Helen Wilson (left), Dr Patricia Edney and Dr Brian Hopkins share their experiences of developing local guidelines on the management of angina in primary care


   

Cardiology services in Sheffield are run by two acute trusts, with cardiothoracic surgery being carried out in only one of the trusts. As a general rule, both trusts work independently, have historically established their own ways of working, and between them employ nine cardiologists.

More than 300 GPs manage the diagnosis and treatment of uncomplicated angina in primary care, referring unstable or more complicated cases, or choosing elective referral for confirmation of diagnosis or prognostic assessment.

Within Sheffield, mortality and morbidity rates for coronary heart disease (CHD) vary widely, and the use of secondary care services is not commensurate with need. This was documented in research carried out in Sheffield by Dr Nick Payne, Director of Public Health at Sheffield Health.1 He subsequently approached Sheffield MAAG to see whether they could develop a clinical audit of referral of angina patients to address this apparent inequality.

Dr Payne and Sheffield MAAG met to discuss the research findings. The opinions of local cardiologists were susequently sought, and the main outcome was a plan to audit the care of patients with angina and CHD in general practice.

For this audit to be workable we needed to produce acceptable and easy-to-use guidelines.

 

First we looked at many existing published guidelines, including Management of Angina by The North of England Stable Angina Develop-ment Group.2

Next we identified the important parts of the guidelines and sought agreement from key people on the logical management of angina.

In total, 13 meetings were held over a 17-month period. The first few were with cardiologists; we sought not only their opinions, but also their cooperation and support.

The main body of the guidelines was established in the first three meetings. The participating groups were then widened to include other clinicians and GPs in order to clarify certain points and fine-tune decisions.

The age of referral, use of different calcium antagonists, and the smoking status of patients were all issues that needed to be addressed if we were to achieve a consensus. We had to accommodate numerous, very strongly held opinions to reach agreement at these meetings, and this improved our skill at diplomacy.

Nine months into the consultation process a pilot study was commenced in eight practices across the city. Its aim was to review the level of care provided to patients with angina in a sample of practices.

The data collected in the pilot study were used in the development of an audit tool. The information gained also contributed to the further development of the guidelines by helping ensure that they were both easy to use and accessible by the clinicians who would be using them.

We looked at patient records to see how patients were currently being managed.

Draft guidelines were then distributed to participating practices, together with the pilot study results to show the reasons for any changes that we were recommending in the guidelines. It was felt that the guidelines promoted good practice that was achievable.

 

The eight practices involved represented a practice population of more than 62000. Letters were sent to 521 patients to obtain consent for inclusion in the study, and the records of 364 (70%) of these were examined.

The data collected are shown below (Criteria 1-4).

Criterion 1
Basic data set
% recorded
Blood pressure
97
ECG
95
Lipids
53
Urine
65
Family history
55
Smoking
79
Diet
50
Alcohol
60
Exercise
42

 

Criterion 2
Prescribing
% prescribed
% stopped
 
Aspirin
70
10
9% contraindicated
Beta-blocker
32
21
12% solely on beta-blocker
Statin
25
2

51% under 70 years

 

Criterion 3

Angina grading
% recorded
Grading <1 year
37
Grading >1 year
21
No grading
42

 

Criterion 4
Practice referral pattern
% recorded
Cardiologist
26
Physician
53
No referral
21

 

Most patients had been prescribed aspirin, and further audits are ongoing in general practice to maintain a high level of aspirin prescription.

A third of patients had been prescribed beta-blockers, although 50% do not seem to have been considered for beta-blocker treatment. This could be an area that GPs may need to look at in future in the light of new evidence showing the effectiveness of beta-blockers as the drug of choice in the management of angina.

Approximately half of the patients under 70 years of age had been prescribed statins, but we did not collect sufficient data to show whether or not the other patients under 70 years of age had been assessed as needing statins.

More than 40% of patients did not have a written record of the grading of angina in their notes.For the purposes of continuing treatment, an indication of the level of angina symptoms experienced at past consultations is important, as it enables the clinician to compare the patient's current level of illness with previous levels and hence assess any changes.

Most patients were referred to secondary care. Reasons for referral included:

Assistance with drug therapy
Unstable angina
Other risk factors such as multiple health problems that included angina
Confirmation of diagnosis
History of MI
Prognostic assessment.

Patients with multiple morbidity that included angina tended to be referred to a physician specialising in their other health problems, who either managed their angina alongside their other conditions or referredthem on to a cardiologist.

The main problems encountered in the pilot project arose from the use of information technology. It was often difficult to identify the practice population with CHD, and from that the subset of patients with angina (for the purposes of the pilot study patients with hypertension and/or diabetes were excluded).

This has had an effect on the planning of CHD management in Sheffield, and highlighted the need to help GPs create and maintain their own practice registers. Some practices have adopted the use of a CHD card for patients' notes, while others have used the prompts and adapted them for a computer template.

The pilot study was completed by the end of March 1999. The final draft of the guidelines was sent to the printer in July. In October, laminated guidelines (see Figure 1,below) were distributed to each GP and practice nurse in the city, and to cardiologists and physicians in secondary care, together with a covering letter offering an information pack for audit support purposes.

More than 50 packs have been requested by practices. Angina audit information packs were also used as supporting information at primary care group CHD events in November 1999. All of the four PCGs in Sheffield are working towards meeting the National Service Framework milestones for CHD.

The angina audit information pack developed from our pilot study is a useful tool for identifying and auditing patients with angina, which follows the Sheffield angina guidelines.

Figure 1:
Front page of the ‘Sheffield Guidelines for Angina Management in General Practice 1999’, produced by Sheffield MAAG
front page of guidelines
Back page of the ‘Sheffield Guidelines for Angina Management in General Practice 1999’, produced by Sheffield MAAG
back page of guidelines
  • Copies of the Sheffield Guidelines for Angina Management in General Practice and the angina audit information pack may be obtained from your local MAAG or primary care group.

 

  1. Payne P, Saul C. Variations in the use of cardiology services in a health authority: comparison of coronary artery revascularisation rates with prevalence of angina and coronary mortality. Br Med J 1997; 314: 257-61.
  2. Eccles M et al. North of England Evidence Based Guideline Development Project. Evidence based clinical practice guideline: the primary care management of stable angina. Centre for Health Dervices Research, Newcastle upon Tyne. Report No. 98, 1999.

 

 

Guidelines in Practice, January/February 2000, Volume 3
© 2000 MGP Ltd
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