Strengths and limitations of the study
This study represents a repeat measure of routine clinical care in a large cohort of practices, with a substantial group of patients. The data are not individually matched and therefore the two cohorts and the composition of the groups will differ to an extent between the two time periods, through new diagnoses, deaths and changes in registration. The patients of these and similar practices have been shown to be representative of the patients in the Trent region, but these practices may be unusual in their response to this National Service Framework. The recruitment and undertaking of this research has been ‘low key’, but a surveillance bias cannot be totally excluded. We were surprised by the reduction in the proportion of patients identified as smokers, but acknowledge that the data in this study reflect self-reported measures.
Implications for general practice
We previously reported on the substantial workload facing general practice in meeting the expectations of the National Service Framework for Coronary Heart Disease.6 This study broadens the baseline by including those over 74 years, primary as well as secondary prevention, and compares changes in annual recording rates. It also reports on progress towards delivering the National Service Framework in the first year.
Given the magnitude of the task, we might have expected one of two undesirable outcomes: the size of the effort required might have demotivated general practices with no or negative progress, or the number of other demands on primary care might have meant slow but unexceptional progress. However, these data demonstrate that there has been a substantial improvement in activity and clinical control. There are a number of possible reasons why this initiative has worked while many other health service interventions have failed. Firstly, it could be due to the increasing weight of evidence showing health gains from statins. Secondly, there have been many years of research underpinning this National Service Framework and, finally, financial rewards were likely to be attached to achieving targets. This possibility has now become a reality with the new General Medical Services contract for GPs.
These practices differentially targeted their efforts on secondary prevention (group A), but also showed substantial increases in recording activity for both people at high risk (group B) and the general population (group C). While group A still need further targeting with serum cholesterol estimations, the 69% relative increase in recording of cholesterol levels in the previous year shows the progress that is being made. This offers clear evidence that primary care health professionals are identifying those patients at highest risk and are differentially targeting their efforts on them.
Most importantly, there have been substantial improvements in disease management during the year, particularly for those with CHD. There has been an increase in the proportion of patients on lipid lowering drugs, from 30.7% to 40.4%; a decrease in current smokers from 18.0% to 13.8%; and an increase in the percentage of patients with excellent blood pressure control (140/85 mmHg). These achievements are all substantial in themselves; taken together they represent an outstanding shift in the quality of care, and if the predictions from the evidence are correct, of lives saved.
Even in the general population, the reduction in coronary risks in this large cohort of almost 50 000 people who do not have hypertension, diabetes or established cardiovascular disease, and the reduction in smoking and blood pressure is gratifying. It is somewhat counterbalanced by the increasing obesity of the population, a trend that general practice is relatively powerless to influence. The fact that a quarter of this low-risk cohort is recorded as taking aspirin, either on prescription or over-the-counter, is surprising and interesting. It may reflect a growing awareness of cardiovascular risk and its prevention.
When an intervention first occurs, it is likely to increase inequalities.7 Those who need the intervention least often take it up first, with those at greatest risk being late in adopting the change. The data presented here bear this out for CHD in one dimension of inequality. We have shown that older people are disadvantaged in terms of coronary risks recorded and clinical management achieved, and that the care divide between older and younger patients is widening for blood pressure control. Primary care is concentrating on patients aged 35 to 74 years, and achieving great success. As the National Service Framework is implemented, there needs to be an effort to strengthen the focus on the care of the older patient, especially those at high risk (in groups A and B) to ensure that the benefits of improved care are enjoyed by all. This is particularly pertinent now that the evidence base for the reduction in coronary risk for older people is more robust.5-18 Longitudinal studies are needed to determine the trend over time.
