A quality improvement approach to clinical audit in COPD and heart failure :The GRASP Suite

Vanessa Brown

NHS Improving Quality

Living Longer Lives

• Engaging with clinicians and primary care in the nation’s biggest killers

• Raising public awareness of symptoms and supporting early diagnosis of diseasee

• Supporting implementation of the CVD Outcomes Strategy (and NHS Health Check)

What is GRASP?

• Initially commissioned by the WYCN & PRIMIS to improve the management of AF it now also includes COPD and HF

• Sponsored by NHS IQ so FREE to end user• Based on PRIMIS’ CHART ‘freeware’ which uses MIQUEST• Compatible with all GP systems in England• Aligned to NICE/ best practice guidance• Comprises of a case-finder and care management audit tool• Patient identifiable version• Pseudonymised data can be uploaded to CHART Online for

benchmarking purposes• NOT a clinical decision support tool

Why GRASP-COPD?

• 1 person dies from COPD every 20 minutes • 1 in 8 people over 35 has COPD that has not been

properly identified or diagnosed, and over 15% are only diagnosed when they present to hospital as an emergency

• COPD is the second most common cause of emergency admissions to hospital

• Over 50% of people currently diagnosed with COPD are under 65 years of age

• COPD costs the NHS more than £800 million each year, (equivalent to £1.3 million per 100,000 population)

GRASP-COPD Case finder

• Patients not yet diagnosed with COPD• Identify patients potentially missing a

COPD diagnosis code• Identify patients at risk of developing

COPD • Prioritise those patients most likely to need

a review using pre-set (or user-defined) filters

GRASP-COPD Care Management

• Identifies patients who have been coded with COPD, providing practice prevalence

• Enables practices to audit the management of patients with COPD against current NICE guidance

• Provides a summary of practice results and patient level detail for case review

• Identifies where quality of care can be improved

What is CHART Online?

• Voluntary upload of data to CHART online• Web based analysis tool with a variety of comparative

viewing options available– Benchmark own practice against others in CCG– Benchmark CCG against others in SCN/ National– View change (improvements!) over time

• Secure and restricted access– Practices control who sees their national identifier

• For both providers and commissioners

5 key actions after running GRASP-COPD

• Use the COPD case finder to identify patients who may have a missing diagnosis of COPD or who may go on to develop COPD

• Compare COPD severity with the current treatment regime and target COPD patients for review

• Target patients with an MRC score of 3+ who have no evidence of pulmonary rehabilitation

• Target all COPD patients with these cost effective strategies:– annual ‘flu vaccination– helping smokers to quit

• Upload data to CHART Online for benchmarking and comparison

An example of implementing GRASP COPD

to improve patient care

An innovative 2 year Local Incentive Scheme Objectives to:

• decrease unplanned admissions and• highlight patients with a primary diagnosis of COPD

3 Components• GP to attend monthly Locality commissioning meeting• Casefinder and GRASP-COPD use and monthly reporting• Practice action planning to improve patient care

Practice managers were up skilled to run GRASP Clinical templates were designed for use in consultation

GRASP COPD The Blackpool Experience

Blackpool’s experience of GRASP-COPD• CCG quality premium target was to ↑ COPD recorded

prevalence by 10% from 2012/2013 baseline• Key objectives of the initiative were to increase and improve

identification and management of COPD and reduce COPD related NEL admissions

• Practices set individual prevalence targets• In addition to pro-actively screening smokers/ex-smokers through

COPD-6 practices were encouraged to utilise GRASP case finder to validate their COPD register

“Patients with a COPD monitoring code ever”• Blackpool achieved and exceeded their target by April 2014 i.e.

recorded prevalence rose by 11.08% (n 5406 → n6005 patients)• COPD register sizes have continued to rise

Why GRASP-HF?• Around 900,000 people in the UK have heart failure (HF)• Like AF, the incidence and prevalence of HF increase steeply with

age• The prevalence of HF is expected to rise in future as a result of an

ageing population, improved survival of people with CHD and more effective treatments

• HF has a poor prognosis: 30–40% of patients diagnosed with heart failure die within a year

• HF accounts for a total of 1 million inpatient bed-days – 2% of all NHS inpatient bed-days – and 5% of all emergency medical admissions to hospital

• Good heart failure care increases longevity, reduces symptoms and improves quality of life

• Evidence suggests that community based (primary care-led) care can reduce readmissions and save money for the NHS

GRASP-HF Case finder

• Patients not yet diagnosed • Identify patients potentially missing a heart

failure and LVSD diagnosis code• Identify patients who have risk factors indicating

LVSD that should be considered for review for possible inclusion in the register and treatment

• Prioritise those patients most likely to need a review using pre-set (or user-defined) filters

5 key actions after running GRASP-HF

• Run the case finder to identify patients with missing diagnoses of HF and/ or LVSD

• Ensure that patients are on the most effective treatment regimen

• Undertake regular reviews of patients• Target HF patients with these cost-effective strategies:

– Annual ‘flu vaccination– Cardiac rehabilitation

• Upload data to CHART Online for benchmarking and comparison

GRASP-AF

• Guidance on Risk Assessment and Stroke Prevention in AF• Case finder- accurate coding of possible and probable AF• Identifies patients with a history of atrial fibrillation• Searches for co-morbidities and calculates both a CHADS2 and

CHA2DS2-VASc score

• Searches for current medication- warfarin, aspirin or newer oral anticoagulant

• Searches for recorded reasons for NOT treating with warfarin• Highlights those at high risk and not on warfarin or newer oral

anticoagulant

Case finder

How to get GRASP

1. Register for free basic PRIMIS Hub membership (if you are not already a PRIMIS Hub member ) at https://www.primis.nottingham.ac.uk/registration/registration/default.asp

2. Sign in to PRIMIS Hub

3. Visit the GRASP suite page in PRIMIS Hub in order to:

1. Request access* (if this is the first GRASP tool you have used)

2. Sign the terms and conditions agreement (if you have not done so already)

4. Ensure you have the latest version of CHART installed - see the CHART page within the Hub for full details

5. Download and install the GRASP-AF installer file by clicking on 'CHART updates' within the CHART software tool

USER GUIDES AVAILABLE FROM PRIMIS AND NHS IQ

CONTACT THE PRIMIS HELPDESK

Summary• The GRASP Suite is a cornerstone of NHS IQ’s programme of

work for engaging with clinicians to tackle the five big killers• GRASP-AF is improving the way stroke risk in AF is

managed; changes are small but potential impact is great• NHS IQ has built on the success of GRASP-AF by developing

similar tools for other long term conditions• Each toolkit in the GRASP suite has a number of features and

benefits of value to providers and commissioners in primary care

• GRASP is free to all practices in England through PRIMIS Hub membership

@NHSIQ

#GRASP_suite

Vanessa.Brown@nhsiq.nhs.uk

Technical help: ian.robson@nhsiq.nhs.uk

www.nhsiq.nhs.uk

Start using GRASP for FREE by signing up for free PRIMIS Hub membership at:

www.primis.nottingham.ac.uk/hub

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