Audit and Practice Survey Posters 200 – 206
200 An audit of the quality of care indicators for the management of Diabetes in Family Medicine clinics in King Abdul-Aziz National Guard Hospital
Al Ahsa-KSA Yasser
Introduction Epidemiological data shows the current disease rate of Type 2 diabetes pose an on-going menace to global health security. In spite of advances in clinical advancements to manage several types of type 2 diabetic patients, still huge segment of the patients have suboptimal glycaemic control.
Aim To assess the quality of diabetes care provided by family medicine clinics at King Abdulaziz Hospital, NGHA, Al Ahsa, KSA through a medical audit MethodsA clinical audit was conducted at family medicine clinics, between January and December of 2015. The indicators and criteria of quality care were based on the international clinical practice guidelines for type 2 DM.
Results A total Sample of 3372 patients. Based on the inclusion criteria of the audit only 1272 patients with type 2 diabetes mellitus were selected and analysed. According to the results, 93% of the patients had glycosylated haemoglobin (HbA1c) done every 3 months, 49.8% had HbA1c values less than 7.5%, 67.8% had blood pressure controlled at 140/80mm Hg and below and 76.3% had total cholesterol values of 5.0mmol/L or less. Additionally 50.6% with microalbuminuria treated by ACE-I or ARB.
Conclusion The outcome of result generated found suboptimal diabetic care. This audit identified a gap between guidelines and clinical diabetic management and emphasized the feasibility of improving the current clinical practice. To improve quality of diabetic care certain measures should be implemented as: further audits and research, formulating and using protocols for diabetes management, continuing education and better training of health-care providers.
201 Use of Ambulatory Blood Pressure Monitoring in diagnosis of systemic hypertension: an audit of clinical practice at a primary care unit
Background Hypertension is the most common preventable cause of premature death in the UK and an important risk factor for cardiovascular disease. National guidelines recommend Ambulatory Blood Pressure Monitoring (ABPM) to help establish an early and accurate diagnosis.
Aims An audit to assess clinicians’ adherence to guidelines from National Institute of Clinical Excellence (NICE) with regards to requesting ABPM. Methods From August 2014-July 2015, 25 newly diagnosed hypertensive patients were randomly selected using ‘SystemOne’ patient database. Casenotes were reviewed and analysed using SPSS Version 22.
Results ABPM was offered to 22 patients (88%) in a median of 20 days (range 8-203 days) with 14 patients (64%) receiving within 1 month. Three patients (14%) had 2 consecutive Blood Pressure (BP) readings >140/90mmHg in one sitting prompting ABPM. Nine patients (41%) were offered ABPM after 1 reading >140/90mmHg. In 10 cases (45%) the clinicians repeated the BP on a second occasion (range 2-74 days) before organising ABPM.
Discussion Our audit suggests that most clinicians are requesting ABPM after only 1 elevated BP reading (without verifying the result) or they are prolonging the diagnosis by repeating the BP at a subsequent date before organising ABPM. This is not necessary as 2 elevated readings, taken bilaterally, during one consultation gives sufficient information to initiate ABPM. Delaying the treatment of hypertension is serious with each 2mmHg rise in systolic BP being associated with a 7% increase in mortality from ischaemic heart disease. Therefore the importance of arranging ABPM in a timely manner should be emphasised.
202 Audit of two week wait referrals conversion rate in a busy GP surgery
Aims/Objectives To evaluate the two week wait referral conversion rate in a busy GP surgery to assess the appropriate utilisation of this pathway. Content of Presentation: 50 Patients were selected over a 2 month period, Retrospective case notes were analysed from EMIS computer systems. Analysis of cancer diagnosis was done and conversion rates calculated i.e number of new cancer cases treated who were referred in through the two week wait route divided by the total number of two week wait referrals. National average conversion rates are 8-14%. Figures above and below this will indicate under or over utilisation of this pathway.Relevance/Impact: 1 in 3 of us will get cancer at some point in our lives and 1 in 4 of us will die because of cancer.
Outcomes for cancer patients in UK are not as good as in other European and North American countries. Some studies have suggested that poorer outcomes are related to late diagnosis. According to one estimate nearly 7500 to 10,000 lives are lost each year due to late diagnosis. Appropriate use of GP referrals will help to improve these figures.
Discussion The findings of this audit suggest that in specialities like breast, head and neck and upper GI, conversion rate is less than national average. However in other specialities like Lower GI, Urology, Gynaecology, conversion rate is higher than national average. A re-audit with a larger sample size is recommended to help identify areas for improvement.
203 Barriers to GP Identification of Perinatal Mental Health problems
The negative impact of maternal mental health problems is particularly significant in the perinatal period (from conception until 1 year postnatal). Research shows that perinatal mental health problems are underreported and underdiagnosed (20% women affected but only half of these detected). As well, only 50% cases are appropriately treated and the consequences of this are far reaching for the woman affected, her partner and their child.
