Dr Nigel Watson describes an audit carried out in his practice to improve the care of CHD patients and hence reduce the associated mortality and morbidity
The prevention and management of coronary heart disease (CHD) was identified as a major priority for the Government in the Health of the Nation document,1 and reinforced in the National Service Framework for Coronary Heart Disease2 published last year.
CHD is a major cause of death in both men and women below 75 years of age. Reduction in deaths from CHD is a local and national priority.
The purpose of this audit was to establish the baseline of current care provided to patients aged <75 with established CHD. Having identified the problems with the current system, we would then put in place an action plan and repeat the audit.
Aims of care
The aims of care for patients with established CHD in the practice are to reduce the morbidity and mortality associated with CHD.
- To recognise the symptoms of CHD and initiate appropriate investigations, management and treatment.
- To encourage compliance with lifestyle changes and therapy.
- To review all patients with CHD at least annually.
- To maintain a disease register for all patients with CHD.
- To encourage patients to take responsibility for their health.
Definition of CHD
The category of CHD includes a diagnosis of one or more of the following:
- Myocardial infarction (MI)
- Angina pectoris
- Heart failure.
All patients aged <75 years with CHD should:
- Be on a CHD database.
- Have blood pressure measured in the past 12 months.
- Take aspirin unless contraindicated.
- Be screened for diabetes mellitus in the past 5 years.
- Have a serum cholesterol measured in the past 5 years.
- Have smoking status recorded in the past 5 years.
- Have BMI measured and recorded in the past 5 years.
Table 1 (below) shows standards for the audit of patients aged <75 with CHD.
Table 1: Standards for the audit
|All patients aged <75 with coronary heart disease:|
Criteria for annual follow-up
Record blood pressure
Hypertension is an independent risk factor for CHD and there is a progressive increase in MI, angina pectoris and sudden death associated with an increase in blood pressure.
Control of blood pressure should follow the British Hypertension Society Guidelines for hypertension management 1999.3
The targets for blood pressure measured in the clinic are:
Check patient is taking aspirin unless contraindicated
All patients with CHD should receive aspirin indefinitely, unless there are contraindications. Aspirin reduces the absolute risk of vascular events by 3.6%, and also decreases non-fatal MIs, non-fatal strokes, vascular deaths and all-cause mortality.4 Doses of 75–150mg of aspirin are effective.
Test and record urine for glucose
Diabetes mellitus is an independent risk factor for CHD. There is also an increased incidence of diabetes mellitus in patients with CHD.
Check lipid levels
There is good evidence that all patients with established CHD benefit from a reduction in cholesterol levels. Dietary advice and modification will reduce cholesterol level by 5–10%.
If drug treatment is required, a statin is the best form of treatment.
The target is to reduce cholesterol levels to <5mmol/l and total cholesterol/HDL ratio to <3.
If cholesterol level is <5mmol/l, repeat measurement every 3 years. If cholesterol level is 5 mmol/l repeat measurement annually, and consider treating with a statin.
Record smoking status and advice given to smokers
Smoking is an independent risk factor for heart attacks and stroke and sudden death. Repeated advice, guidance and support on how to stop smoking are thus of major importance.
If a patient with CHD stops smoking their risk of death is reduced by around 50% over a 5-year period.2
BMI >30 is associated with an increased risk of hypertension and diabetes mellitus. It is therefore suggested that the target should be to achieve a BMI <30 and preferably <25.2
It should be noted that there are no randomised controlled trials to show that a reduction in weight improves the outcome in CHD.
A computerised search of all patient computer records to identify all those with a history of CHD was undertaken in November 1999 and repeated in September 2000 (see Table 2 and Figure 1, below). The records of these patients were then searched for the above data.
Table 2: Comparison of results of the two computer searches
|Nov 1999||Sep 2000|
|Total no. patients aged <75||10555||10185|
|Total no. patients aged <75 with CHD||406 (3.9%)||353 (3.5%)|
|No. patients with myocardial infarction||147||135|
|No. patients with angina pectoris||268||233|
|No. patients with heart failure||57||45|
|Figure 1: Age and sex distribution of patients with known CHD, Sep 2000|
The results of the computer searches carried out in November 1999 and September 2000 are summarised in Table 3 and Figure 2 (below).
Table 3: Audit summary – comparison of achievement vs standards
|Aim: To improve current monitoring of patients aged <75 years with coronary heart disease|
|November 1999||September 2000||Change in %||Standard|
|All patients aged <75 with CHD||406||354||100%|
|BP recorded in past 12 months||277||68%||294||83%||+15||90%|
|Currently taking aspirin or aspirin contraindicated||214||53%||275||78%||+25||90%|
|Screened for diabetes in past 5 years||263||65%||268||76%||+11||90%|
|Cholesterol measured in past 5 years||265||65%||280||79%||+14||90%|
|Smoking status recorded in past 5 years||229||56%||291||82%||+26||90%|
|BMI measured in past 5 years||234||58%||229||65%||+7||75%|
|Figure 2: Improvement in care|
The disease database reflects the fact that the practice is 'paperless' and all data are entered on the computer.
There was no formal call/recall system for patients with CHD until April 2000.
Monitoring of patients had probably largely relied on symptom control and thought was not always given to specific monitoring measures.
Cholesterol levels are surprisingly low, but may also reflect poor data received from the hospital.
Aspirin recording largely reflects prescriptions and few patients have code entries for over-the-counter aspirin or aspirin contraindicated.
The low levels of recording of smoking status, BMI and blood pressure reflect the poor uptake of the well person clinic.
Action taken following the first audit
- The results of the audit were fed back to the doctors and nurses.
- A practice protocol was agreed and distributed.
- All nurses attended CHD training.
- A call/recall system was developed for all patients with CHD.
The decrease in total patients aged <75 years reflects closure of the practice list to new registrations in August 1999.
The decrease in total patients with CHD is partly due to closure of the practice to new registrations, but also reflects the fact that all patient records have been reviewed. The review revealed a number of patients with incorrect computer entries for CHD. The second audit excluded these patients.
Initially the practice needed to ensure that all patients were being reviewed regularly and that there is a standard data set. This has been achieved through the call/recall system.
The call/recall system has only been in operation for 6 months. Initially, high-risk patients or those who had not been seen for more than 1 year were targeted.
GPs are monitoring some patients with CHD during routine follow-up appointments, but are poor at checking BMIs and updating health promotion data, e.g. smoking status. The monitoring is better done by the practice nurses.
- Department of Health. The Health of the Nation: A Strategy for Health in England. London: HMSO, 1995.
- Department of Health. National Service Framework for Coronary Heart Disease. London: The Stationery Office, March 2000.
- Ramsay LE, Williams B, Johnston GD et al British Hypertension Society guidelines for hypertension management 1999: summary. Br Med J 1999; 319: 630-5.
- MeReC Bulletin: Secondary prevention of myocardial infarction. Number 2, 1999, Vol 10.
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