There is an enormous opportunity to prevent the occurrence of coronary heart disease (CHD) through early diagnosis of the inherited lipid disorder familial hypercholesterolaemia (FH) but national prevalence estimates show that FH is substantially underdiagnosed. Medway Clinical Commissioning Group used clinical decision support software ('Audit +' from the BMJ) and developed an FH audit tool to support primary care physician decision-making in considering a diagnosis of FH in adults and children with raised cholesterol. After initial positive results showed an increase in the identification of FH cases, the FH audit tool was refined and nurse-led support clinics were introduced; the audit showed an increase in the identification of individuals, with FH prevalence increasing from one in 750 to one in 357 within the Medway population over the 3-year period.
Aims and objectives
Reasons for implementing your project
Medway CCG collaborated with BMJ, utilising their clinical decision support software ('Audit +') and developed an FH audit tool. The BMJ software supports practices to deliver best practice care through prompts during consultations and audit reports for a variety of diseases and act as a performance-enhancing tool. Audits could be conducted within practices on a daily basis. At the CCG level, audits could be conducted weekly, but progress was monitored monthly. In the second phase of the study Medway collaborated with HEART UK - the cholesterol charity, with support from the pharmaceutical company Sanofi, to conduct nurse-led FH clinics to further improve identification of FH cases. Medway CCG considered that putting NICE guidance into practice and increasing detection of patients with FH in the primary care setting would lead to better management of patients, identify additional 'at risk' relatives for screening and evaluation and ultimately prevent cardiovascular events. The CCGs considered that there was a significant benefit to patients as well as an economic benefit to the CCG to diagnose FH and reduce preventable cardiovascular events.
How did you implement the project
NICE CG71 recommends that a diagnosis of FH is based on the 'Simon Broome criteria'. These diagnostic criteria identify FH patients and classify the patient as definite FH or possible FH. There was no Read Code available for patients classified as 'possible FH' and so we sought and obtained a Read Code from the NHS in 2010. After a short single-practice pilot, the study was rolled out across the CCG. The software initially identified all patients with a diagnosis of FH to provide a baseline prevalence, and then the study was conducted in two phases, between 2011 and 2014. Phase 1 was a 2-year audit, and in Phase 2 the software was refined and we introduced nurse-led support clinics. The FH audit tool initially identified all patients with a diagnosis of FH, providing a baseline prevalence within Medway of one in 750. Next, we identified those patients with elevated cholesterol levels without an FH diagnosis and unscreened via the Simon Broome criteria ('at risk and unscreened'). Electronic flags were added to the records prompting assessment when the patient next visited the practice. The prompts contained further information and relevant Read Codes, which the GP added directly into the patient record from the prompt screen, and additional triggers to encourage optimisation of FH management. The audit was completed after two years. In Phase 2, the software was enhanced and we included the Dutch Lipid Clinic Network (DLCN) Score to define the severity of FH to further support clinical management. In response to feedback from participating GPs highlighting a need for additional resource to assess patients at risk and to diagnose FH, we started an 'FH Nurse Advisor' programme. This was a collaboration between NHS Medway CCG and HEART UK, supported by Sanofi. Ashfield Healthcare provided the service and employed the Nurse Advisor. We appointed a single nurse, who visited all the practices during Phase 2, which ran for 9 months.
The study improved diagnosis of FH and raised awareness of FH with GPs and patients within the CCG. The 'Audit +' software and FH audit tool is an inexpensive and helps diagnose FH and will be available to all GP IT systems via GPSOC2. We have shown that nurse-led clinics can further improve FH identification. We believe this audit provides a model for other CCGs to improve diagnosis and management of FH. Improving diagnosis and treatment of FH helped Medway CCG fulfil its role in the delivery of quality healthcare in accordance with Government policy and clinical guidance, including the NHS Outcomes Framework (with impact on Domain 1 - preventing people dying prematurely; Domain 2 - enhancing quality of life for people with long-term conditions; and Domain 4 - ensuring people have a positive experience of care); the NICE FH guidelines (CG71); the NICE Quality Standard on FH (QS41); the Cardiovascular Disease Outcomes Strategy (2013), with its aspiration to find and treat at least 50% of cases of FH in England.
Key learning points
The audit tool was able to measure improvement in diagnosis of FH but we did not capture pre- and post-diagnosis lipid levels. Therefore, we do not know if a diagnosis of FH lead to improved patient management. We have recently revised the FH audit tool to capture lipid levels pre- and post-diagnosis and we can now monitor these at a practice (per patient) and CCG level (change in lipid levels).
In the second phase of the study Medway collaborated with HEART UK - the cholesterol charity, with support from the pharmaceutical company Sanofi, to conduct nurse-led FH clinics to further improve identification of FH cases