INTRODUCTION TO CORONARY HEART DISEASE CHANGE PRINCIPLES

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INTRODUCTION TO CORONARY HEART DISEASE CHANGE
PRINCIPLES Dr Keren Witcombe GP, Ellen St Family
Practice
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OVERVIEW

• Why Coronary Health Disease (CHD) is Australias
  Largest Health Problem
• CHD Aims
• Change Principles
• Change Ideas and Examples

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HEART, STROKE VASCULAR DISEASES

• Australias Largest Health Problem
• 50 294 deaths (37.6 of all deaths)
• 3.76 mil Australians in 2001
• 1.1 million Australians are disabled in1998
• Rising prevalence in last decade
• Death rates 21.4 higher in disadvantaged (2000
  2002)
• Indigenous Australians die 2.6 times faster
• (Heart, Stroke and Vascular Disease, Australian
  Facts 2004, AIHW and National Heart Foundation)

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HEART, STROKE VASCULAR DISEASES

• In 2002, 20 063 Australians lost their lives to
  this single disease
• It is the largest single cause of death (19.5)
  of all cause mortality
• It is the most common cause of sudden death in
  Australia
• 335 600 Australians have CHD (2001- 2002)
• 48 700 events in Australians aged between 40 90
  yrs (2001 2002)
• Approx half were fatal with 86 deaths occurring
  out of hospital
• (Heart, Stroke and Vascular Disease, Australian
  Facts 2004, AIHW and National Heart Foundation)

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HEART, STROKE VASCULAR DISEASES

• AMI related deaths
• 25 die within an hour of first symptom
• gt 4 of 10 die within a year of event
• Death Rate is 28.9 higher for disadvantaged
  (2001 2002)
• If you are an Indigenous Australian then it is
  2.6 times higher
• (Heart, Stroke and Vascular Disease, Australian
  Facts 2004, AIHW and National Heart Foundation)

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National Heart Foundation Guidelines Reducing
Risk in Heart Disease Guidelines for preventing
cardiovascular events in people with coronary
heart disease.
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• The definition of insanity is continuing to do
  the same thing over and over again and expecting
  a different result.
• Albert Einstein

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CHD AIM

• A reduction in the mortality of patients with CHD
  by 30 in 3 years

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CHANGE PRINCIPLES

• Building the practice team
• Establish a system for creating, validating and
  updating a register of people with CHD
• Be systematic and proactive in managing care
• Involve patients in delivering and developing
  care
• Develop effective links with key local partners
• Analyse your secondary care interface

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Change Principle 1 Building the practice team

• Set Goals
• Engage the team
• Assign roles responsibilities
• Communicate
• Reflect review

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Solving Problems and Achieving Goals

• Step 1 What is the problem?
• Think about and discuss the problem or goal and
  then write down exactly what you think is the
  main problem or goal.
• Step 2 List all possible solutions
• Brainstorm and put down all ideas, even bad ones.
• Step 3 Discuss each possible solution
• Quickly go down the list of possible solutions
  and assess the main advantages and disadvantages
  of each one.
• Step 4 Choose the best or the most practical
  solution
• Choose the solution that can be carried out most
  easily with your present resources.
• Step 5 Plan how to carry out the best solution
• List the resources needed and the main problems
  that need to be overcome.
• Step 6 Review how well the solution was carried
  out and praise all efforts
• Revise your plans if necessary. Continue the
  problem solving process until you have resolved
  your stress or achieved your goal.

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CHANGE PRINCIPLE 2 Establish a system for
creating, validating and updating a register of
people with CHD

• Agree on a clear definition of CHD
• Develop a register of people with CHD
• Develop systems to maintain a valid register

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DEFINITION OF CHD

• Myocardial infarction
• Unstable angina pectoris
• Angina
• Revascularisation as evidenced by angioplasty
  /- stent
• Coronary artery bypass surgery

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DEVELOP CHD REGISTER

• Gilbert Road Medical Centre, VIC
• Found 176 patients under separate diagnosis for
  CHD eg angina, CABG, IHD, MI etc)
• Removed duplicates and made deceased patients
  inactive and flagged rest as CHD
• Ended up with 94 patients on CHD register

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MAINTAIN REGISTER

• Hatherley Medical Centre, WA
• Improved coding habits and checked patients were
  coded correctly by simple patient questionnaire
• Of 100 patients, 4 were found to be not coded as
  CHD
• Questionnaire to be used on a regular basis in
  future

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• Patient Survey
• We are checking that our records are correct.
• Please circle if you have ever had?
• Diabetes
• Coronary Heart Disease
• Myocardial Infarction (heart attack)
• Angina
• Angioplasty / stent
• Coronary artery bypass surgery
• Are you taking any of the following?
• Aspirin over-the-counter
• Aspirin prescribed by the doctor
• Lipitor
• Pravachol
• Zocor / Lipex

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CHANGE PRINCIPLE 3Be systematic and proactive in
managing care

• Establish clear practice arrangements
• Establish systems for delivering care to patients
  with CHD
• Establish proactive call and recall arrangements
  for people with CHD
• Use guidelines, protocols and computer templates
  to support care delivery

