CHD Secondary Prevention Clinics in Primary Care; a critical assessment


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There is a need for CHD secondary prevention in primary care. This need has been addressed providing specialized clinics run by nurses or GPs. Whether with this clinics we are meeting this need is a question to be answered.

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CHD Secondary Prevention Clinics in Primary Care; a critical assessment

  2. 2. Health Services Evaluation. Number: 21344Title:Matching provision with need. CHD Secondary Prevention Clinics in Primary Care; acritical assessment.IntroductionWith the term Coronary Heart Disease (CHD) I will be referring to angina,myocardial infarction and heart failure.Coronary heart disease in the form of myocardial infarction first came to attention tothe medical profession early in the 20th century. Mortality from CHD increaseddramatically after the First World War and had assumed epidemic proportions inWestern populations during the 60s and 70s being responsible for almost a third ofdeaths in those populations. Although its mortality rate has being gradually falling inthe last 20 years in certain populations, it still remains the leading cause of death indeveloped countries (Walker, 2001).In the year 2000, the Department of Health presented the National Service Framework(NSF) for Coronary Heart Disease, which set out the standards and services thatshould be available in the country for the prevention, diagnosis and treatment ofCHD. The NSF describes service models that can enable the efficient delivery ofthose standards and explains how the standards can be delivered. The objective is toreduce premature deaths from CHD and promote faster and equal access to highquality services (DOH, 2000).Based on the NSF standards of preventing CHD in primary care, the new GP contractis giving incentives to GPs to identify people with established CHD and offer themcomprehensive advice and appropriate treatment to reduce their risks. GPs areencouraged to provide special clinics (nurse run and doctor supported) to implementsecondary prevention (DOH, 2000) with two objectives: modify the factors that affectthe risk of CHD: exercise, diet, smoking, blood pressure, cholesterol and provideappropriate and evidence based treatment (aspirin, statins, ACE inhibitors, B-Blockers). 2
  3. 3. Health Services Evaluation. Number: 21344The objective of this assignment is to critically assess the need for those CHD Clinicsin primary care, analyse the way those clinics are provided and discuss the best waythose clinics could be evaluated.Assessment of needSize of the problemPrevalence. In UK the prevalence of CHD is increasing and there are around 2.65million of people with CHD (angina or myocardial infarction), of those 1.5 millionare men and 1.15 million are women. There are geographical and ethnicdifferences in the prevalence of CHD; the prevalence is higher in the North ofEngland and Wales than in the South of England and is higher in Indian, Pakistaniand Bangladeshi men living in UK but lower amongst Black Caribbean andChinese men (BHF, 2003, NAW, 2000, Stevens and Raftery, 1994).Mortality. CHD is the most common cause of death in the UK, it is estimated thatCHD caused over 117,000 deaths in the UK in 2001. More than one in five menand one in six women die from the CHD every year. Despite death rates fromCHD has fallen significantly in the last recent years (over 3,000 in the past year),UK is still among the countries with higher death rates (only Finland and Irelandhave higher death rates) and rates have not been falling as fast as in some othercountries. There are important socio-economic differences in mortality and 1 in 3of all deaths under 65 years caused by social class inequalities are due to CHD(BHF, 2003).Economic burden. It is estimated that CHD cost the UK economy 7 billion a year, ofthose 1.7 are direct cost to the healthcare system and the rest are costs in form ofproductivity losses and informal care of people with CHD. Less that 1% of the cost tothe NHS is spent in prevention (BHF, 2003). 3
