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.

1. SUMMATIVE ASSESSMENT
HSE 21
HEALTH SERVICES EVALUATION
Number: 21344
26 April 2004

2. Health Services Evaluation. Number: 21344
Title:
Matching provision with need. CHD Secondary Prevention Clinics in Primary Care; a
critical assessment.
Introduction
With 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 to
the medical profession early in the 20th century. Mortality from CHD increased
dramatically after the First World War and had assumed epidemic proportions in
Western populations during the 60s and 70s being responsible for almost a third of
deaths in those populations. Although its mortality rate has being gradually falling in
the last 20 years in certain populations, it still remains the leading cause of death in
developed 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 that
should be available in the country for the prevention, diagnosis and treatment of
CHD. The NSF describes service models that can enable the efficient delivery of
those standards and explains how the standards can be delivered. The objective is to
reduce premature deaths from CHD and promote faster and equal access to high
quality services (DOH, 2000).
Based on the NSF standards of preventing CHD in primary care, the new GP contract
is giving incentives to GPs to identify people with established CHD and offer them
comprehensive advice and appropriate treatment to reduce their risks. GPs are
encouraged to provide special clinics (nurse run and doctor supported) to implement
secondary prevention (DOH, 2000) with two objectives: modify the factors that affect
the risk of CHD: exercise, diet, smoking, blood pressure, cholesterol and provide
appropriate and evidence based treatment (aspirin, statins, ACE inhibitors, B-
Blockers).
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The objective of this assignment is to critically assess the need for those CHD Clinics
in primary care, analyse the way those clinics are provided and discuss the best way
those clinics could be evaluated.
Assessment of need
Size of the problem
Prevalence. In UK the prevalence of CHD is increasing and there are around 2.65
million of people with CHD (angina or myocardial infarction), of those 1.5 million
are men and 1.15 million are women. There are geographical and ethnic
differences in the prevalence of CHD; the prevalence is higher in the North of
England and Wales than in the South of England and is higher in Indian, Pakistani
and Bangladeshi men living in UK but lower amongst Black Caribbean and
Chinese men (BHF, 2003, NAW, 2000, Stevens and Raftery, 1994).
Mortality. CHD is the most common cause of death in the UK, it is estimated that
CHD caused over 117,000 deaths in the UK in 2001. More than one in five men
and one in six women die from the CHD every year. Despite death rates from
CHD 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 Ireland
have higher death rates) and rates have not been falling as fast as in some other
countries. There are important socio-economic differences in mortality and 1 in 3
of 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, of
those 1.7 are direct cost to the healthcare system and the rest are costs in form of
productivity losses and informal care of people with CHD. Less that 1% of the cost to
the NHS is spent in prevention (BHF, 2003).
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Addressing the need
Although there is not definitive proof for all risks factors of the benefit of secondary
prevention 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 help
reducing the burden of CHD. Primary Care CHD clinics may be a good way of
addressing this need but we need to be sure this measures are effective, efficient and
appropriate.
In addressing need in this way we are taking an epidemiological driven approach to
prioritise health services according to needs (Stevens and Raftery, 1994, Wright et al.,
1998). Some health economists have argued that an economic approach offers a more
satisfactory framework for prioritising healthcare services (Petrou, 1998, Jones,
1998). Other authors have replied that this is why important that our interventions are
effective and efficient (Wright et al., 1998).
We have to recognize that probably this “perceived” need comes from an expert
professional point of view obtained from evidence but that patients may not recognize
or express this need (Frankel and West, 1993, Pencheon et al., 2001).
Provision of service
Clinics to prevent CHD are provided in Primary Care by GPs and practice nurses. I
have personal experience running these clinics and the first problem I encountered
was obtaining a comprehensive list of all patients with CHD in my practice. I found
that the recording of CHD was incomplete and not up to date. This problem is well
known and together with inaccuracies in recording risks factors has been described in
several studies (Bowker et al., 1996).
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Effectiveness
Several studies have demonstrated that CHD secondary prevention clinics in Primary
care 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 Care
produced a significant improvement in aspirin management, blood pressure
management, lipid management, physical activity and diet although had no effect on
smoking cessation. The improvement was regardless of practice baseline performance
(Campbell et al., 1998). The same authors did a follow up study and concluded that
the findings were sustained after 4 years except for exercise. The authors suggested
that nurse led clinics could led to fewer total death and coronary events (Murchie et
al., 2003).
But other studies have not been so positive, for example a study involving 1015
patients showed very poor results for CHD clinics in Primary Care. The study also
demonstrated that the management of CHD secondary prevention was significantly
worse in women than in men (Flanagan et al., 1999). Why do we have gender
differences in the provision of CHD secondary prevention? The authors suggested
that prevention strategies might be more effective in men than in women, other
studies have supported this hypothesis (Field et al., 1995).
Studies have suggested that if we want this clinics in primary care to be effective in
reducing CHD risk, they need to be coordinated with cardiac services in secondary
care (Dalal and Evans, 2003).
