GP Dr David Whitford and Liz Brittlebank describe a comprehensive and structured programme of care for all patients with or at high risk of vascular disease


   

Our practice is situated on the outskirts of Newcastle upon Tyne, in an area of deprivation with a standardised mortality ratio in excess of 140. Much of this excess mortality is related to vascular disease, and the practice population has a similar excess vascular morbidity.

As a consequence we decided to make the implementation of a programme for vascular disease management a priority within the practice. This programme of care was recently recognised in the granting of Beacon status to the practice.

We have developed a programme of care that seeks to incorporate most elements of prevention and management of vascular disease in primary care. The aim of the programme is to provide an integrated, comprehensive and structured system of care for all patients with, or at high risk of, vascular disease.

The programme is centred on a practice philosophy that emphasises quality, team-working and patient empowerment. Key elements of the programme are shown in Table 1 (below).

Table 1: Key elements of the vascular disease programme
  • Computerised registration of diseases and risk factors
  • Guidelines (evidence based where available), practice protocols and standard setting
  • Use of computerised templates for 'prompting' and recording
  • Integrated annual reviews (educational assessment, screening, medical management and goal setting)
  • Multidisciplinary team working
  • Recall system for non-attendees
  • Patient-centred approach with patient empowerment
  • Evaluation and audit

The programme includes preventive care (smoking cessation, exercise on prescription, weight loss, influenza vaccination), management of risk factors (hypertension, diabetes, atrial fibrillation and hyperlipidaemia) and care of those with established vascular disease (ischaemic heart disease, cerebrovascular or peripheral vascular disease, and heart failure).

Patients attending the surgery or visited at home are opportunistically screened for risk factors (blood pressure, smoking, obesity, and exercise). Those with risk factors are referred on to the practice nurse, community nurse or dietitian for further assessment of risk factors and secondary causes.

Education takes place throughout, but is reinforced at this stage. After assessment, management of the risk factors takes place. The patient is then seen for an integrated annual review and further regular reviews as appropriate.

Patients with established vascular disease are seen for annual review, incorporating education and risk factor assessment. Non-attendees are given further invitations.

Evidence base

The evidence base for vascular disease management is now extensive and growing rapidly.1 The areas that we have incorporated into our programme, for which there is good evidence of benefit, are shown in Table 2 (below).

Table 2: Areas of evidence-based practice incorporated in the programme
Primary prevention in high-risk individuals
  • Smoking cessation through ongoing advice, trained nurse counsellors and use of nicotine replacement
  • Increasing exercise through counselling and use of exercise facilitator in local fitness centre
  • Dietary advice to increase consumption of fruit and vegetables
  • Hypertension management with appropriate lifestyle advice and medication
  • Cholesterol lowering in high-risk individuals
  • Warfarin in patients with atrial fibrillation to prevent strokes

Prevention in patients with diabetes

  • Hypertension management
  • Good glycaemic control
  • Statins
  • Smoking cessation
Secondary prevention in patients with vascular disease
  • Aspirin in all patients without a contraindication
  • Beta-blockers after myocardial infarction
  • ACE inhibitors, beta-blockers and spironolactone in patients with left ventricular dysfunction
  • Statins in patients with vascular disease
  • Increase oily fish in diet
  • Cardiac rehabilitation (hospital and community based)
  • Revascularisation and stenting in appropriate individuals
  • Carotid endarterectomy in appropriate individuals with stroke disease
  • Hypertension management
  • Smoking cessation
  • Influenza vaccination

New advances in this area are discussed in practice meetings and a decision made as to whether these should be incorporated into our programme of care.

Guidelines used

We began the programme 10 years ago by establishing practice-based guidelines and protocols, but these have been replaced as national, regional and district guidelines emerged.

The majority of guidelines now used within the practice have been established within the district (including those for new-onset chest pain, angina, myocardial infarction, diabetes, smoking cessation, lipid management, exercise, and heart failure).

These have been developed by a group of GPs working with the community cardiologist, seeking to incorporate established evidence and existing guidelines into locally relevant guidelines.

Within the practice we also use some national guidelines (e.g. British Hypertension Society guidelines2) and continue to use some practice guidelines (e.g. for anticoagulation in atrial fibrillation3).

We use the guidelines to develop computer templates for the management of different conditions. These then act as a prompt for health professionals within the practice and also ensure that data are entered into the computer system with standard Read codes.

