Points to Quality - CHD and LVD
In the first of a new series on how to achieve the necessary standards to meet the quality framework, Dr Lorna Gold looks at CHD and LVD
Standardise the Read codes that the practice will use and use them
Having disease registers for CHD and for subgroups who have had a myocardial infarction (now described in hospital discharge letters as a troponin-positive acute coronary syndrome) or who have left ventricular dysfunction is worth 10 points, and retrieval of data will be much simpler if everyone is using the same code to record the same information across all the indicator sets. Smoking status, for example, attracts points in several disease areas but should only need to be entered once using an agreed code. Every piece of information not entered is potentially lost income.
Use your local specialist services
Thirteen points are available for appropriate referral and investigation. Patients newly diagnosed as having angina should be referred for exercise testing and/or specialist assessment, and patients
suspected of having LVD should have the diagnosis confirmed by echocardiography. The specialist does not have to be a consultant cardiologist. An elderly care physician, or a GP with a special interest with access to the appropriate investigations, would be equally acceptable.
Record smoking status and offer smoking cessation advice
Stopping smoking reduces the risk of acute coronary syndromes in people with CHD, and intervention in the form of counselling, nicotine replacement and bupropion improves cessation rates. Lifelong nonsmokers need to have their smoking status recorded only once, but the information should be entered annually for current smokers and ex-smokers.
Measure blood pressure at least once a year, and treat levels greater than 150/90
Recording blood pressure in 90 per cent of patients on your CHD register is worth seven points, but having 70 per cent of those patients well controlled will generate a worthwhile 19 points. To maximise your prospects of treating your patients to target, follow the guidelines published by the British Hypertension Society. These are available online at www.bhsoc.org . Don't forget the value of lifestyle interventions such as weight reduction, salt restriction in some patients, and exercise.
Measure total cholesterol at least once a year, and treat levels greater than 5.0mmol/l
As with blood pressure, seven points are available for recording total cholesterol in 90 per cent of patients on your CHD register, but 16 points are available for achieving the target of 5mmol/l or less as agreed by national guidelines. In practice, this is likely to mean more widespread use, and higher doses, of statins. If your laboratory measures LDL levels, record these, as future guidelines may use LDL rather than total cholesterol.
Ensure all CHD patients are on aspirin (75-150mg daily), another anti-platelet agent, or warfarin, unless contraindicated
If a patient is taking OTC aspirin, remember to enter this in the computer record.
Ensure all patients are on a ?-blocker, unless contraindicated
This is particularly important for patients who have had a myocardial infarction. As there is no direct evidence that ?-blockade is of benefit to patients who have CHD but have not had an acute coronary event, the maximum seven points can be earned from 50 per cent coverage.
Ensure all patients who have had a myocardial infarction or who have left ventricular dysfunction are treated with an ACE inhibitor or an angiotensin-2 antagonist, unless contraindicated
Don't rely on the hospital to initiate treatment following an MI check the discharge summary yourself. There are seven points for 70 per cent coverage in post-MI patients and 10 points for 70 per cent coverage in LVD patients.
Offer all patients on your CHD register influenza
Although GPs in England may not be able to claim an item-of-service fee for immunising at-risk patients under the age of 65 against influenza, this is partly offset by the fact that practices can earn seven quality points by immunising 85 per cent of their CHD patients.
Use the exception reporting system
This is a safeguard to protect GPs from being compromised financially by patients who will not attend for review or refuse to take their medication. Individual patients can be excluded from your statistics under the following circumstances:
mWhen they have not come for review despite at least three invitations in the past 12 months.
mWhen aggressive CHD management is not appropriate in the frail elderly or terminally ill patient, for example.
mNewly registered or newly diagnosed patients,
in whom measurements should be made within three months and targets achieved within nine.
mPatients whose control remains sub-optimal on maximum tolerated doses of medication.
mPatients in whom treatment is contraindicated by another medical condition, such as statins in liver disease or ?-blockers in asthma.
mPatients who do not tolerate medication due to allergy or other adverse effects.
mPatients who refuse investigations or treatment. Remember to include those who refuse influenza immunisation.
mWhere a secondary care service, or access to a particular investigation, is unavailable.
This information must come from the patients' notes in most cases.