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Montrose GP Dr John Griffith, winner of the Guidelines in Practice Awards 2002, describes his teamÍs project to improve primary and secondary prevention |
The Government White Paper Towards a Healthier Scotland identifies the prevention of coronary heart disease as a national priority.
CARDIA, a computer program developed for Angus Local Health Care Cooperative by a team from Townhead Surgery, Montrose, Finix (the IT Directorate of Tayside Health Board) and Saragon Ltd, has been created to facilitate the provision of effective evidence based care to patients with existing CHD or those at significant risk of developing it.
CARDIA incorporates SIGN Guidelines 40 and 41, the British Hypertension SocietyÍs management guidelines for hypertension and the Tayside Diabetes Handbook based on SIGN Guideline 55.
CARDIA uses the Tayside electronic health record which is held on a central server outside the practice, at Tayside Health Board. Data are collated from practice systems (GPASS), laboratory systems and hospital discharges as well as from direct entry into CARDIA itself.
The fundamental aim for managing data has been to ïcollect onceÍ and ïuse oftenÍ. Access to the system is via a closed secure intranet site using a standard web browser. The electronic health record is based on the area community health index number that is a unique patient identifier.
CARDIA collates all the electronic data held for each individual patient. The system prompts the entry of missing data and determines if a patient requires primary or secondary CHD prevention (Figure 1, below).
For patients not identified as having existing CHD, CARDIA calculates risk using the Framingham equation (Figure 2, below).
| Figure 1:The CARDIA summary screen |
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| Figure 2:The CARDIA primary risk assessment screen |
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For both primary and secondary prevention, CARDIA gives detailed advice in terms of managing:
CARDIA can be used to search for patients under all data headings and also has an audit facility allowing individual practices to be compared.
Incidence and trends in CHD in Angus reflect those nationwide. Shortly after the Angus LHCC and its sister organisation in Arbroath and Froickheim were established in 1999, a group was formed to tackle CHD prevention. Although a considerable amount of work was going on in Angus practices to achieve a reduction in CHD, the level of commitment and the effectiveness of interventions showed a wide variation.
There were problems in identifying those patients who required interventions and in standardising the interventions using evidence-based guidelines. There was a need to develop a system that:
Most importantly, a patient centred approach was required that looked at managing patients with existing CHD and those at risk rather than a disease centred process that managed hypertension, diabetes, lipid lowering and lifestyle as separate and unconnected conditions.
In implementing CHD guidance we studied:
In consultation with other Angus practices and in particular practice pharmacists, we identified quality markers (prescribing of aspirin, statins, ACE inhibitors and beta-blockers) that could be used to audit existing CHD prevention activity and then monitor future progress.
We looked at clinical processes, particularly those that involved recording clinical measurements (weight, blood pressure, biochemistry) lifestyle data (smoking, exercise, alcohol consumption) and summarising clinical data (CHD, hypertension, stroke, family history) to develop a system that required single data entry. This mixture of paper based and electronic systems allowed benchmark comparisons to be made of quality indicators across the LHCC practices.
Pulling together clinical processes in this way led to a patient centred approach that became a stepping stone to the electronic method that has evolved through CARDIA.
CARDIA was funded through a Primary Care Development Fund grant. Development involved extracting the algorithms presented in the reference works, linking them together where links exist and translating these algorithms into a form that could be programmed electronically.
The improvement has been in two areas:
Between 2000 and 2001 there was a general improvement in most practicesÍ outcomes even before CARDIA had been released (Figures 3, 4, 5 and 6 below). This yearÍs data will soon be available.
| Figure 3: Post-MI patients taking aspirin, clopidogrel or warfarin (%) |
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| Figure 4: Patients under 75 years with total cholesterol <5.0mmol/l (%) |
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| Figure 5: Patients under 75 years taking a beta-blocker (%) |
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| Figure 6: Patients under 75 years taking an ACE inhibitor (%) |
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There has been a subjective improvement in awareness of CHD prevention by clinical and clerical staff.
The new electronic system allows a more structured approach to patient management and is a significant improvement over previous paper based and uncoordinated systems.It ensures that clinicians give patients consistent advice and that patients do not have to attend several different disease based clinics.Instant audit is available as part of the routine clinical process, thus streamlining the benchmarking process.
CARDIA is pushing back the boundaries of clinical database linking and is now being rolled out to all practices in the Angus LHCC. It comes as part of a suite of programs that facilitate investigation reporting, electronic ordering of investigations, electronic referrals and discharge and rheumatology monitoring.
We await with anticipation the development of its full potential as a tool for implementing CHD prevention guidelines and the automatic monitoring of that process.
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Guidelines in Practice, October 2002, Volume 5(10) |