Maximising quality earnings for stroke and TIA
our series on
the quality framework,
Dr Lorna Gold discusses the implications for stroke and TIA quality markers
In the past few years, stroke has managed to shake off the 'geriatric heartsink' image that made it the province of the physiotherapist, the occupational therapist and social services rather than an acute medical condition despite the fact that one in four stroke deaths occurs in people under 65.
When I was a GP registrar just over a decade ago, 'good' GPs managed stroke patients at home whenever possible, calling upon the services of the extended primary health care team, rather than letting them take up hospital physicians' time and valuable inpatient beds.
Transient ischaemic attacks (TIA) were managed with reassurance and aspirin and a nihilistic acceptance of a statistical increase in future stroke risk. Now prevention and management of stroke is a medical discipline on its own, with high-tech investigations and proactive use of anticoagulation as well as aggressive management of risk factors.
The new contract acknowledges this, and allocates 31 points for stroke and TIA. As many patients with cerebrovascular disease also have ischaemic heart disease, much of the data collection for stroke and TIA will overlap with that for CHD. It is only necessary to record any piece of information about a patient once, so a practice on top of its CHD management and data recording will be well placed to maximise its income from stroke and TIA. The following information may already be coded:
lSmoking status (three points).
lSmoking cessation advice (two).
lBlood pressure measurement in last 15 months (two).
lLast recorded blood pressure 150/90mmHg or less (five).
lTotal cholesterol measured in last 15 months (two).
lLast recorded total cholesterol 5mmol/l or less (five).
lTaking aspirin, an alternative anti-platelet therapy, or an anticoagulant, unless contraindicated (four).
lFlu immunisation given the previous winter (two).
Tasks specific to stroke and TIA
Build a stroke and TIA register (four points). Everyone in the practice should use the same code or subset of codes. A list of preferred codes from the new contract document is included. The % sign after a Read code indicates that any code in the group can be used.
Search for patients who are on warfarin, aspirin, clopidogrel or dipyridamole, and check their records, adding a stroke code where this is relevant.
A further search for those who are on these drugs and do not have a CHD code will provide a list of patients who may need to have the above data entered, or to be called for review if up-to-date information is not available. Remember to add those patients aged under 65 to your flu immunisation target group for this winter.
Ensure all patients diagnosed as having a probable stroke after April 1, 2003, have been referred for confirmation of the diagnosis by CT or MRI scan (two points).
In reality, most patients who have a completed stroke are referred urgently for inpatient care, but it remains the GP's responsibility to check on discharge that the patient has either been scanned during their stay or given an outpatient appointment for a scan, and to refer them to the stroke or neurology clinic if this has not been done. Patients who are not admitted to hospital because their stroke is relatively minor, or who refuse admission, should also be referred for outpatient scanning.
hose patients who totally refuse investigation, cannot tolerate medication or are too frail or unwell to attend clinic, should be excluded from your statistics under exception reporting, which was dealt with in detail previously (July 14 issue).
It is not necessary to collect referral statistics on TIA patients at present, but patients who have had an ischaemic TIA are generally regarded as having a stroke risk of similar magnitude to patients who have already had a completed stroke, and most secondary care services encourage the referral of such patients for scanning and/or assessment of the carotid arteries.
I think the small amount of effort involved in recording this information on computer is worthwhile insurance against the goalposts being moved in a year's time.
Preferred Read codes
Haemorrhagic stroke G61%
Non-haemorrhagic stroke G64%
CT scan 5674
MRI (abnormal) 5693
MRI (normal) 5692
Never smoked 1371
Smoking cessation advice 8CAL
BP measured 246
Blood pressure Text in numerical value
Serum cholesterol measured 44P%
Cholesterol Text in numerical value
OTC aspirin 8B3T
Medication stopped, interaction 8BI6
Aspirin prophylaxis contraindicated 8I24
Warfarin contraindicated 8I25
Adverse reaction to warfarin TJ421
Adverse reaction to salicylates TJ53
History of aspirin allergy ZV148
Flu vaccination given 65E
Flu vaccine contraindicated 8I2F