Alternatives
Feder et al. conducted an study providing CHD secondary prevention though postal
prompts containing recommendations for reducing the risk of another CHD event
(lifestyle changes, drugs), they also offered the patients an appointment with their GP
or practice nurse. Despite the prompts increased the consultation rates, they did not
improve the prescription of effective drugs for secondary prevention and they did not
produce reported changes in lifestyle (Feder et al., 1999).
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6. Health Services Evaluation. Number: 21344
Acceptability
Looking for effectiveness is a very good way to assess the quality of the provision of
a service but we should not forget to check patients’ satisfaction. A qualitative study
looking at patients’ and nurses’ perception of CHD secondary prevention clinics
reported that patients had generally positive views about nurse led care (Wright et al.,
2001).
GPs’ acceptability is obviously very important as well. Another qualitative study
demonstrated that GPs are convinced about the effectiveness of secondary prevention
in CHD but they are concerned about workload and costs. They also recognize that
they often respond to social and psychological needs rather than addressing longer
term prevention needs (Summerskill and Pope, 2002).
Evaluation
I have mentioned before several studies that looked t the effectiveness of CHD
secondary prevention clinics in primary care. Using a Donabedian approach I will
describe the way in my opinion these clinics should be evaluated:
Structure or inputs
It 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 the
case I am analysing this process can be examined in terms of indexes such as number
of consultations (volume of activity), number of referrals, number of complications,
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7. Health Services Evaluation. Number: 21344
number of complaints, geographical variation in utilization of the service and number
of re-admissions (Stevens and Raftery, 1994). Donabedian also includes accessibility
(some patients may not be able to attend CHD clinics), adequacy of the services
provided (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 but
should not be considered in isolation.
Outcome
They are the results or end-product of a programme. It shows the impact of the
programme 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 and
morbidity, quality of life, satisfaction with care (Stevens and Raftery, 1994), anxieties
addressed, changes in patient’s attitudes and knowledge (e.g. changes in lifestyle) and
changes in uptake of services.
Methods
The “goal standard” method to evaluate the benefit of an intervention is the
randomized controlled trial (RCT). RCTs are difficult to conduct when assessing
complex interventions like secondary prevention clinics, some reasons for this are
contamination of the placebo or control groups, unblinded nature of the study and
difficulties with randomization (Pencheon et al., 2001).
We should not underestimate the importance of clinical audit, a tool readily available
in primary care.
Costs
The cost-effectiveness of the clinics needs to be evaluated. We have studies looking at
the cost-effectiveness of interventions looking at individual risk factors but I am not
aware of studies looking at cost-effectiveness of clinics addressing several risk
factors.
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Conclusions
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.
Some evidence, including a RCT (Campbell et al., 1998) is already available about
the effectiveness of CHD secondary prevention clinics in primary care. More
evidence is needed about the efficiency of these clinics.
Data recording needs to improve in clinics. As study by de Lusignan et al. showed
that educational interventions targeted at primary care professionals in the form of
data quality workshops can led to an increase in data quality in primary care (de
Lusignan et al., 2004).
Evaluation in the form of economic analyses, such as cost-effectiveness studies, is
needed to justify allocation of scarce resources to this type of intervention. We need
to answer the question of whether these clinics are beneficial enough to deserve the
high priority they are receiving.
We need to explain to the patients why we think they need these clinics but we also
have to ask them if they want this kind of services. They may not very happy having
to wait for a week to see their GP for an acute problem and the GP being busy running
CHD secondary prevention clinics.
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9. Health Services Evaluation. Number: 21344
References
BHF (2003) 'Coronary Heart Disease Statistics', British Heart Foundation,
<http://www.bhf.org.uk/professionals/index.asp?secondlevel=519&thirdlevel=
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:
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Dalal, H. M. and Evans, P. H. (2003) 'Achieving national service framework
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de Lusignan, S., Hague, N., Brown, A. and Majeed, A. (2004) 'An education
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DOH (2000) National Service Framework for Coronary Heart Disease, Department
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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
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'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.
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Jones, 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
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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
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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,
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Robinson, J. G. and Leon, A. S. (1994) 'The prevention of cardiovascular disease.
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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
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primary health care., Oxford University Press, Oxford.
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Wood, D. A. (1998) 'European and American recommendations for coronary heart
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Word count: 1934 (excluding references)
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Reflective statement
This assignment has constituted a challenge, as I am aware Dr West is a leading
expert in the CHD and Cardiovascular field. He is in the steering board of the
Coronary Heart Disease National Service Framework Implementation Plan for Wales
and 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 my
practice 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 was
not fully aware of the effectiveness of these type of clinics. For me has been very
useful to do an extensive literature search looking at the evidence. This evidence is
not as strong as I expected but I think this fact should not deter us from continuing the
clinics.
As consequence of this assignment I am planning to undertake an audit of the CHD
secondary prevention clinics I have run in the last few months, I hope this will allow
me to reflect on my practice and improve the care I provide.
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