Aim To improve GP detection perinatal mental health problems by suggesting the following audit standards for all women: documented antenatal mental health screening by GPs; documented postnatal mental health screening by GPs if medication prescribed; documented risk benefit discussion by GPs; documented evidence Multidisciplinary Team working if PnMH problem. The audit was conducted in a GP practice in Oxfordshire and a “perinatal register” was compiled of 187 women. 47 of these women had mental health code in their notes (17 active, 30 past) and were looked at in more detail.Antenatal Screening – excluding active diagnosis – 9/30 women Postnatal Screening – excluding antenatal or active diagnosis – 6/12 womenMedication – 8 women ( 5 citalopram, 2 sertraline, 1 methadone) – 4 documented discussion MDT working – rarely referenced, few entries from Midwives. Discussed in practice meeting – antenatal template added to computer system, lunchtime education session for all doctors, sharing education resources between members in practice. This audit will be repeated 3months after this round, due in April 2016 and evidence of positive impact and change in behaviour is anticipated.
204 Musculoskeletal ultrasound scan requests in primary care
Ultrasound scanning is a useful and essential imaging modality for soft tissue/joint related abnormalities when GPs are assessing the Musculoskeletal system. Musculoskeletal ultrasound is a practical, fast, inexpensive imaging technique, which many primary care physicians have open access to. There are limited guidelines available in literature regarding what information should be included in requests for MSK ultrasound scans.
The aim of this audit was to determine if MSK ultrasound scan requests made by GPs are sufficiently detailed and appropriate and suggest reccomendations to ensure appropriateness is improved. Audit standards were acquired from the Royal College of Radiologists with a target compliance of 100%. 49 patients data from General Practices were collected from CRIS software and requests were manually checked to determine whether appropriate or not. Overall, 47% of MSK ultrasound scan requests were appropriate based on clinical information included. Clinical history was the best indicator (90% of requests) and examination findings were included the least (75% of requests). MSK ultrasound was used as the wrong modality in 24% of cases.
There is significant room for improvement in ensuring MSK ultrasound scan referrals are appropriate and contain relevant, necessary information to prevent scans being rejected. This will ultimately ensure there is no delay in delivery of optimal patient care. Increased awareness in primary care through educational meetings and distribution of leaflets to practices containing essential criteria can improve this. Re-auditing in 6-12 months will show if changes make a difference and improve quality of GP referrals for MSK ultrasound.
205 Uptake of the 2015/16 seasonal influenza vaccination by diabetic patients: a primary care audit
Public Health England devised a national target to vaccinate 75% of diabetics over 6 months old against the 2015/16 seasonal influenza virus. A retrospective search, conducted using the EMIS healthcare database, determined if a single primary care centre achieved this goal between 1/09/2015 – 25/01/2016. Each diabetic patient’s electronic notes were analysed for data on age, gender, co-morbidities, glycaemic control, GP contact and previous vaccination status.
A standardised telephone survey was then conducted on 56 verbally consented unimmunised diabetics to evaluate the influence of patient perceptions on uptake. Vaccination rates were substandard as only 204 of 305 diabetics (66.9%) at the practice were immunised. Uptake was higher in males (53.4% versus 46.6% in females), patients aged ≥60 and those who were immunised in the 2014/15 season (87.7%).
Patients with concomitant chronic cardiovascular disease had superior uptake, along with patients who received greater GP contact (6-8 appointments) in the past year. The two predominant reasons for declining the vaccine were that patients lacked knowledge about it or perceived its benefits to be minimal. It is concluded that uptake of the seasonal influenza vaccination by diabetic patients in primary care is inadequate. Strategies must be implemented immediately to identify and promote vaccination in vulnerable diabetic patients prior to the upcoming influenza season. Improving immunisation rates will reduce influenza-related complications and hospital admissions, alleviating pressures on the NHS and its resources.
206 Audit to review the monitoring and duration of bisphosphonate therapy – how can we do it better?
Bisphosphonates are regularly prescribed in primary care, and though effective do carry a substantial side effect profile. For this reason they require annual blood test monitoring, and consideration for a medication holiday should be given at five years.This audit looks at current clinical guidelines for management of osteoporosis, and aims to review our current practice for monitoring of patients taking bisphosphonates.
The objective is to identify where the pitfalls in surveillance of bisphosphonate therapy lie, to make improvements to our clinical practice, and disseminate this information to other primary care providers for educational purposes.All patients taking bisphosphonates who were managed by primary care in this practice were identified, giving a cohort of 71 patients. The initial outcomes showed that of these, 69% were due updated blood test monitoring, including renal function, bone profile and CTX.
Of the total, 19.7% required review for a medication holiday. With strategic interventions, the number of patients who required blood tests fell to below 20%, whilst the number requiring review fell to 12% over a three month period. Discussion with staff revealed that there was some lack of clarity around monitoring, in particular interpretation of CTX levels, and some uncertainty around discontinuing bisphosphonate therapy thus identifying areas for further learning.
Furthermore discussions with patients highlighted the need for patient information leaflets about bisphosphonates to encourage them to engage in the monitoring and review process. The outcomes here identify areas for improvement in patient care which can be applied widely in most general practice settings.