By introducing incentives to achieve clinical indicators for secondary prevention, the new GMS contract will raise standards of CHD care, says Dr Alan Begg
As prevention of coronary heart disease is a key clinical priority throughout the UK, it is not surprising that CHD is one of the 10 disease areas covered by the clinical indicators under the new GMS contract (Table 1, below). There is good evidence for the effectiveness of most aspects of secondary prevention,1 and responsibility for ongoing management lies with the GP and the primary care team.
|Table 1: Clinical indicators for coronary heart disease|
|Disease/ indicator no||Clinical indicator||Points||Qualifier||Preferred Read code||Exception reporting & Read codes*||Payment stages|
|CHD 1||A register of CHD patients||6||CHD: G3% Myocardial infarction: G30||
Reduce CHD set denominator by:
1) No. patients invited for review at least 3 times and refused to attend in preceding 12 months
2) No. patients unfit for review because of frailty, terminal illness or other relevant circumstances
|CHD 2||% patients with new onset angina referred for exercise testing and/or specialist assessment||7||From 1.4.03||Exercise testing: 3213% Referral to specialist: 8H44||Patient does not agree to investigation; exercise testing service or chest pain assessment service unavailable||25-90%|
|CHD 3||% patients with smoking status
|7||Recorded in past 15 months||Never smoked: 1371 (record only once) Ex-smoker: 137L Smoker: 137R||25-90%|
|CHD 4||% smokers offered or referred for smoking cessation advice||4||Recorded in past 15 months||Smoking cessation advice: 8CAL||25-70%|
|CHD 5||% with BP recorded||
|Recorded in past 15 months||Examination of BP: 246||25-90%|
|CHD 6||% patients with BP 150/90 mmHg or less||19||Measured in past 15 months||Numeric value||On maximum tolerated doses of medication (or not tolerated)||25-70%|
|CHD 7||% patients who have cholesterol measured||7||Measured in past 15 months||Cholesterol: 44P%||25-90%|
|CHD 8||% patients whose cholesterol is 5 mmol/l or less||16||Measured in past 15 months||Numeric value||On maximum tolerated doses of lipid lowering medication (or not tolerated) and cholesterol level sub-optimal. Lipid lowering medication contraindicated, allergy or adverse reaction||25-60%|
|CHD 9||% patients on antithrombotic therapy||7||Recorded in past 15 months||Specific drug OTC aspirin: 8B3T||Medication stopped - interaction: 8B16; aspirin contraindicated: 8125; adverse reaction to warfarin:TJ421; adverse reaction to salicylates:TJ53; history of aspirin allergy: ZV148||25-90%|
|CHD 10||% patients on beta blocker||7||Currently taking (in past 6 months)||Specific drug||Beta blocker not indicated: 8162; beta blocker contraindicated; beta blocker refused: 8136; adverse reaction or allergy||25-50%|
||% patients with MI on ACE inhibitor||7||Currently taking (in past 6 months) if MI diagnosed after1.4.03||Specific drug||ACE inhibitor contraindicated: 8128 adverse reaction or allergy||25-70%|
|CHD 12||% CHD patients given flu vac||7||In previous 6 months September - March||Flu vac given: 65E||Flu vac contraindicated: 812F; flu vac refused by patient||25-85%|
|LVD 1||A register of CHD patients who have left ventricular dysfunction||4||Left ventricular failure: G581||CHD set denominator is reduced by number of patients who refuse to attend for or are
unsuitable for review
|LVD 2||% patients with CHD and LVD who have had diagnosis confirmed by echocardiogram||6||Diagnosed after 1.4.03||Echo abnormal: 58531||Patient does not agree to investigation Echocardiogram service is not available
Consultant orders alternative test
|LVD 3||% patients with CHD and LVD on ACE inhibitor or A2 antagonist||10||Currently taking (in past 6 months)||Specific drug||
ACE inhibitor contraindicated: 8128
|* Informed dissent for any category should be recorded in medical record|
The CHD clinical indicators
The main evidence sources used are, as far as possible, national clinical guidelines that have been systematically developed using a robust approach with proper evaluation and interpretation of the evidence. This results in recommendations that are graded according to the level of evidence.
Clinical guidelines require constant updating as the evidence base changes, and this may have a future bearing on the clinical indicators in the quality and outcomes framework of the new contract. However, constant change will have an impact on practice systems and any arrangements put in place to help them achieve these clinical indicators.
