Management of coronary heart disease in primary care Professor Azeem Majeed Primary Care Research Unit University College London

Outline of talk Importance of CHD National Service Framework Overall study results Results for practice size Limitations Conclusions

Why is CHD important CHD is the single most common cause of death in both men and women. One in four men and one in six women die from CHD (about 125,000 deaths in the UK in 2000) CHD is also the commonest cause of premature death (about 45,000 deaths)

CHD prevalence per 1,000

SMR in men by social class

CHD NSF Set national standards for preventing and treating CHD Define service models Establish targets and performance measures Identify practical tools and methods to support its implementation

Some initial NSF targets Identify all patients with CHD Establish CHD disease registers Examine the current standard of care

Wandsworth study: Phase 1 63 practices (out of 69 in PCT) September May 2001 Patients aged 45+ years Paper/computer records examined to confirm diagnosis 350,000 registered patients 6778 patients with CHD

Data collected Risk factors Body mass index Smoking Blood pressure & cholesterol Treatment Aspirin & statins Beta-blockers & ACE-inhibitors

Risk factors

No. of risk factors controlled

Prescribing in CHD patients

Wandsworth study: Phase 2 Examine association between practice size & quality of care Not a primary objective but important in view of policy developments Same data set 62 practices CHD patients of all ages

Risk factors: practice variation

Treatment: practice variation

Quality & practice size: 1

Quality & practice size: 2

Percentage of CHD patients with cholesterol recorded by practice size

Percentage of CHD patients prescribed a statin by practice size

Percentage of CHD patients prescribed aspirin by practice size

Main findings Large variation in quality of care between practice Some room for improvement in management & recording No significant association between quality & practice size

Limitations Limited range of quality measures Study confined to CHD Little information on practice characteristics No information on patient satisfaction Carried out in one part of London

Discussion Patient satisfaction high with small practices Little objective evidence that quality of care worse in small practices Despite this, long-term future of small practices remains in doubt Smaller practices need to show quality care as good as in larger practices

Conclusions More research needed Wider range of diseases New GP contract (if and when implemented) will provide information on quality of care In the interim, PCTs can carry out their own evaluations of quality

Acknowledgements Battersea Primary Care Research Group Dr Jeremy Gray, GP Dr Kevin Carroll, Public Health Doctor Ms Caroline Firth, Nurse Dr Gareth Ambler, Statistician Prof. Andrew Bindman, Internist, UCSF