  4. 4. Health Services Evaluation. Number: 21344Addressing the needAlthough there is not definitive proof for all risks factors of the benefit of secondaryprevention in CHD, we have evidence that smoking cessation, blood pressure control,cholesterol reduction and taking determinate drugs is effective (Merz et al., 1997,Robinson and Leon, 1994, Stevens and Raftery, 1994, Bowker et al., 1996, Wood,1998). If we consider need as “the capacity to benefit from an intervention”(Pencheon et al., 2001) we can conclude that there is a need for measures that helpreducing the burden of CHD. Primary Care CHD clinics may be a good way ofaddressing this need but we need to be sure this measures are effective, efficient andappropriate.In addressing need in this way we are taking an epidemiological driven approach toprioritise health services according to needs (Stevens and Raftery, 1994, Wright et al.,1998). Some health economists have argued that an economic approach offers a moresatisfactory framework for prioritising healthcare services (Petrou, 1998, Jones,1998). Other authors have replied that this is why important that our interventions areeffective and efficient (Wright et al., 1998).We have to recognize that probably this “perceived” need comes from an expertprofessional point of view obtained from evidence but that patients may not recognizeor express this need (Frankel and West, 1993, Pencheon et al., 2001).Provision of serviceClinics to prevent CHD are provided in Primary Care by GPs and practice nurses. Ihave personal experience running these clinics and the first problem I encounteredwas obtaining a comprehensive list of all patients with CHD in my practice. I foundthat the recording of CHD was incomplete and not up to date. This problem is wellknown and together with inaccuracies in recording risks factors has been described inseveral studies (Bowker et al., 1996). 4
  5. 5. Health Services Evaluation. Number: 21344EffectivenessSeveral studies have demonstrated that CHD secondary prevention clinics in Primarycare are effective (Campbell et al., 1998, McLeod et al., 2004). Campbell et al.conducted a RCT involving 1173 patients in which nurse run clinics in Primary Careproduced a significant improvement in aspirin management, blood pressuremanagement, lipid management, physical activity and diet although had no effect onsmoking cessation. The improvement was regardless of practice baseline performance(Campbell et al., 1998). The same authors did a follow up study and concluded thatthe findings were sustained after 4 years except for exercise. The authors suggestedthat nurse led clinics could led to fewer total death and coronary events (Murchie etal., 2003).But other studies have not been so positive, for example a study involving 1015patients showed very poor results for CHD clinics in Primary Care. The study alsodemonstrated that the management of CHD secondary prevention was significantlyworse in women than in men (Flanagan et al., 1999). Why do we have genderdifferences in the provision of CHD secondary prevention? The authors suggestedthat prevention strategies might be more effective in men than in women, otherstudies have supported this hypothesis (Field et al., 1995).Studies have suggested that if we want this clinics in primary care to be effective inreducing CHD risk, they need to be coordinated with cardiac services in secondarycare (Dalal and Evans, 2003).AlternativesFeder et al. conducted an study providing CHD secondary prevention though postalprompts containing recommendations for reducing the risk of another CHD event(lifestyle changes, drugs), they also offered the patients an appointment with their GPor practice nurse. Despite the prompts increased the consultation rates, they did notimprove the prescription of effective drugs for secondary prevention and they did notproduce reported changes in lifestyle (Feder et al., 1999). 5
  6. 6. Health Services Evaluation. Number: 21344AcceptabilityLooking for effectiveness is a very good way to assess the quality of the provision ofa service but we should not forget to check patients’ satisfaction. A qualitative studylooking at patients’ and nurses’ perception of CHD secondary prevention clinicsreported that patients had generally positive views about nurse led care (Wright et al.,2001).GPs’ acceptability is obviously very important as well. Another qualitative studydemonstrated that GPs are convinced about the effectiveness of secondary preventionin CHD but they are concerned about workload and costs. They also recognize thatthey often respond to social and psychological needs rather than addressing longerterm prevention needs (Summerskill and Pope, 2002).EvaluationI have mentioned before several studies that looked t the effectiveness of CHDsecondary prevention clinics in primary care. Using a Donabedian approach I willdescribe the way in my opinion these clinics should be evaluated:Structure or inputsIt is the environment of care. Includes health professionals (numbers, qualifications,way in which they are organized, hierarchical lines of command), equipment,geographic distribution of Primary Care Centres, patients, consumables (drugs, heat,light, laboratory reagents), demographics, etc.Process or output“The process is how things are organized and done” (St Leger et al., 1994). In thecase I am analysing this process can be examined in terms of indexes such as numberof consultations (volume of activity), number of referrals, number of complications, 6
