The clinical indicators: secondary prevention of CHD one year on

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By now, practices will know whether they have achieved the quality points to which they aspired, as well as how much financial reward they will receive for their hard work in managing CHD patients over the past 15 months (Table 1, below, Figure 1, below). Payments for quality achievement are being made this month, but where there is a dispute or amendments are necessary it may be June before payment arrives in full.

Table 1: Clinical indicators for coronary heart disease
Disease	Clinical indicator	Points	Payment stages
indicator			Min (%)	Max (%)
CHD 1 CHD 2 CHD 3 CHD 4 CHD 5 CHD 6 CHD 7 CHD 8 CHD 9 CHD 10 CHD 11 CHD 12 LVD 1 LVD 2 LVD 3	A register of CHD patients % CHD patients with newly diagnosed angina after 1/4/03 referred for exercise testing and/or specialist assessment % CHD patients with smoking status recorded in past 15 months % smokers offered or referred for smoking cessation advice % CHD patients with BP recorded in past 15 months % CHD patients with BP 150/90 mmHg or less, measured in 70 past 15 months % CHD patients who have cholesterol measured in past 15 months % CHD patients whose cholesterol is 5 mmol/l or less, measured in past 15 months % CHD patients on antithrombotic therapy, recorded in past 15 months % CHD patients on beta-blockers CHD patients with MI after 1/4/03 on ACE inhibitor or A2A % CHD patients given flu vaccination in preceding 1 September — 31 March A register of CHD patients who have left ventricular dysfunction % patients with CHD and LVD who have had a diagnosis confirmed by echocardiogram after 1/4/03 % CHD patients with LVD on ACE inhibitor or A2A	6 7 7 4 7 19 7 16 7 7 7 7 4 6 10	25 25 25 25 25 25 25 25 25 25 25   25 25	90 90 90   90 90 60 90 50 70 85   90 70

Figure 1: Townhead Practice contract reporting secondary prevention in CHD

Disease prevalence

Objective evidence on the quality of care delivered under the new contract is provided by the Quality Management and Analysis System (QMAS) national IT system.¹ QMAS extracts information from practices’ clinical computer systems so as to provide feedback and progress on both data collection and financial achievement.

National prevalence rates were measured on 14 February 2005 and prevalence rates for practices were extracted from QMAS on 14 March 2005.

The quality achievement payments will be calculated in exactly the same way for each practice, with prevalence adjustments made to each clinical category. This will ensure that the financial rewards reflect the greater workload in practices with higher levels of disease.

Data collection

Data collection is important but practices must ensure that it does not deflect efforts away from the clinical care of CHD patients, for which a comprehensive service must remain the priority (Box 1, below).

Box 1: Components of structured review

Ensure register is up to date and accurate Provide comprehensive patient education Ensure patients fully understand all aspects of their care Deal with any misconceptions Identify symptoms and address accordingly Assess and monitor all risk factors Measure required blood parameters including lipid profile Help with lifestyle and behaviour change to modify risk Provide appropriate drug therapy Monitor treatment adherence Identify and record side-effects Use IT interrogation programmes to identify incomplete data fields Record exception codes and justification for their use

However, unless the required data have been correctly entered into the practice computer system using the recommended Read codes (Box 2, below), QMAS is unable to reflect the points achieved.

Box 2: CHD action Read codes
CHD 2 Cardiological referral Exercise ECG normal Exercise ECG abnormal Referral for exercise ECG Exercise test refused	8H44 32130 32131 8HRA 8135
CHD 4 Smoking cessation advice	8CAC
CHD 5 BP checked	246
CHD 7 Total cholesterol measurement	44PH
LVD 2 Ultrasound heart scan Echocardiogram abnormal Echocardiogram declined	5853 58531 56F1

Our practice’s biggest frustration has been that data that have been correctly entered are not reflected in the reporting database of the practice system. We have therefore had to scrutinise closely the report we generate for practice-based contract reporting and the QMAS data to ensure that they reflect our clinical achievement.

We understand that a review of primary care computing in Scotland has been initiated to identify the best solution compatible with the demands of the nGMS contract.

Up-to-date registers

Having invested much time and effort in creating accurate records, it is important that practices have an efficient means of adding new patients to registers and removing those no longer with the practice.
One of the strengths of the quality and outcomes framework is that it is intended to be an ongoing process, and not just to give a snapshot of current clinical care. It is therefore in the practice’s interest to have a robust system in place; in fact, this may need to be demonstrated as part of the inspection process.

