Medicines Management
Issue no 1, pp17-18
January/February 2002

This article
Reprint
Photocopy

Features

How to manage heart disease with GPs

I was challenged to provide a practical outline of our coronary heart disease (CHD) strategy in Dundee. Although based on Scottish experiences, I hope that this will help pharmacists and GPs in other parts of the UK think about their approach to CHD management. I work as a practice pharmacist in the Princes Street Surgery in Dundee, an urban city centre practice with moderate to high deprivation rates. It has roughly 9,000 patients and a wide range of healthcare staff from GPs to counsellors and administrative staff, and myself (PP).

CHD is a major cause of mortality and morbidity in Scotland and is a local, as well as a national, clinical priority. The disease is a chronic progressive condition, mainly managed in primary care, which requires on-going long-term investment of time, commitment and finances. For secondary prevention of CHD, the evidence is well published and supported in many documents (www.show.scot.nhs.uk – ie, Scottish Intercollegiate Guidelines Network, Clinical Standards Board for Scotland, CHD/Stroke Reference Group).

At Princes Street, a system of management for CHD patients was required. However, in 1997 when I joined the practice, there was no chronic disease management register to identify these patients, no clinics, no systematic review of these patients and limited staff resource. Our aim was to establish a strategy for the management of CHD within our practice and to promote the adoption of more effective care (evidence-based), via a systematic team approach.

The Princes Street study began in May 1998. Eight key aspects were integral to the success of the strategy:

1. Who do you involve in the team?

We looked at the current staff experiences and resources within the practice before establishing a number of different teams to facilitate the study; including the PP, GPs, nurses (PN) and health visitors (HV), the dietician, practice manager, support staff and external evaluators. There is no correct answer to team involvement; it is dependent on your local practice area, whether in a practice, local health care co-operative (LHCC), prescribing team or in a community pharmacy.

2. Protocols and documentation?

A structured and systematic approach is essential in any quality system. Based on available evidence-based practice, three practice protocols were written: CHD, hypertension and hyperlipidaemia.

These were later summarised into simple-to-use laminated coloured flow-charts and distributed to each clinic room, for clarity and as a useful reference for practice and locum staff. Data collection and monitoring sheets were used to facilitate a structured approach for clinic review. These were held in the patient's notes and used by CHD clinic nurses for screening risk factors and by the PP delivering medicines management.

3. Education and training

The proposed CHD strategy was presented and discussed with the practice team. The education and training of nurses was initially completed in-house and through continuing professional development. Later the PNs and HVs attended the area CHD training scheme organised by the Dundee LHCC. Open training evenings were held by the LHCC for pharmacists, GPs, cardiologists, nurses and rehabilitation teams to encourage open discussion across the various NHS boundaries of a patient's journey.

4. How to identify target patients

Patient listings could be retrieved via the G-PASS computerised repeat prescribing system (the national primary care computerised system for Scotland) although this was not very good and time-consuming.

Fortunately, we also had access to information from the Medicines Monitoring Unit (MEMO) at the University of Dundee which holds morbidity records dating back to 1980. It provided lists of all patients with a hospital diagnosis of previous myocardial infarction (MI). This, together with the G-PASS prescribing data, was used to create our first chronic disease management register.

5. How we structured our clinic

Initially a few teething problems were found. However, these were resolved after open discussion with the practice team, by the creation of simple-to-use flow-charts and by revision of the data collection sheet. This led to streamlining of clinic time and the inclusion of a referral system within the strategy (eg, to a dietician).

The clinics started in October 1998; first appointments were allocated 30 minutes and subsequent appointments 20 minutes per patient.

All relevant patients were sent a standard letter requesting them to attend a CHD clinic. If a patient did not attend, letters and telephone calls were made by the nurse to encourage attendance. If no attendance resulted, the case notes were referred to me for review. The PN and HV ran the CHD screening clinics and provided relevant lifestyle advice, health promotion and identified potential risk factors (ie, smoking, diet, alcohol, exercise, blood pressure, cholesterol, biochemical results etc).