Benefits to patients

We measure the effectiveness of the delivery of this programme of care by auditing all aspects of care annually. Changes in health outcomes are difficult to measure in small populations, but several proxy measures based on available evidence have been incorporated in our programme:

  • Implementation of anticoagulation in patients with atrial fibrillation in the practice is likely to prevent two to three strokes or deaths from strokes over 5 years3
  • Use of aspirin in patients with vascular disease is likely to reduce morbidity and mortality (see Table 3, below)
  • Use of influenza vaccination (with more than 75% of patients with diabetes or ischaemic heart disease receiving influenza vaccine each year)
  • Use of statins (Table 3)
  • Control of blood pressure and diabetes.
Table 3: Audit of aspects of management of patients with ischaemic heart disease
  March 1995 April 1997 March 1999 February 2000
1. Diagnosis
Patients on register 166 206 210 211
Practice prevalence 4.4% 4.8% 4.8% 4.8%
Past myocardial infarct 79 97 88 95
Angina 130 160 157 167

2. Investigations

ECG 132 (80%) 153 (75%) 160 (76%) 185 (88%)
Full blood count 92 (56%) 159 (77%) 179 (85%) 199 (94%)
Urea and electrolytes 99 (66%) 150 (73%) 184 (88%) 202 (96%)
Thyroid function 42 (27%) 138 (67%) 167 (79%) 183 (87%)
3. Exercise ECG
Eligible patients 88 105 110 108
Exercise ECG 56 (64%) 79 (75%) 75 (68%) 76 (70%)
4. Risk factor screening
  Previous 5 years Previous 2 years
Smoking status 163 (98%) 166 (81%) 181 (86%) 193 (91%)
Blood pressure 163 (98%) 184 (89%) 199 (95%) 208 (99%)
Body mass index 131 (79%) 135 (66%) 147 (70%) 169 (80%)
Glucose 72 (43%) 124 (60%) 170 (81%) 198 (94%)
Cholesterol (<70 years) 53/88 (60%) 74/105 (71%) 91/110 (83%) 102/108 (94%)
5. Risk factor management
Smokers 54 (33%) 73 (35%) 72 (34%) 42 (20%)
Diabetes 17 (10%) 26 (13%) 28 (13%) 35 (17%)
Hypertension (on Rx) 51 (31%) 90 (44%) 100 (48%) 113 (54%)
Uncontrolled BP 44 (21%) 31 (15%) 99 (47%)
Obese (BMI >30) 32 (19%) 46 (22%) 57 (27%) 58 (27%)
Cholesterol >5.0mmol/l 71 (34%) 65 (31%) 39 (18%)
6. Aspirin prophylaxis
Contraindications 12 18 13 15
Number taking aspirin 135 (89%) 177 (94%) 189 (96%) 186 (95%)
7. Beta-blockers post-MI
Number on beta-blocker 16/79 (20%) 29/97 (30%) 39/88 (44%) 50/95 (53%)
8. Referrals aged <70
Referred to cardiology 68/88 (77%) 94/105 (90%) 96/110 (87%) 95/108 (88%)
Angiography 27 (31%) 43 (41%) 43 (39%) 44 (41%)

CABG/angioplasty/stenting

13 (15%) 28 (27%) 34 (31%) 39 (36%)

While we have seen a steady improvement in reduction of smoking and cholesterol values, we have also recently seen an increase in patients with uncontrolled blood pressure. This is not related to a decline in effectiveness of treatment, but rather to a change in targets for blood pressure control from 160/90mmHg to 145/85mmHg. We have also seen an increase in the number of patients undergoing re-vascularisation.

Risk factor screening in patients with vascular disease has improved over the years (Table 3, above), particularly with regard to diabetes and hyperlipidaemia.

We have also shown that it is possible to offer a risk factor assessment to more than 80% of the practice population over a 5-year period. In addition, more than 80% of patients with risk factors or established vascular disease are reviewed each year.

Development of our team

A team approach to care has developed, with GPs, practice nurses, community nurses, a dietitian, administrative staff and an exercise trainer all involved.

The process of clarifying and writing up the vascular disease programme prompted us to think about how well we promote best practice within our team. It was evident that patients predominantly cared for in the home did not receive the same level of care as those attending the surgery.

Our new district nursing team is now seeking to redress this. We have bought new equipment for the community staff to use in the home and plan to make use of the EMIS community care module to help record and monitor patient data.

Our aim is to standardise practice between patients who are housebound and those attending the surgery. If this proves successful, it could provide a model for dissemination to other practices.

We have no formal feedback from patients, but anecdotal feedback indicates a high level of satisfaction with care.

Heart failure – an example of implementation

Successful management of heart failure is important, because of both the high mortality associated with the condition and the presence of good evidence to support interventions that can improve quality and length of life.

Nevertheless, heart failure is seen by many GPs (including us) as a difficult condition to manage because of diagnostic uncertainty. Studies have shown that the diagnosis of heart failure appears to be wrong in up to 50% of cases.4 We have recently begun to address our management of this important disease.

