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