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Type and Title of Submission


Title:

Statins for ischaemic heart disease: Excellence and equity

Description:

Three east London PCTs Hackney, Newham and Tower Hamlets, have 15,000 people on GP Ischaemic Heart Disease Registers. In 2004 65% were on statins and in 2010 93% were on statins. Serum cholesterol less than 5mmol/l increased from 67% to 83%. The Clinical Effectiveness Group used local summaries of NICE guidance, in-practice facilitation and practice audit reports to support improvement, contributing to some of the best levels of statin prescription in E&W at low cost. Identifying equity of provision by age, sex and ethnic group, has also been an important feature in an ethnically diverse area with some of the highest deprivation and CVD mortality. We estimate we prevent 37 people a year from recurrent CVD through this low cost improvement.

Category:

2010-11 Shared Learning examples

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG67 - Lipid modification

Category(s) that most closely reflects the nature of the submission:

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

We aimed to increase prescribing of statins at low cost, to people known to have ischaemic heart disease and stroke. We also aimed to describe whether prescription was equitable by age, sex and ethnic group.

Objectives

Provide all primary care teams with the best information on cardiovascular disease treatment by summarising NICE guidance in local guidance agreed by primary and secondary care clinicians and prescribing advisors. Provide all practices annual information on statin prescribing in their own patients Provide educational sessions in each PCT and in-practice facilitation to practices with less satisfactory prescribing. Provide clinical and IT support to a locally enhanced service to achieve targets. To provide a PCT level equity audit.

Context

The project is set in three inner east London PCTs with some of the highest levels of social deprivation and CVD mortality in the UK. Half the population is non-white; in City and Hackney 25% of the population are Black African or Black Caribbean, in Newham 23% are Indian or Bangladeshi and in Tower Hamlets, 34% are Bangladeshi. In 1998-2003 male standardised IHD mortality rate was 161 compared to 54 in Kensington and 65 in Kingston and life expectancy is 10 years less. South Asian people have very high rates of IHD and Black African/Caribbean people stroke. We have promoted the use of statins, antihypertensive and other drugs recommended since the CHD NSF and NICE guidance started. In 2004 prescribing for people with IHD was suboptimal; only 65% were on statins and 67% had serum cholesterol less than 5mmol/l. There was substantial local variation in the use of less effective lipid lowering agents and wide practice variation in the dose, extent and prescription of generic statins.

Methods

Meetings with major stakeholders/'opinion formers' among local hospital consultants, GPs, prescribing advisors and commissioners agreed on summary local guidance for prescribing for IHD and stroke consistent with the CHD National Service Framework 2000 NICE guidance CG67 2008. This guidance started in 2000 with updates in 2005 (advocating first line low cost simvastatin) and 2009. The guidance went to all GPs and nurses in 150 GP practices in Newham, Tower Hamlets and City and Hackney with four educational meetings per PCT per update. Almost all practices used a common IT system and templates using agreed codes, enabling annual audits of IHD and stroke registers, the proportion on statins, dose and brand. Annual practice reports with peer comparison and PCT averages went to each practice so that progress or the lack of it could be monitored by staff. Poorly performing practices were offered in-practice visits from a trained facilitator to discuss obstacles - both organisational or professional attitudes - to improvement. From 2007 we also supported a locally enhanced service designed to promote improved prescribing for IHD and stroke and developed a health equity which included prescribing. In 2008/9 we introduced descriptions of statin prescribing and cholesterol by age group, sex and ethnic group across each PCT and included this in Joint Strategic Needs Assessment.

Results and evaluation

East London PCTs, despite the most adverse social circumstance, high levels of CVD and low levels of NHS resources , have done better than expected for statin prescribing for people with CVD. We believe part of the reason for this has been the Clinical Effectiveness Group local initiative to promote national and NICE guidance in a systematic and effective manner. The three PCTs have the highest prescription of statins in England and Wales and some of the best levels of prescribing using low cost statins (PACT data). We have described a linear relation between the rise in statin prescribing for IHD and the proportion of people with serum cholesterol below 5mmol/l. Control of cholesterol is better than average in comparison to other London PCTs. In 2010 93% of 15,000 the people with IHD were prescribed statins - an increased from 65% in 2004; and 83% had serum cholesterol <5mmol/l compared to 67% in 2004. (CEG data). Though less evident than in earlier years, women and people at older ages were slightly less likely to be prescribed statins and South Asian people were most likely to be prescribed statins. Statin prescription on the IHD register has risen steadily over the last decade in east London associated with national guidance from NICE/NSF, the Quality and Outcomes Framework and local financial incentives. It is impossible to disaggregate the impact of these initiatives but we consider the Clinical Effectiveness Group has made an important contribution to this.

Key learning points

Engage key stakeholders; agree consensus - this process itself creates change. Objective; what do you want practices to do - guideline with clear simple messages. Show: practices how they are doing in comparison to their peers - high quality, timely audit. Assist; poorly performing practices to overcome barriers - in-practice facilitation. Professional barriers - discuss in group setting - variation within the practice - clarify beliefs and review evidence. Organisational barriers - data entry; no agreed follow up; clarity over nurse role; admin and clinical staff involved. Integrate action - guidelines, QoF, local enhanced services, PCT prescribing advisors - PCT vascular strategy group connected to practices through the CEG. Equity - equity is integral to quality and excellence - describe equity of provision and discuss options to improve this.



This submission was shortlisted for the 2011 Shared Learning Award.

View the supporting material

Contact Details

Name:John Robson
Job Title:Senior lecturer
Organisation:East London Clinical Effectiveness Group
Address:Centre for Health Sciences
Town:London
Postcode:E1 2AT
Phone:02078 882 2553
Email:j.robson@qmul.ac.uk

 

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This page was last updated: 06 February 2011

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.