Disease register (CHD 1)
The practice is responsible for developing and maintaining a register that is as accurate and up to date as possible. This is seen as the basis for a systematic approach to the management of this disease category, and it will assist with the comparison of reported prevalence with the expected prevalence.
Since April 2001, as part of the implementation of the National Service Framework for Coronary Heart Disease,2 all practices in England are expected to have a systematically developed and maintained CHD register. The new contract should provide the opportunity for all practices that are still using a paper format to graduate to an electronic version.
Diagnosis: acute coronary syndrome (CHD 1)
A joint European and American consensus document has recently resulted in myocardial infarction (MI) being redefined within the clinical parameters of acute coronary syndrome (Table 2, below).3
|Table 2: Coronary heart disease diagnostic categories|
|Acute ischaemic-like chest pain||Persistent ST elevation on ECG||Raised biochemical markers of myocardial necrosis|
Although this leads to difficulty with clinical coding for epidemiological purposes, it does reflect the improved outcomes for minor degrees of myocardial necrosis. However, patients previously diagnosed as having unstable angina are now diagnosed as having had a myocardial infarction, so appropriate coding will have a bearing on indicator CHD 11.
This has additional relevance in general practice because patients with non-ST elevation myocardial infarction (NSTEMI)/unstable angina have been shown to benefit from the concurrent use of two antiplatelet agents, aspirin and clopidogrel (CHD 9).4
Diagnosis: underlying CHD (CHD 1 and 2)
Angina as a new symptom may signify underlying CHD. This has important implications for future ongoing management. The NSF for CHD was the stimulus for the establishment of chest pain assessment clinics for patients presenting for the first time with exertional chest pain that may be caused by CHD.
Some 90% of acute trusts in England have now established these clinics,5 although we have yet to see published randomised clinical trials to confirm the coronary morbidity and mortality benefits for the rapid assessment of these patients.6 Patients with a history of a revascularisation procedure also need to be included, although their presenting event may have been unstable angina rather than MI.
Left ventricular dysfunction (LVD 1 and 2)
Left ventricular systolic dysfunction (LVSD) is the most common cause of the syndrome of heart failure and usually results from underlying CHD or the effects of a myocardial infarction.
The NICE chronic heart failure guideline 7 confirms that Doppler 2D echocardiographic examination should be the basis for the diagnostic confirmation and that a normal 12-lead ECG and/or natriuretic peptides can help to exclude the diagnosis.
Evidence shows that the confirmation of LVSD in patients suspected of heart failure in general practice is not high (41% in Scotland;8 29% in London 9) so it is important that practices do not make the diagnosis without full assessment and confirmation.
Smoking cessation (CHD 3 and 4)
Based on observational data, patients with established CHD who cease smoking can reduce their mortality rate by 50% compared with those who continue to smoke. However, these patients’ success in maintaining their non-smoking status long-term as part of a structured approach to CHD prevention is not encouraging.10-12 A recent systematic review noted that there was limited evidence for the effectiveness of stage-based interventions in changing smoking behaviour in all patients.13
On the whole, however, patients with CHD are expected to be more likely to be motivated to stop smoking. Studies using pharmacological methods in patients with cardiovascular disease do not confirm any specific benefit as a group,14 so the approach perhaps needs to combine different strategies.
Raised BP (CHD 5 and 6)
Up to 25% of patients with CHD have raised blood pressure, and raised blood pressure after an MI is a risk factor for subsequent cardiovascular events, although the benefits of treatment are extrapolated from primary prevention trials.15 The risk is sufficient in patients with CHD and a sustained blood pressure greater than 140/90 mmHg to justify consideration for therapeutic intervention. A target blood pressure of 140/85 mmHg is based on data from the HOT trial,16 and as only 10% of patients on antihypertensive treatment reach this target,17 the British Hypertension Society Audit Standard of 150/90 mmHg 18 is a pragmatic minimum acceptable level of control. Clinicians should, however, be aware that the lower the blood pressure the lower the risk of a subsequent vascular event, so good control is important.
Patients with hypertension (BP 4), it would appear, need to be reviewed within a 9-month period, whereas in patients with CHD who are at higher risk the review interval is 15 months.