Patient-centred care

Nurse-led secondary prevention clinics in primary care lead to improvement in the uptake of secondary prevention in patients with CHD. This in turn has reduced deaths, and also probably reduced coronary event rates, after 4.7 years of follow up.²

Although clinics are run by specialist nurses, comprehensive care requires a team effort (Box 3, below). Structuring review around a one-stop vascular clinic avoids multiple reviews and enables staff with the appropriate skills to review patients whose condition is covered by more than one disease category.

Box 3: Practice team skill mix

Administrative assistants Full administrative support to practice team Data processor Data input and patient recall Healthcare assistant Phlebotomy and clinical measurements Specialist practice nurse Structured surveillance and appropriate disease management Practice pharmacist Medication monitoring and dose adjustment

In this review process we include those high-risk patients with intermittent claudication who have established atherosclerotic disease, with the aim of preventing a vascular event.

Annual surveillance

The reporting database of practice computer systems has allowed practices to identify easily patients on the CHD disease register for whom data required by the clinical indicators are missing.

If these indicators have been addressed but the data are not recorded electronically, the computer can then be updated. However, if care is being provided on an opportunistic basis, recalling patients to address these missing indicators can add significantly to an already high practice workload.

Regular review means that all clinical indicators and aspects of care can be addressed (see Table 1 and Box 1). In addition to undergoing annual review, patients can be recalled at appropriate intervals to action clinics to demonstrate the effectiveness of any increase in medication for lipid or blood pressure lowering or of lifestyle advice.

Prescribing costs

The first year of the quality and outcomes framework has almost certainly increased pressure on drug budgets. We have seen the rate of increase in our nicotine replacement therapy prescribing rise from 4.4% in 2002/3 to 29% in 2003/4. Similarly, the rise in our statin prescribing has gone from 21% to 34% over the same period.

Smoking cessation with nicotine replacement therapy is felt to be cost effective, with the cost per life-years saved calculated to be between £1000 and £2300.

Reaching the cholesterol target

CHD 8

There is increasing evidence from large scale secondary prevention trials in patients with CHD that statins reduce the clinical effect of atherosclerosis, including cardiovascular death, myocardial infarction, stroke, hospitalisation for unstable angina and heart failure, as well as the need for coronary revascularisation.

Failure to specify using a statin to lower cholesterol in patients on the CHD register is a major deficiency of the new contract. Further evidence for the aggressive lowering of cholesterol in these patients comes from the recently published Treating to New Targets Trial.³

The comparative lipid lowering efficacy of different statins has been demonstrated.⁴ Doubling the starting dose will result in a further 6% reduction in cholesterol, although side-effects such as myositis may occur and are dose-dependent with all statins.⁵

An alternative approach is to add a cholesterol absorption inhibitor to a lower dose statin, which can reduce LDL cholesterol by around a further 20%.⁵

To ensure a cholesterol level consistently below 5 mmol/l, because of the variability in cholesterol measurement there is merit in aiming for an even lower level.⁶

Exception reporting

To achieve maximum points it is essential to ensure that exception coding is used on an individual basis in line with the contract guidance (Box 4, below).

Box 4: CHD exception codes
CHD 1 Patient unsuitable Informed dissent	9h01 9h02
CHD 6 Maximum tolerated BP treatment	8BLO
CHD 8 Maximum tolerated lipid lowering treatment	8BL1
CHD 9 Warfarin not indicated Warfarin contraindicated Warfarin adverse reaction Warfarin declined Warfarin allergy Warfarin not tolerated Aspirin not indicated Aspirin contraindicated Aspirin refused Salicylates – adverse reaction Aspirin allergy Aspirin not tolerated Clopidogrel not indicated Clopidogrel contraindicated Clopidogrel declined Clopidogrel allergy Clopidogrel adverse effect Clopidogrel not tolerated	8165 8125 TJ421 813E 14LP 8171 8166 8124 8138 TJ53 14LK 8170 816B 812K 813R 14LQ U6048 816B
CHD 10 Beta-blocker not indicated Beta-blocker contraindicated Beta-blocker refused Beta-blocker – adverse reaction Beta-blocker h/o allergy Beta-blocker not tolerated	8162 8126 8136 TJC6 14LL 8173
CHD11/LVD3 ACE inhibitor not indicated ACE inhibitor contraindicated ACE inhibitor declined ACE inhibitor allergy ACE inhibitor not tolerated Angiotensin II receptor antagonist not indicated Angiotensin II receptor antagonist contraindicated Angiotensin II receptor antagonist declined Angiotensin II receptor antagonist allergy Angiotensin II receptor antagonist not tolerated	8164 8128 813D 14LM 8174 816C 812H 813P 14LN 817S
CHD 12 Influenza vaccination not indicated Influenza vaccination contraindicated Influenza vaccination h/o allergy Influenza vaccination declined Influenza vaccination no consent	816D 812F 14LJ 90XS 68NE
LVD1 Patient unsuitable Informed dissent	9h11 9h12

Higher level, full category exception reporting is used if:

• The patient has refused to attend for review
• The patient’s circumstances mean that disease management review is inappropriate.