I confirmed the diagnosis and reviewed the medication, potential risk factors, biochemistry results and made appropriate therapy recommendations. Initially, for alteration of drug therapy the patients were referred to their GPs.

On review, this process was difficult to monitor and time-consuming; so it was decided that I would see the patients for initiation or review, and discussion of their drug therapy. Other medical problems (eg, abnormal test results) highlighted at screening or review were documented in both the data collection sheet and clinical sheet in the case notes. These patients were recalled in three months or asked to make an appointment with the GP. Once stabilised, patients were recalled annually via our G-PASS system.

6. Minimum data set and database

I established a minimum data set and review system via G-PASS, an integral part of our practice protocol. In the future, a national minimum data set is required for both audit and research purposes. In Tayside a regional and collaborative approach was established in 2000 called Hearts-disease Evidence-based Audit & Research in Tayside, Scotland (HEARTS) (www.hearts.org.uk). This system now feeds back clinical information to practices to support improving patient care and provides high quality epidemiological data suitable for research.

7. Audit

Audit is an accepted part of health care. Indeed, it is an integral feature of the NHS. Several different audits were completed in the practice; this facilitated our review and continual improvement of our approach in a structured and systematic way.

8. Additional resources

The lack of money available to finance the project was of particular concern and initially, external funding from local project bursaries supported the study. However, prevention and treatment are linked to equity of access and quality of care. The Dundee LHCC has now supported the CHD initiative across all practices and £350,000 is allocated annually. Information from the process and results of the study undertaken at Princes Street were used to inform this extended and equitable approach.

Project results and discussion:

A record search of case notes found that MEMO data was 75.5 per cent sensitive and 99.7 per cent specific for MI. After review of the case notes, 130 (76 per cent) of MI patients were offered clinic appointments. Of these, 108 (83 per cent) were seen at the clinic and reviewed. Of the 108 MI patients reviewed, statistically significant increases in both prescribing and medication compliance were noted (P<0.05). Aspirin, warfarin or clopidogrel prescribing increased (from 76 per cent to 95 per cent) and statin prescribing increased (from 39 per cent to 90 per cent). Medication compliance also increased (from 62 per cent to 76 per cent); and of the patients on statin therapy, the achievement of a target total cholesterol level of less than 4.8mmol/L increased (from 27 per cent to 72 per cent).

Team members and patients believed that the clinic provided a valuable addition to the services provided by the practice. In addition to increasing relevant provision of secondary prevention therapy the team perceived that increased interaction time with patients was beneficial, and advice, particularly on medication and compliance with medication could be provided. Patients valued the reassurance of 'normal' results and were aware of the benefits of early intervention if abnormalities were discovered. They also appreciated being able to discuss their condition with familiar professionals, the convenience of the surgery compared with hospital clinics, and the efficiency of the appointment system.

Since the implementation of our CHD initiative, we have established closer links with national and local CHD networks. These have opened and improved communication lines to various health care professionals including secondary care cardiologists, nursing teams, clinical pharmacists, the rehabilitation team, other practices, professions allied to medicines and patient representative groups.

The team approach was felt to work extremely well and improved communications have enhanced relationships between team members. Early involvement in discussions has been found to facilitate acceptance of decisions, and has been incorporated into future initiatives. We have successfully established and will continue with our strategy for the management of CHD, which is in accordance with the latest evidence-based guidelines and research. This project has been used to inform other practices initiating similar projects in our local area.

This study has shown that collaboration between GPs, pharmacist, nursing staff, support staff and pharmacoepidemiologists can achieve and help maintain significant improvements in prescribing performance, thereby improving patient care. This can only improve in the future with new CHD initiatives following a patient's journey and crossing NHS boundaries to bring together a wider range of health care professionals.

A national target of reducing the death rate from heart disease in people under 75 years by 50 per cent between 1995 to 2010 was set in the White Paper: "Towards a Healthier Scotland", so there is much work still required.