-month period, a great improvement in CVD risk scoring was seen, rising from only 58.7% to 96% of the target population. A learning and development culture was established within the team, which included ongoing discussions about recent articles, guidelines, and individual cases. This in turn led to an overall benefit for patients by identifying those at high risk and, therefore, targeting and managing them earlier, in accordance with national guidelines such as JBS 2.2
This project has brought many benefits to the practice and has been furthered in numerous ways. It helped with setting up a practice register for patients who are at high risk of developing primary heart disease, which is part of the Southwark local enhanced services. It has also meant adding CVD risk assessment to the hypertension template and assessing CVD risk at annual hypertension check-ups—both of which should be done as standard good practice in most general practices.
The work has been presented to the Southwark Hypertension Steering group. It has also been recognised as ‘good and original’ by Southwark PCT and was chosen to be presented at the Southwark PCT 2007 Annual Clinical Governance Conference ‘Embedding Best Practice’, which was held in March this year. Furthermore, the project and its successes were presented at a local PCT educational event, which took place in May 2007.
The team at the Bermondsey and Lansdowne Medical Mission will be continuing their work with CVD risk assessment, making it a part of their routine work. This initiative has demonstrated that positive changes are possible if:
- effective team work is in place to raise awareness of the issue involved
- coherent participation and communication between all team members can identify weak areas
- the team can agree on specific action points then make a joint effort to implement them before the final re-evaluation.
When putting a new procedure in place in a busy general practice, a good rule to stick by is ‘KISS: keep it short and simple’.
Furthering the project
To follow on from this successful work, a number of potential adaptations have been suggested. It would be useful to audit the accuracy of CVD risk assessments, checking whether all clinical and additional risk factors been considered when conducting an assessment. Cardiovascular disease risk assessments could be carried out in other high-risk groups, such as those with obesity, a strong family history of CVD, and those from certain ethnic minorities. It is also important to assess how patients with a high CVD risk (>20%) are being managed, and to decide if it has been worthwhile replacing the Framingham tool5 with the new JBS 2 calculator (CVRA—cardiovascular risk assessment).7 The JBS 2 tool is easier to use, more accurate, and would, therefore, seem to be a sensible choice of risk calculator.
The practice is currently undergoing a pilot study using the JBS 2 calculator, and has also updated its CVD and primary prevention clinical protocol.
The only way to assess CVD risk is to measure and record it in a patient’s notes. Individuals need to be aware of their overall CVD risk in order to have a better understanding of their health, and they should learn to address and modify any risk factors as early as possible because these issues have more of an effect as age increases. The key to reducing blood pressure and risk of cardiovascular events is estimating an overall risk and subsequent protocol-driven monitoring with regular follow-up by the practice. It is worth investing time and resources in CVD risk recording because so much cardiovascular morbidity and mortality is preventable.
- CVD risk assessment is quick and easy to perform as part of routine hypertension review
- It will identify groups of patients requiring CVD prophylaxis with statins and aspirin
- The evidence for primary prevention is for simvastatin 40 mg, which is now very inexpensive, at £1.31 a montha
- This is likely to reduce costs and morbidity in relation to CVD in future
- The risk assessment is also likely to identify new patients with type 2 diabetes at an early stage
- National Institute for Health and Care Excellence. Hypertension: management of hypertension in adults in primary care (partial update). Clinical guideline 34. London: NICE, 2007.
- JBS 2: Joint British Societies guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91 (suppl 5): v1–v52.
- Department of Health. National Service Framework for Coronary Heart Disease: modern standards and service models. London: DH, 2000.
- Southwark PCT. Local enhanced services document. London: Southwark PCT, 2007.
- British Medical Association. Revisions to the GMS Contract, 2006/07. Delivering Investment in General Practice. London: BMA, 2006.