Cholesterol lowering (CHD 7-8)
In recent years, clinical trials have clearly shown the benefits in patients with CHD of lowering cholesterol with a statin.19-22
The lower cholesterol threshold of 3.5 mmol/l was chosen by the Medical Research Council in the Heart Protection Study so as not to exclude anyone on the basis of their cholesterol level.22 These trials showed that when using a statin, the more the cholesterol is lowered the greater is the risk reduction, with lower event rates.
Updated guidelines are likely to reflect this and a case can be made for all patients with atherosclerotic vascular disease to be prescribed a statin, irrespective of their cholesterol level. Clinicians should be aware of this as it is not reflected in the clinical indicators. Patients with a baseline cholesterol of less than 5 mmol/l do not need to take a statin to reach the target which has been set at this level. Nevertheless, these patients may benefit from statin therapy. Using only total cholesterol as the lipid parameter is certainly appropriate and simplifies the process.
Renin blockade (CHD 11)
The benefits of ACE inhibitors in reducing subsequent events after a myocardial infarction without LVSD have been shown in the Hope Study.23 The reduction of blood pressure shown in a sub-study recorded by ambulatory monitoring of some patients rather than the clinic blood pressures in the main study has generated much interest but does not detract from the overall benefit of this class of drugs.24
Disease category or patient-centred approach?
Patients may suffer from combinations of atherosclerotic disease, diabetes and hypertension, and one of the strengths of general practice in the UK is that the patient is at the centre of any process of patient care. There is a danger that this move from a patient-centred approach, based on reduction of global risk, to one of specific disease categories will fragment the care that a patient receives despite the considerable overlap of the clinical indicators.
Practices need to ensure an integrated approach, to avoid duplication and prevent confusion, uncertainty and frustration for both practice staff and patients.
Problems will arise as it is not clear whether the register of patients with established hypertension (BP 1) refers only to those with primary hypertension and excludes those with established CHD (CHD 1) stroke (Stroke 1) and diabetes (DM 1).
The additional workload implications of implementing the NSF for CHD in primary care have been determined and documented.25 Meeting the framework clinical indicators will also involve a significant amount of work for practices. It is important that each practice has an agreed and documented clinical process, to include:
- Multidisciplinary working
- Appropriate use of skill mix
- Delegation as necessary
- Good management support.
The benefits of structured care in managing patients with CHD are clear (Table 3, below). The way in which this is organised will depend on local circumstances, although high-level clinical indicators cannot be expected to be achieved by ‘usual care’. The main benefit of the contract, however, is that it should make resources available for direct clinical care rather than placing clinical staff in facilitation and co-ordination roles.
|Table 3: Evidence for structured systematic care in the secondary prevention of CHD|
|Grampian secondary prevention clinics10||Nurse-led secondary prevention clinics in general practice for patients with CHD||Short-term improvements in secondary prevention can be maintained in the longer term.Therapeutic prevention and lifestyle change can lead to fewer total deaths and coronary events|
|SHIP11||Specialist liaison nurse led programme to co-ordinate and support follow up care in general practice after diagnosis of CHD||Effective in promoting follow-up in general practice|
|POST12||Postal prompts to patients with acute coronary syndrome to encourage review in general practice||Postal prompts can help improve recording of cardiovascular risk factors and provision of lifestyle advice|
|Belfast26||Personalised health promotion by health visitors for patients with angina||Ongoing intervention is desirable to maintain immediate benefits in respect of exercise and prophylactic drug taking|
|ASSIST27||Benefits of audit summary feedback to primary healthcare team, assistance with setting up disease register and systematic recall to nurse clinic or general practitioners||Setting up a CHD register increases follow-up and assessment of patients at risk. Nurse follow-up may be more effective than follow-up by doctors|
|Systematic review of randomised trials of secondary revention CHD programmes28||Assessment of multidisciplinary disease management programmes||Comprehensive disease management programmes can have a positive impact on the process of care in terms of risk factor management and the prescribing of vascular protective drugs. They also reduce hospital admissions and enhance the quality of life|
Ideally, national guidance will address the inconsistencies in terms of diagnosis, recording and lack of comprehensive Read codes for exception reporting. The verification process, which will be carried out on a ‘high trust’ basis, should meet the following criteria:
- Be based on the appropriate use of electronic reporting
- Be fair and not intrusive
- Visits should be kept to a minimum
- Team members are credible, knowledgeable and have appropriate training
- Confirmation that comprehensive systematic care is being provided (Box 1, below)
- Data collection is part of the system of clinical care.
|Box 1: Components of systematic CHD care not included in clinical indicators|
The introduction of incentives for achieving clinical indictors for the prevention of CHD is an important and significant step towards improving CHD care. A consistent and sustainable approach is required, but practices need to guard against a possible gradual fragmentation of patient care by managing patients based on specific disease categories. One of the keys to success of the framework will be good IM&T systems.