These patients should be reassessed and, if necessary, the exception coding entered again towards the end of each contract year.

In the absence of specific national guidance, practices should develop their own protocol for exception reporting.

The reason for each exception needs to be clearly recorded for each individual. The protocol can be used at verification visits to justify the action the practice has taken (Box 5, below).

Box 5: Quality and outcomes framework practice visit

Points covered at the practice visit include: Use of preparation funding Development of chronic disease management clinics Effective use of skill mix Involvement of the practice team Approach to category and indicator exception reporting Use of IT and monitoring of progress Integrity of practice data Need for further support

Points to consider

CHD 6

In defining maximally tolerated blood pressure therapy it is important to consider:

• the number of drugs used
• response to treatment
• the level of side-effects.

CHD 8

The evidence for the use of statins in the elderly comes from the Heart Protection Study, in which the upper age limit was 80 years, and the Prosper Study for which the upper age limit was 82 years.^7,8 When making decisions on an individual basis, clinicians should balance the individual’s expectation and quality of life against the competing risks as a function of age.⁹

CHD 9

A recent Cochrane review concluded that proton pump inhibitors probably significantly reduce the risk of symptomatic peptic ulcers caused by non-steroidal anti-inflammatory drugs.¹⁰ Co-prescription of a gastro-protective agent with aspirin is often advocated so that patients are not denied the benefit of an antiplatelet agent because of gastrointestinal side-effects.

CHD 10

The Committee on Safety of Medicines recommends that in patients with a history of asthma or bronchospasm, even beta-blockers considered to be cardioselective should not be given.

Year 2 and beyond

The benefits of actively managing patients with CHD need to be maintained in the long term. The new contract gives us the opportunity for structured review on a sustainable basis and with it, we hope, long-term improvements in health.^11,12

A group has been formed to review the quality and outcomes framework, and before considering new disease categories deficiencies of the current clinical indicators need to be addressed.

References

1. Quality Management and Analysis System. www.npfit.nhs.uk/programmes/qmas/
2. Murchie P, Campbell NC, Ritchie LD et al. Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care. Br Med J 2003; 326: 84.
3. La Rosa JC, Grundy SM,Watters DD et al; for the Treating to New Targets (TNT) Investigators. Effect of lowering LDL cholesterol with intensive atorvastatin therapy in patients with stable coronary disease. N Eng J Med 2005; 352. www.nejm.org
4. Jones PH, Davidson MH, Stein EA et al; STELLAR Study Group. Comparison of the efficacy and safety of rosuvastatin versus atorvastatin, simvastatin, and pravastatin across doses (STELLAR* Trial). Am J Cardiol 2003; 92(2): 152-60.
5. Gagne C, Bays HE,Weiss SR et al; Ezetimibe Study Group. Efficacy and safety of ezetimibe added to ongoing statin therapy for treatment of patients with primary hypercholesterolemia. Am J Cardiol 2002; 90(10): 1084-91.
6. Williams B, Poulter NR, Brown MJ et al. British Hypertension Society. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004 18(3): 139-85.
7. 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.
8. Shepherd J, Blauw GJ, Murphy MB et al; PROSPER study group. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002; 360: 1623-30.
9. Welch HG, Albertsen PC, Nease RF et al. Estimating treatment benefits for the elderly: the effect of competing risks. Ann Intern Med 1996 124(6): 577-84.
10. Hooper L, Brown TJ, Elliott R et al. The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by nonsteroidal anti-inflammatory drugs: systematic review. Br Med J 2004; 329: 948.
11. 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.
12. Murchie P, Campbell NC, Ritchie LD et al. Effects of secondary prevention clinics on health status in patients with coronary heart disease: 4 year follow-up of a randomized trial in primary care. Fam Pract 2004; 21(5): 567-74.

Guidelines in Practice, April 2005, Volume 8(4) © 2005 MGP Ltd further information | subscribe