Secondary Prevention of CHD in Primary Care.

1. Secondary Prevention of CHD in Primary Care. Nurse Led Clinics by Susan Neal Nurse Practitioner North Street Medical Care

2. Why Do It? • HIMP Targets around setting up CHD clinics • National Service Framework • Audit revealed care gaps

3. North Street Medical Care • 12,500 patients • Six partners. • Three practice nurses • One nurse practitioner • Paperless, fully computerised • Computer held CHD register of 418. • Opportunistic approach

4. Results • Performance in risk factor modification variable • Recording of advice given poor (except smoking) • Half on medication they should be • Cholesterol management fair, lipid prescribing low.

5. Evidence Base • HA Guidelines • Aspirin • Ace Inhibitors • Advice • Beta Blockers • Cholesterol • Risk Factors including Blood pressure

6. Evidence Base • Systematic, dedicated approach is beneficial (BMJ 1998, 316: 1434-7 Campbell et al, study of 1173 patients across 19 practices)

7. Systematic Approach • Aims of dedicated consultations • Support to patients • Identification of uncontrolled symptoms • Modification of risk factors

8. Organisation • Dedicated nurse time • Extended Model of Practice • Guided by evidence based protocol • Computer based call and recall • Clerical support

9. Outcomes • 82 consultations, 50% uptake • 10 patients prescribed/advised aspirin • 1 commenced beta blockers • 20 patients required cholesterol check • 9 subsequently required action • 24 required BP check • 14 subsequently required action

10. Case Study • 48 year old male • 1990 raised cholesterol • 1992 MI • 1992 2 vessel CABG • Dipyridamole • No surgery contact • 1998 called for check

11. Risk factors identified • Symptom deterioration • No medication • Cholesterol 7.5 mmols/l • BP 140/100

12. Lessons from Experience • Key is organisation with evidence based, focused, approach. • Extended model of practice. • ? Concept of dedicated “clinic” • Patient response • Needs resourcing