  7. 7. Health Services Evaluation. Number: 21344number of complaints, geographical variation in utilization of the service and numberof re-admissions (Stevens and Raftery, 1994). Donabedian also includes accessibility(some patients may not be able to attend CHD clinics), adequacy of the servicesprovided (e.g. appropriateness of test and investigations ordered during the clinics)and interpersonal relationships between patients and heath care professionals.Measures of process are important to define the effectiveness of an intervention butshould not be considered in isolation.OutcomeThey are the results or end-product of a programme. It shows the impact of theprogramme on individuals and communities (St Leger et al., 1994, Wilkin et al.,1992). In his case some measures of outcome are: changes in patients’ mortality andmorbidity, quality of life, satisfaction with care (Stevens and Raftery, 1994), anxietiesaddressed, changes in patient’s attitudes and knowledge (e.g. changes in lifestyle) andchanges in uptake of services.MethodsThe “goal standard” method to evaluate the benefit of an intervention is therandomized controlled trial (RCT). RCTs are difficult to conduct when assessingcomplex interventions like secondary prevention clinics, some reasons for this arecontamination of the placebo or control groups, unblinded nature of the study anddifficulties with randomization (Pencheon et al., 2001).We should not underestimate the importance of clinical audit, a tool readily availablein primary care.CostsThe cost-effectiveness of the clinics needs to be evaluated. We have studies looking atthe cost-effectiveness of interventions looking at individual risk factors but I am notaware of studies looking at cost-effectiveness of clinics addressing several riskfactors. 7
  8. 8. Health Services Evaluation. Number: 21344ConclusionsThere is a need for CHD secondary prevention in primary care. This need has beenaddressed providing specialized clinics run by nurses or GPs. Whether with thisclinics we are meeting this need is a question to be answered.Some evidence, including a RCT (Campbell et al., 1998) is already available aboutthe effectiveness of CHD secondary prevention clinics in primary care. Moreevidence is needed about the efficiency of these clinics.Data recording needs to improve in clinics. As study by de Lusignan et al. showedthat educational interventions targeted at primary care professionals in the form ofdata quality workshops can led to an increase in data quality in primary care (deLusignan et al., 2004).Evaluation in the form of economic analyses, such as cost-effectiveness studies, isneeded to justify allocation of scarce resources to this type of intervention. We needto answer the question of whether these clinics are beneficial enough to deserve thehigh priority they are receiving.We need to explain to the patients why we think they need these clinics but we alsohave to ask them if they want this kind of services. They may not very happy havingto wait for a week to see their GP for an acute problem and the GP being busy runningCHD secondary prevention clinics. 8
  9. 9. Health Services Evaluation. Number: 21344ReferencesBHF (2003) Coronary Heart Disease Statistics, British Heart Foundation, < 520&artID=3350>, (Accessed: 18.04.04).Bowker, T. J., Clayton, T. C., Ingham, J., McLennan, N. R., Hobson, H. L., Pyke, S. D., Schofield, B. and Wood, D. A. (1996) A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events). Heart, 75, 334-42.Campbell, N. C., Thain, J., Deans, H. G., Ritchie, L. D., Rawles, J. M. and Squair, J. L. (1998) Secondary prevention clinics for coronary heart disease: randomised trial of effect on health, BMJ, 316, 1434-7.Dalal, H. M. and Evans, P. H. (2003) Achieving national service framework standards for cardiac rehabilitation and secondary prevention, BMJ, 326, 481- Lusignan, S., Hague, N., Brown, A. and Majeed, A. (2004) An education intervention to improve data recording in the management of ischaemic heart disease in primary care. Journal of Public Health, 