I am grateful to Dr J Griffith for his assistance with the preparation of this article and to Mrs Karen Dunn for her secretarial help.
- Scottish Intercollegiate Guidelines Network. SIGN 41. Secondary prevention of coronary heart disease following myocardial infarction a national clinical guideline. Edinburgh: SIGN, 2000.
- Modern Standards and Service Models. Coronary Heart Disease: National Service Framework for Coronary Heart Disease. London: Department of Health, 2001. www.doh.gov.uk/nsf/coronary.htm
- Myocardial Infarction redefined – A consensus document of The Joint European Society of Cardiology/American College of Cardiology for the redefinition of myocardial infarction. Eur Heart J 2000; 21: 1502-13.
- Yusuf S, Zhao F, Mehta SR et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345: 494-502.
- Department of Health. Delivering better heart services. NSF for CHD Progress Report 2003. London: DoH, 2003. www.doh.gov.uk/heart/progress2003
- Wood D,Timmis A, Halinen M. Rapid assessment of chest pain. Br Med J 2001; 323: 586-7.
- National Institute for Clinical Excellence. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. Clinical Guideline 5. London: NICE, July 2003.https://www.nice.org.uk/Docref.asp?d=79726
- Wheeldon NM, MacDonald TM, Flucker CJ et al. Echocardiography in chronic heart failure in the community. Q J Med 1993; 86: 17-23.
- Cowie MR,Wood DA, Coats AJ et al. Incidence and aetiology of heart failure: a population-based study. Eur Heart J 1999; 20: 421-8.
- Murchie P, Campbell NC, Ritchie LD, Simpson JA, Thain J. Secondary prevention clinics for coronary heart disease: four year follow-up of randomised controlled trial in primary care. Br Med J 2003; 326: 84.
- Jolly K, Bradley F, Sharp S et al. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP collaborative group. Br Med J 1999; 318: 706-11.
- Feder G, Griffiths C, Eldridge S, Spence M. The effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial. Br Med J 1999; 318: 1522-6.
- Riemsma RP,Pattenden J,Bridle C et al.Systematic review of the effectiveness of stage based interventions to promote smoking cessation. Br Med J 2003; 326: 1175-7.
- National Institute for Clinical Excellence.Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation.Technology Appraisal 39. London: NICE, March 2002.
- Joint British recommendations on prevention of coronary heart disease in clinical practice.British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society, endorsed by the British Diabetic Association. Heart 1998; 80(Suppl 2): S1-29.
- Hansson L, Zanchetti A, Carruthers SG et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998; 351: 1755-62.
- Primatesta P, Brookes M, Poulter NR. Improved hypertension management and control: results from the health survey for England 1998. Hypertension 2001; 38: 827-32.
- Ramsay LE,Williams B, Johnston GD et al. British Hypertension Society guidelines for hypertension management 1999: summary. Br Med J 1999; 319: 630-5.
- Athyros VG,Papageorgiou AA,Mercouris BR et al. Treatment with atorvastatin to the National Cholesterol Educational Program goal versus ‘usual’ care in secondary coronary heart disease prevention. The GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) study. Curr Med Res Opin 2002; 18(4): 220-8.
- Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: 1383-9.
- Shepherd J, Blauw GJ, Murphy MB et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002; 360: 1623-30.
- Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360: 7-22.
- Yusuf S, Sleight P, Pogue J et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. N Engl J Med 2000; 342: 145-53.
- Svensson P, de Faire U, Sleight P, Yusuf S, Ostergren J. Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE Substudy. Hypertension 2001; 38: E28-E32.
- Hippisley-Cox J, Pringle M. General practice workload implications of the national service framework for coronary heart disease: cross sectional survey. Br Med J 2001; 323: 269-70.
- Cupples ME, McKnight A. Five year follow up of patients at high cardiovascular risk who took part in randomised controlled trial of health promotion. Br Med J 1999; 319: 687-8.
- Moher M, Judkin P, Wright L, Turner R et al. Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care. Br Med J 2001; 322: 1338.
- McAlister FA, Lawson FME, Teo KK, Armstrong PW. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. Br Med J 2001; 323: 957-62.