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Hyperlipidaemia in patients with ischaemic heart disease

Cycle 1

Audit date

May 1999

Target population

Well Close Square patients with a diagnosis of ischaemic heart disease.

Method

look at all patients who fulfil the criteria of ischaemic heart disease

Previous MI
CABG/PCTA
Angina
Cardiac failure
Atrial fibrillation

These records were examined and a current problem Ischaemic heart disease was added if appropriate. Computer search to find number who have had a cholesterol measurement. Cut off point aged 80 yrs.

Results

Patients with IHD								% of practice IHD patients
Date	TBL	BCS	JMW	BNC	ACB	RMW	Total	TBL%	BCS%	JMW%	BNC%	ACB%	RMW%
May-99	133	104	117	109	34	99	596	22%	17%	20%	18%	6%	17%

	May 1999
Total no of patients with ischaemic heart disease	576	100%
Number of IHD patients with cholesterol measurement	370	62%
No of IHD patients without cholesterol measurement (some will be >80yrs)	266	38%

62% of patients had a cholesterol recorded:

Patients with IHD aged <80yrs	May 1999
Number with cholesterol level > 5mmol/l	83%
No without cholesterol level < 5mmol/l	17%

Breakdown by usual doctor:

Patients with IHD aged <80yrs with cholesterol >5mmol/l								% of practice IHD patients aged <80yrs with cholesterol >5mmol/l
Date	TBL	BCS	JMW	BNC	ACB	RMW	Total	TBL%	BCS%	JMW%	BNC%	ACB%	RMW%
May-99	44	27	39	32	15	37	194	23%	14%	20%	17%	8%	19%

Patients with IHD aged <80yrs with cholesterol <5mmol/l								% of practice IHD patients aged <80yrs with cholesterol >5mmol/l
Date	TBL	BCS	JMW	BNC	ACB	RMW	Total	TBL%	BCS%	JMW%	BNC%	ACB%	RMW%
May-99	27	11	18	17	8	13	94	29%	12%	19%	18%	9%	14%

Average cholesterol level of each patient with IHD 5/98-5/99

Comment

62% of patients in with IHD had a cholesterol measurement.
Average cholesterol for this group was 5.9mmol/l.
83% with a cholesterol meaurement were above 5mmol/l.

The results of the 4S study together with the North Northumberland PCG and Northumberland healthy heart program suggests that this group should be below 5mmol/l.

Action as a result of cycle 1

Feedback was given to the doctors and nurses of the audit results.
- Dr to identify patients in target group without cholesterol measurement.
- Dr to identify patients in target group not on lipid lowering drugs who possibly should.
- Feasability of trying to further reduce cholesterol levels as recomended.
- Justification in the 80+ group to continue lipid lowering drugs?
- Cost implications
A S6000 Sophie template was developed to assist in recording of appropriate data for each patient with IHD, and teaching sessions arranged so that doctors and nurses understood its use.
Standard setting: over the next year, the practice will work towards the following targets:
1. Number of patients in the target group with a recorded cholesterol level: from 62% to 80%
2. Reduction of average cholestol in this group from 5.95mmol/l to 5.93mmol/l.

Cycle 2

Audit date

May 2000

Target population

Well Close Square patients with a diagnosis of ischaemic heart disease.

Method

Look at all patients who fulfill the criteria of ischaemic heart disease

Previous MI
CABG/PCTA
Angina
Cardiac failure
Atrial fibrillation

Results

	Patients with IHD							% of practice IHD patients
Date	TBL	BCS	JMW	BNC	ACB	RMW	Total	TBL%	BCS%	JMW%	BNC%	ACB%	RMW%
May 1999	133	104	117	109	34	99	596	22%	17%	20%	18%	6%	17%
May 2000	127	109	124	125	31	121	637	20%	17%	20%	20%	5%	19%

	May1999	May 2000
Total no of patients with ischaemic heart disease	576	637
Number of IHD patients with cholesterol measurement	370	401
No of IHD patients without cholesterol measurement (some will be >80yrs)	266	236

64% of patients had a cholesterol recorded:

Patients with IHD aged <80yrs	May 1999	May 2000
Number with cholesterol level > 5mmol/l	83%	58%
No without cholesterol level < 5mmol/l	17%	41%

Breakdown by usual doctor:

Patients with IHD aged <80yrs with cholesterol >5mmol/l								% of practice IHD patients aged <80yrs with cholesterol >5mmol/l
Date	TBL	BCS	JMW	BNC	ACB	RMW	Total	TBL%	BCS%	JMW%	BNC%	ACB%	RMW%
May 1999	44	27	39	32	15	37	194	23%	14%	20%	17%	8%	19%
May 2000	43	32	42	43	13	61	234	19%	14%	18%	18%	6%	26%

Patients with IHD aged <80yrs with cholesterol <5mmol/l								% of practice IHD patients aged <80yrs with cholesterol >5mmol/l
Date	TBL	BCS	JMW	BNC	ACB	RMW	Total	TBL%	BCS%	JMW%	BNC%	ACB%	RMW%
May 1999	27	11	18	17	8	13	94	29%	12%	19%	18%	9%	14%
May 2000	41	26	40	29	8	23	167	24%	16%	24%	17%	5%	14%

Comment

64% of patients in with IHD had a cholesterol measurement.
Average cholesterol for this group was 5.1mmol/l.

41% with a cholesterol measurement were below 5mmol/l.

58% with a cholesterol measurement were above 5mmol/l.
The results of the 4S study together with the North Northumberland PCG and Northumberland healthy heart program suggests that this group should be below 5mmol/l.

Results of Cycle 2

Percentage of patients with cholesterol below 5mmol/l has risen from 17% to 41%. This is a 150% improvement throughout the year in the Target Group.

Further effort needed to identify the 36% of patients without cholesterol in last 12 months
Dr to identify patients in target group not on lipid lowering drugs who possibly should be.
Feasibility of trying to further reduce cholesterol levels as recommended.
PCG suggests only lipid lowering agents in Target Population under 75years
Cost reduction with switching to Atorvastatin.
Ethical dilemma in treatment of older age group
Standard setting: over the next year, the practice will work towards the following targets:

1. Identify the 36% of Target Group without a cholesterol measurement

Number of patients in the target group with a recorded cholesterol level: from 62% to 80%
Reduction of average cholesterol in this group from 5.95mmol/l to 5.1mmol/l.

Cycle 3

Audit Date

July 2001

Target Population

Well Close Square patients with diagnosis Ischaemic Heart Disease

Method

Review data over last 12 months
Number of patients taking STATINS
Percentage patients fulfilling NSF criteria and CHOLESTEROL measurement
Percentage NSF patients CHOLESTEROL <5rnmol/l

Results

639 of our Patients have marker for IHD ( 6% ) of Practice patients

77% of our Patients with IHD have had a cholesterol measurement
52% with cholesterol measurement <5mmol/l —> GOOD
48% with cholesterol measurement >5mmol/l —> BAD

Comment

142 of our NSF patients still no cholesterol measurement ( 23% of IHD patients)
383 patients taking STATINS
3.6% of our practice patients take STATINS

Analysis

There has been a 13% increase in cholesterol measurement over 12 months
23% of our NSF patients still no cholesterol measurement
48% of our NSF patients not fulfilling NSF cholesterol levels

Cycle 4

Audit Date

July 2002

Target Population

Well Close Square patients with IHD >80 yrs old

Method

Review 12 months data
Review STATIN uptake in
- IHD
- PVD
- HYPERTENSION

Results

5.2% Practice patients age under 80yrs have IHD
96% IHD patients have had CHOLESTEROL MEASUREMENT
45% with cholesterol measurement <5mmol/l —> GOOD
55% with cholesterol measurement >5mmol/l —> BAD

STATINS

6% of Practice now take a STATIN
60% Stalin takers are for IHD
5% Statin takers are for HYPERTENSION
8% Statin takers are for PVD
4% Statin takers are for CVA

Comment

A 19% increase in CHOLESTEROL measurement has been achieved in 12 months
There has been a 7% reduction in good cholesterol control and this will need to be addressed
We are fast approaching the 8.4% of NSF recommendation population taking STATINS

Discussion

Cholesterol reduction is attainable but by how much
STATINS are safe and well tolerated
Which STATIN

Heart Protection Study ( November 2001)

40mgs Simvastatin reduces risk heart attack, stroke and revascularisation by 1/3
Five years STATIN treatment prevents 'major vascular events' in about
- 100 of every 1000 with previous Ml
- 80 of every 1000 with previous CHD
- 70 of every 1000 with previous diabetes
- 70 of every 1000 with previous stroke
- 70 of every 1000 with previous PVD

Logo Brent Smith: endspan

Brad Cheek: last updated Dec 2006
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