management of coronary heart disease in primary care professor azeem majeed primary care research...
DESCRIPTION
Why is CHD important CHD is the single most common cause of death in both men and women. One in four men and one in six women die from CHD (about 125,000 deaths in the UK in 2000) CHD is also the commonest cause of premature death (about 45,000 deaths)TRANSCRIPT
Management of coronary heart disease in primary care
Professor Azeem MajeedPrimary Care Research UnitUniversity College London
Outline of talk Importance of CHD National Service Framework Overall study results Results for practice size Limitations Conclusions
Why is CHD important CHD is the single most common cause
of death in both men and women. One in four men and one in six women
die from CHD (about 125,000 deaths in the UK in 2000)
CHD is also the commonest cause of premature death (about 45,000 deaths)
CHD prevalence per 1,000
0
50
100
150
200
250
35-44 45-54 55-64 65-74 75-84 85+
MenWomen
SMR in men by social class
020406080
100120140160180200
I I I I I IN II IM IV V
CHD NSF Set national standards for
preventing and treating CHD Define service models Establish targets and performance
measures Identify practical tools and methods
to support its implementation
Some initial NSF targets Identify all patients with CHD Establish CHD disease registers Examine the current standard of
care
Wandsworth study: Phase 1 63 practices (out of 69 in PCT) September 2000 - May 2001 Patients aged 45+ years Paper/computer records examined
to confirm diagnosis 350,000 registered patients 6778 patients with CHD
Data collected Risk factors
Body mass index Smoking Blood pressure & cholesterol
Treatment Aspirin & statins Beta-blockers & ACE-inhibitors
Risk factors
0102030405060708090
100
Women Men
Smoking statusrecordedBMI > 30 kg/ m2
BMI recorded
Cholesterol >5mmols/ LCholesterolrecordedBlood pressureraisedBlood pressurerecorded
No. of risk factors controlled
05
101520253035404550
Men Women
01234
Prescribing in CHD patients
010203040506070
Women Men
History of MI &prescribed beta-blockerAngina &prescribed beta-blockerHistory of MI &prescribed ACE-inhibitorPrescribed statin
Prescribed aspirin
Wandsworth study: Phase 2 Examine association between
practice size & quality of care Not a primary objective but important
in view of policy developments Same data set 62 practices CHD patients of all ages
Risk factors: practice variation
Average Minimum Maximum
Blood pressure
recorded
95 70 100
Blood pressure
optimal
52 17 82
Cholesterol
recorded
60 0 83
Cholesterol
optimal
49 15 77
BMI recorded 69 2 99
BMI optimal 75 33 100
Treatment: practice variation
Average Minimum Maximum
Prescribed statin 45 19 67
Prescribed
aspirin
61 21 85
Prescribed beta-
blocker
21 0 45
Prescribed ACE
inhibitor
24 0 47
Quality & practice size: 1Odds ratio (95% CI) P-value
Blood pressure
recorded
1.04 (0.95-1.14) 0.36
Blood pressure optimal 0.99 (0.96-1.02) 0.63
Cholesterol recorded 1.05 (0.98-1.13) 0.18
Cholesterol optimal 1.02 (0.99-1.05) 0.21
BMI recorded 1.04 (0.95-1.14) 0.36
BMI optimal 0.99 (0.97-1.02) 0.51
Quality & practice size: 2Odds ratio (95% CI) P-value
Prescribed statin 1.03 (1.00-1.05) 0.08
Prescribed aspirin 1.01 (0.97-1.05) 0.53
Prescribed beta-blocker 1.06 (0.96-1.16) 0.28
Prescribed ACE
inhibitor
1.05 (0.96-1.16) 0.27
Percentage of CHD patients with cholesterol recorded by practice size
0102030405060708090
0 5000 10000 15000
Percentage of CHD patients prescribed a statin by practice size
01020304050607080
0 5000 10000 15000
Percentage of CHD patients prescribed aspirin by practice size
0102030405060708090
0 5000 10000 15000
Main findings Large variation in quality of care
between practice Some room for improvement in
management & recording No significant association between
quality & practice size
Limitations Limited range of quality measures Study confined to CHD Little information on practice
characteristics No information on patient
satisfaction Carried out in one part of London
Discussion Patient satisfaction high with small
practices Little objective evidence that quality
of care worse in small practices Despite this, long-term future of small
practices remains in doubt Smaller practices need to show quality
care as good as in larger practices
Conclusions More research needed Wider range of diseases New GP contract (if and when
implemented) will provide information on quality of care
In the interim, PCTs can carry out their own evaluations of quality
Acknowledgements Battersea Primary Care Research
Group Dr Jeremy Gray, GP Dr Kevin Carroll, Public Health Doctor Ms Caroline Firth, Nurse Dr Gareth Ambler, Statistician Prof. Andrew Bindman, Internist, UCSF