26, 34-7.DOH (2000) National Service Framework for Coronary Heart Disease, Department of Health, London.Feder, G., Griffiths, C., Eldridge, S. and Spence, M. (1999) Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial, BMJ, 318, 1522-6.Field, K., Thorogood, M., Silagy, C., Normand, C., ONeill, C. and Muir, J. (1995) Strategies for reducing coronary risk factors in primary care: which is the most cost effective? BMJ, 310, 1109-12.Flanagan, D. E. H., Cox, P., Paine, D., Davies, J. and Armitage, M. (1999) Secondary prevention of coronary heart disease in primary care: a healthy heart initiative, QJM, 92, 245-50.Frankel, S. and West, R. (1993) Rationing and rationality in the National Health Service: the persistence of waiting lists., Macmillan, Basingstoke. 9
  10. 10. Health Services Evaluation. Number: 21344Jones, J. (1998) Clinical and economic perspectives have to be integrated when selecting priorities for intervention, BMJ, 317, 1124.McLeod, A. L., Brooks, L., Taylor, V., Currie, P. F. and Dewhurst, N. G. (2004) Secondary prevention for coronary artery disease, QJM, 97, 127-31.Merz, C. N., Rozanski, A. and Forrester, J. S. (1997) The secondary prevention of coronary artery disease. American Journal of Medicine, 102, 572-81.Murchie, P., Campbell, N. C., Ritchie, L. D., Simpson, J. A. and Thain, J. (2003) Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care, BMJ, 326, 84-9.NAW (2000) Tackling CHD in Wales: Implementing Through Evidence, The National Assembly for Wales, Cardiff.Pencheon, D., Guest, C. and Melzer, D. (2001) Oxford handbook of public health practice., Oxford University Press, Oxford.Petrou, S. (1998) Health needs assessment is not required for priority setting, BMJ, 317, 1154a-.Robinson, J. G. and Leon, A. S. (1994) The prevention of cardiovascular disease. Emphasis on secondary prevention. Med Clin North Am, 78, 69-98.St Leger, A. S., Schnieden, H. and Walsworth-Bell, J. P. (1994) Evaluating health services effectiveness, Open University Press, Buckingham.Stevens, A. and Raftery, J. (1994) Health care needs assessment : the epidemiologically based needs assessment reviews, Radcliffe Medical, Oxford.Summerskill, W. and Pope, C. (2002) "I saw the panic rise in her eyes, and evidence- based medicine went out of the door." An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease. Family Practice, 19, 605-10.Walker, A. R. P. (2001) With increasing ageing in Western populations, what are the prospects for lowering the incidence of coronary heart disease? QJM, 94, 107- 12.West, R. R. (1977) Geographical variation mortality from ischaemic heart disease in England and Wales, British Journal of Preventive & Social Medicine, 31, 245-50.Wilkin, D., Hallam, L. and Doggett, M.-A. (1992) Measures of need and outcome for primary health care., Oxford University Press, Oxford. 10
  11. 11. Health Services Evaluation. Number: 21344Wood, D. A. (1998) European and American recommendations for coronary heart disease prevention. Eur Heart J, 19, A12-9.Wright, F. L., Wiles, R. A. and Moher, M. (2001) Patients and practice nurses perceptions of secondary preventive care for established ischaemic heart disease: a qualitative study, Journal of Clinical Nursing, 10, 180-8.Wright, J., Williams, R. and Wilkinson, J. R. (1998) Health needs assessment: Development and importance of health needs assessment, BMJ, 316, 1310-13. Word count: 1934 (excluding references) 11
  12. 12. Health Services Evaluation. Number: 21344Reflective statementThis assignment has constituted a challenge, as I am aware Dr West is a leadingexpert in the CHD and Cardiovascular field. He is in the steering board of theCoronary Heart Disease National Service Framework Implementation Plan for Walesand has published several books and articles about the subject (Frankel and West,1993, West, 1977).I have experience running CHD secondary prevention clinics in primary care. In mypractice I started this clinics during which I saw 116 patients with history of CHD.Although I was aware about the effectiveness of reducing risk factors in CHD I wasnot fully aware of the effectiveness of these type of clinics. For me has been veryuseful to do an extensive literature search looking at the evidence. This evidence isnot as strong as I expected but I think this fact should not deter us from continuing theclinics.As consequence of this assignment I am planning to undertake an audit of the CHDsecondary prevention clinics I have run in the last few months, I hope this will allowme to reflect on my practice and improve the care I provide. 12