This began with a district decision to develop local guidelines on heart failure. The community cardiologist circulated the papers containing evidence on the diagnosis and management of heart failure to the local primary care protocol group, which comprised six GPs and the community cardiologist.

In addition, the group looked at the section on heart failure in the National Service Framework for Coronary Heart Disease5 and the Scottish Intercollegiate Guidelines Network (SIGN) guideline on Diagnosis and Treatment of Heart Failure due to Left Ventricular Systolic Dysfunction (LVSD).6

From these a protocol on the diagnosis and management of heart failure due to LVSD was developed (see Figure 1, below).

Figure 1: Protocol for the diagnosis and management of heart failure due to left ventricular systolic dysfunction
Protocol

The diagnosis is established by a major abnormality on chest X-ray and ECG, followed by echocardiography where the diagnosis is not secure.

Our practice adopted this protocol and used audit to examine the established register of patients with heart failure and to look for patients with heart failure who were not on the register.

At least 12 of the 42 patients on our register of heart failure do not have LVSD and we await echocardiography results on a further nine patients. In addition, a trawl of the notes of 226 patients on ACE inhibitors and loop diuretics revealed a further 22 patients (9.7% return) with possible or established LVSD who were not on the register.

These results and a paper on the management of heart failure were discussed in a multidisciplinary practice meeting. As a consequence we have established a computer template for heart failure incorporating both a diagnostic pathway and management.

We are now implementing changes in the management of heart failure, with nurse reviews of risk factors and doctor reviews of medication, to ensure that patients with established LVSD receive optimum care.

Promoting best practice

Beacon funding of £4000 per year was available to the practice to help in disseminating best practice. We have done this in three main ways.

1. Open days

We have hosted a series of open days – a model preferred by the creators of the Beacon programme. These were advertised nationally in the Beacon handbook and by our own publicity to local practices.

Uptake locally was discouraging at first, and we requested support from our health authority to help raise our profile. We subsequently organised a Beacon Day for our PCG. The open days incorporated:

  • Gathering the learning needs of delegates
  • Introduction to the programme
  • Workshop on templates
  • Workshop on medical record summaries
  • Attending annual review by nurse of a 'model' patient
  • Audit presentation and multidisciplinary team discussion.

The local 'Healthy Hearts' team invited us to include a Beacon Day as part of their 5-day training course on ischaemic heart disease for practice nurses. We have held four sessions for this course to date.

2. Handbook

Part of our approach to disseminating the programme has been to write up a summary of each element, together with supporting documents, to form a Beacon Handbook. This contains:

  • Example of computerised patient record summary
  • Case studies following patients with ischaemic heart disease and diabetes
  • Examples of templates used in practice
  • Copies of guidelines and protocols
  • An illustration of our model of team-working
  • Copies of the literature available to patients.

The handbook has been distributed to other practices on request.

3. Workshops

We have attended two Beacon Fairs hosted by the Northern NHS Executive to run workshops that offer a brief overview of our programme of care. These have resulted in some follow-up contacts, particularly requests for handbooks.

Conclusion

This programme of care was developed to address the high vascular morbidity within our practice. We have seen a steady improvement in the standards of care delivered to the practice population and a reduction in inequities of care between individual patients. We believe that the different elements of the programme all contribute to the delivery of comprehensive vascular disease care.

References

  1. Barton S (Ed). Cardiovascular disorders. In: Clinical Evidence. London: BMJ Publishing Group, 2000: 1-153.
  2. Ramsay LE, Williams B, Johnston DG et al. Guidelines for management of hypertension: report of the third working party of the British Hypertension Society, 1999. J Hum Hypertens 1999; 13: 569-92.
  3. Whitford DL, Scott TA. Quality improvement in the prevention of thromboembolic complications in atrial fibrillation in one general practice. J Clin Governance 2000; 8: 39-43.
  4. Cleland JGF. Diagnosis of heart failure. Heart 1998; 79: SP10-SP16.
  5. Department of Health. National Service Framework for Coronary Heart Disease. London: DoH, March 2000.
  6. Scottish Intercollegiate Guidelines Network. Diagnosis and Treatment of Heart Failure due to Left Ventricular Systolic Dysfunction. SIGN Guideline No. 35. Edinburgh: SIGN, February 1999.

NHS Beacon Awards
Beacon status is awarded to practices, trusts and other healthcare organisations within the NHS that have demonstrated good practice. The NHS Beacon programme aims to spread best practice across the health service. For further information visit the website: www.nhs.uk/beacons

      

Guidelines in Practice, June 2001, Volume 4(6)
© 2001 MGP Ltd
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