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How to 'succeed' with cardiac care in primary care

Developing a framework for Successful Cardiac Care based on Evidence for Effectiveness in Dorset (SUCCEED)
Why was the initiative launched?
What was done?
Working with a pharmaceutical company
Creating a care pathway
Talking to practices in Dorset
Getting the work done within practices
Did it work?
Building on early progress
Tips for success
For more information about SUCCEED contact

Why was the initiative launched?

A number of studies in 1996 raised questions about the quality of secondary prevention of ischaemic heart disease in primary care in Dorset. Growing research evidence was showing the benefits of tackling risk factors such as lifestyle and the control of hypertension as a way of reducing morbidity and mortality. But this was not the reality of everyday practice. At the same time Dorset Health Authority was looking for ways to change the methods of funding health promotion clinics in primary care to focus more on outcomes and efficiency: were resources being used effectively?

A small group of general practitioners and nurses from across Dorset, led by Dr Graham Archard, decided to try to help practices improve the quality of their cardiac care. The challenge was to create a mechanism that would stand the test of time and not gradually fade away like so many other initiatives. Could they develop evidence-based standards and help practices to implement change?

What was done?

The project group's first task was to draw up a project plan including agreement of clinical standards, a mechanism for delivering messages to practices and steps to measure the impact of their work. Additional staff and resources (such as training material) would be required.

Working with a pharmaceutical company

After some debate the group decided to ask a pharmaceutical company (Merk, Sharpe and Dohme) for financial support. Terms for the company's involvement and funding were agreed for three years. They would be represented at general meetings but have no clinical input to the work. The project would not promote the medications from any particular company. Funding would cover a half-time rehabilitation nurse, sessional costs for the Project Director and members of the proposed Steering Group, the costs of accommodation for training meetings and related training material. Funding also covered the costs of creating posters to promote the SUCCEED project. The group devised a logo to give a sense of identity for the work.

Creating a care pathway

Work then started in earnest to create a set of county standards for cardiac care in primary care. The group decided to present this as a care pathway and base it on the Oxford model. The pathway would apply to care following coronary artery bypass grafting, coronary artery angioplasty and would apply following acute myocardial infarction. Three stages were planned. Stage 1 would focus on newly diagnosed patients. Stage 2 would pick up patients with a history of cardiac events. Stage 3 might follow and tackle patients at risk of developing heart disease: primary prevention. Taken together the work would create a practice-based register of cardiac patients

The pathway would cover the collection of data on history, medications and lifestyle and offer a sound basis for auditing progress. Patient care would be personalised through patient record cards and represent a contract between the patient and the care manager. When a draft care pathway was ready the group invited all practices across the county to an initial meeting to talk about the plans. The meeting would provide a forum to review the care pathway and an opportunity to invite nominations for a SUCCEED Steering Group. Involvement with the project would be acceptable to the health authority in the context of health promotion funding. About half of the practices in the county were represented at the initial meeting.

Talking to practices in Dorset

The meeting stimulated extensive discussion about the pathway and eleven drafts were circulated before it was adopted as a working document for use from 1 st April 1997. Three evening meetings were arranged to explain what would be involved if practices joined the project. The meetings were open to all practice staff. The agenda covered the evidence-base for the pathways, why the initiative was important and the work involved at practice level.

Practices were given the options of working incrementally (starting with stage 1 before moving on to stage 2) or tackle both stages together. A separate fast track committee was set up representing by eight practices to develop the care pathways and alterations in care pathways and then pilot them. A key consequence of the three meetings was the identification of local care managers (a GPs or nurse) who would lead the work within individual practices. They would identify the patients and develop personalised packages of care with them.

Getting the work done within practices

Once care managers had been identified they attended a training day at which all the steps in the care pathway were explained. Hospital cardiac rehabilitation nurses, pharmacists, GPs and practice nurses led the teaching sessions. The agenda for the day covered all aspects of the pathways as well as the practical tasks of identifying, from practice records, the patients who would need to be seen.

Care was taken to ensure that practices knew what this meant and how many patients would be involved. Data suggested that each practice would treat about 18 new MIs each year. The review of individual patients in either stage 1 or stage 2 was expected to take about 30 minutes. Project nurses' time was allocated time to individual practices to help them with this task. The pathway has been converted into a patient-held record card. This is now used extensively across the county, for example it is now used within hospitals and patients are increasingly discharged with their card.