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PRACTICE ARRANGEMENTS

• Establish a small, multi-disciplinary team to
  lead the work
• Identify someone who will take overall
  responsibility for arrangements across team
• Consider making registers a recurring agenda item
  at practice meetings

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DELIVERING CARE

• East Bentleigh Medical Group, VIC
• Established a Healthy Heart Clinic
• Nurse providing education and non-drug advice
• Patients identified and referred to clinic by GPs

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NPCC Handbook p.10

• Ellen St Family Practice planned to increase the
  of patients with IHD prescribed statins. A list
  of 116 patients with IHD was generated vie query
  builder. On a quiet day, two of the PNs
  individually checked electronic files to see if a
  statin had been prescribed in the last 6 mths. If
  not a patient alert and a message in the patient
  taskmaster were added This patient has IHD.
  Consider a statin. In all 45 alerts were added.

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CALL AND RECALL

• Daisy Hill Medical Centre, QLD
• Identify CHD patients who would benefit from GPMP
  / TCA
• Patients recalled and flagged for another recall
  in three months time
• Resulted in uptake in GPMPs TCAs and increase
  in patients health outcomes

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GPMP / TCA template for CHD
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GUIDELINES, PROTOCOLS TEMPLATES

• Hampton Bayside Medical Centre, VIC
• Aligned protocols for CHD management with NHF
  guidelines
• PM produced wall chart of protocols for each GP
  workstation
• Reminder prompts were also developed for GP
  computer screens

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One page summary guide of National Heart
Foundation, Reducing Risk in Heart Disease Guide
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CHANGE PRINCIPLE 4 Involve patients in
delivering and developing care

• Implement a deliberate strategy for
  self-management
• Integrate the patients perspective constantly in
  the design of services
• Ensure written communication is appropriate and
  understood
• Pay special attention to the needs of people from
  hard to reach groups

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Written action plans
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SELF MANAGEMENT

• Springwood Family Medical Centre, NSW
• Increased patient self-involvement in management
  of CHD by providing education sheets and
  pamphlets
• GPs participated in delivering and developing
  self-care information

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Chest Pain Management Plan
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PATIENTS PERSPECTIVE

• Involve patients in decision-making about how
  care can be designed and provided
• AGPAL have some useful resources for obtaining
  patient feedback on their website

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COMMUNICATION

• Written resources should be pitched at a reading
  age of seven to be understood by 90 of the
  population
• Available from
• Heart Foundation Heartline
• Heart Support Australia
• Local Division

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Heart Foundation Resources
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HARD TO REACH GROUPS

• Where possible pay special attention to people
  who have particular needs, including patients
  from minority ethnic groups and patients with
  disabilities

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Dr Troy PDSA

• Aim Establish open access for ATSI patients.
• Reception staff asked to give same day
  appointments to all ATSI patients that present
  from June 06.
• Study Found surprising number of ATSI patients
  had not been coded for ethnicity despite this
  being a practice policy for more than 6mths. 40
  ATSI patients now updated for ethnicity.
• With open access/same day appts a major decrease
  in DNAs for ATSI patients was found
• May 12 patients seen, 8 DNA 40 DNA rate
• June 16 patients seen, 5 DNA 23 DNA rate

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CHANGE PRINCIPLE 5Develop effective links with
key local partners

• Engage local organisations and other sources of
  care in developing CHD services

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CHD SERVICES

• Prescription for physical activity schemes
• Lifescripts
• Targeted dietary advice and classes
• Local support groups

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Lifescripts Resources
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Local Services and Resources

• Fremantle GP Network www.frdgp.com.au
• Healthy Lifestyle Database local programs and
  services for Physical Activity, Smoking,
  Nutrition, Alcohol and other drugs and Weight
  Management
• Allied Health Database currently being updated,
  ready 23rd Oct.
• Physical Activity Programs in the Cities of
  Melville, Cockburn and Fremantle
• Canning Division www.canningdivision.com.au
• Physical Activity Services Directory

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Home Medicines Reviews
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CHANGE PRINCIPLE 6Analyse your secondary care
interface

• Enlist your Division to assist in co-ordination
  at the primary/secondary care interface
• Analyse the patient journey and redesign where
  necessary

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Cardiac Rehabilitation Services

• Only 30 of eligible patients attend cardiac
  rehabilitation after a cardiac event
• Programs
• HeartBeat- Exercise, education and support
  program for patients with CHD who live in Canning
  Division www.canningdivision.com.au
• Fact sheets
• CHD Services around the Fremantle Region
• CHD Services around the Perth and Hills Region

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CHD MEASURES

• Patients with CHD on aspirin
• Patients with CHD who are on a statin
• Patients who have had an MI in past 12 months and
  who are on beta-blockers
• Patients with CHD whose last recorded BP within
  the last 12 months lt140/90 mmHg

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• the determination to make it work. If we are
  truly committed to quality, almost any mechanism
  will work. If we are not, the most elegantly
  constructed of mechanisms will fail.
• Avedis Donebedian

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Questions?