Did it work?

Since the project was launched in June 1997 there has been a gradual increase in the number of participating practices. SUCCEED has been particularly well received by nurses in primary care. It has precipitated the creation of nurse-led cardiac care clinics. A description of the experience in one practice as part of SUCCEED follows in a brief case study: Tacking cardiac care: being part of SUCCEED

By June 2000, 84 out of the total of 109 practices in Dorset were involved (Table 1). Over 1,000 patients have been brought within the pathway model of care. Local audits have been able to measure significant improvements against key interventions. Using published research and NNTs it is estimated that 22 deaths, 39 re-infarctions and 1 non-fatal strokes are being prevented in Dorset each year.

Table 1: Getting Involved - progress with SUCCEED: Summer 2000

  Acute MI Cardiac angioplasty Coronary artery bypass graft Total Percent
No of patients presented April 97/March 98 183 25 95 303 100
No of patents entered Care Pathway 154 21 75 250 82
No of patents stopped attending Care Pathway 16 0 9 25 10
121.25 GPs from 38 practices          
No of patients presented April 98/March 99 260 38 128 426 100
No of patents entered Care Pathway 197 26 145 368 86
No of patents stopped attending Care Pathway 45 5 12 62 17
157 GPs from 48 practices          

Patients have almost universally welcomed the project. They have indicated their support for involvement in their own care and, indeed, Dr Archard had one letter form an irate patient asking why the practice (who had decided not to be part of SUCCEED) with which they were registered 'was not allowed to take part'! The popularity of the project with patients is demonstrated by the low drop out rate (Table 1).

Building on early progress

The approach developed by SUCCEED has now been adopted by Poole and Bournemouth Hospital Trusts. Both now discharge patients following significant cardiac events with the patient-held record cards. A link rehabilitation nurse, funded by the British Heart Foundation, now follows up hospital discharges to ensure continuity in primary care. The project has been given a further boost following its inclusion, as an example of good practice, in the Cardiovascular National Service Framework.

The project continues to provide a practical framework for development in Dorset. Arrangements are in place to provide practice-based training as other practices in Dorset ask to join in and to ensure that training is available for new staff joining the practices already working with SUCCEED. Following the initial three-year funding from Merk, Sharp and Dohme, the project is now being jointly financed by Bayer, Pfizer, Parke Davies and Bristol Myers Squibb. There are encouraging signs that SUCCEED will not simply become another project rapidly forgotten, but rather a practical way of working across practices.

A more recent success has been the agreement to set up a mirror project to tackle diabetes across Dorset. This new programme of work, again funded in partnership with pharmaceutical companies, will have a research arm as well as the work to improve the standards of care to patients.

Tips for success

Improving cardiovascular care is on the agendas of all the new organisations being established in primary care. SUCCEED has shown that common standards can be agreed and implemented but those improvements have a price. People must be in place to co-ordinate the work, to provide necessary training and provide hands on help at practice level.

Specific points that merit attention are:

√ Don't expect everyone to be enthusiastic. Maintain a regular flow of information about progress to all those involved. Avoid the question: 'Is that project still going?'
√ Finds ways to present the impact of the work on GPs and practices. How many of their patients are likely to be involved? What does it mean for them?
√ Explore funding opportunities with pharmaceutical companies who may be willing to fund work in ways acceptable to clinicians.
√ Create realistic expectations of practices and do the homework. Which office procedures and systems do they use? Do they have the staff time to get involved?
√ Get hospital staff involved in the work from the beginning. Use of a patient held record used in primary and secondary care might help.
√ Don't let continuing staff turnover undermine your efforts. Create a training package to help ensure new staff adopt the approach you have striven to introduce.
√ Explore ways to talk through your plans with patients. They may have helpful ideas about how to get the messages over.

For more information about SUCCEED contact

Dr Graham Archard
Willowmarsh, St Catherone's Hill Lane
Dorset BH23 2NL

Telephone 01202 470318 Fax 01202 490718

The following material is available:

• SUCCEED project report
• Cardiac Care Pathway with recommendations on data collection.
• Patient record card
• Calculations of projected outcome from the SUCCEED project from NNTs.

ImpAct bottom line

External funding can strengthen the identity of and assure independence for project work


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