Audit and Practice Survey Posters 227 – 234
227 Investigating the management of non-responders to the NHS Cervical Screening Programme (NHSCSP)
Abdel Hakim Rezgui
Introduction: The NHS cervical screening Programme (NHSCSP) was implemented in 1988 by the Department of Health to detect potentially malignant cervical abnormalities. This has been successful in reducing the incidence, prevalence and mortality of cervical cancer. In England, the average uptake of screening is 72.6% so amongst the women eligible for screening exists a population of non-responders to the NHSCSP.
Aims To investigate the management of non-responders to the NHSCSP at a GP practice in Salford and the impact of letter reminders on screening uptake.The age, non-responder status; defaulter or non-defaulter, history of cervical abnormality, type of cervical abnormality were investigated.
Methods Data was collected using an EMIS search identifying 173 patients aged 25-69 years over a 6 month period.
Outcomes 100% of non-responders were issued a reminder letter by the practice. 79% of non-responders were aged between 25-49 years and 21% over 50 years. 53% of defaulters had a history of cervical abnormalities. The findings are consistent with reports that signify a trend between women under 30 and non-responders, with 47% response rate to letter reminders from the GP.
Conclusions/Discussion: We concluded that the practice is strictly adhering to guidelines regarding the issuing of letter reminders. However, 53% of defaulters had a history of cervical abnormality and a relationship exists between younger age and non-attendance to the NHSCSP. Upon recommendation, we agreed to review the letter format and to trial the modified reminder letters amongst the defaulter population.
228 An audit to explore whether investigations for renal impairment are being performed in hypertensive patients
This paper focuses on the detection of hypertensive renal damage in primary care. National Institute of Health and Care Excellence (NICE) guidelines recommend that all hypertensive patients be considered for investigations to assess renal function due to hypertension-associated renal disease.
An audit was performed at a Practice to find out how many hypertensive patients had investigations to detect renal damage. Using the NICE hypertension audit tool to devise our criteria, it was found that out of all patients placed on the hypertension register in the last 12 months, 86% had an initial estimated Glomerular Filtration Rate (eGFR) calculated of which 50% went on to have a repeat eGFR; 27% of patients had urine tested for the presence of protein and blood, and 20% had urine Albumin:Creatinine Ratio (ACR) estimated. Two patients were resultantly placed on the Chronic Kidney Disease (CKD) register though they may require further investigations. The effect of Angiotensin Converting Enzyme (ACE) inhibitor titration and co-morbid conditions such as diabetes were also observed in our results.
It is concluded that the Practice may benefit from working closer to NICE guidance, as this may provide a consistent method for measuring improvement over time. Specifically, more hypertensive patients may benefit from having ACR estimated or urine dipstick performed to detect the presence of protein and blood.
229 Audit of rheumatoid arthritis annual reviews including mood enquiry within a semi-rural GP practice
Dr Annabelle Machin
Aims/objectives To determine the proportion of patients with Rheumatoid Arthritis (RA) who have an annual review in primary care, what this consists of and whether the use of case-finding questions for anxiety and depression is documented.
Content of presentation Audit of all patients with RA at a small urban GP practice between April 2013-15, with re-audit April 2015-16. The proportion who had diet, exercise, alcohol, smoking, weight, pulse rate, blood pressure, FRAX, QRisk and mood assessments were recorded. Between April 2013-15, 95% of twenty eligible patients were reviewed annually. Mood was assessed in an average of 9% over the two years. Lifestyle and physical health reviews varied, with only 38% being advised about exercise and 60% alcohol and smoking. Following the initial audit, clinicians were encouraged to use an existing template and to assess mood. On re-audit between April 2015-16, most assessments including FRAX and QRisk improved. However, mood was only assessed in 10%.
Relevance/ ImpactRA is the commonest inflammatory arthritis and can be associated with co-morbid anxiety and depression, which impacts negatively on outcomes. QOF incentivises an annual review for patients with RA but doesn’t specify what this should entail. NICE (CG33) recommends that clinicians assess mood.
OutcomesApart from case-finding for mood disorders, all assessments improved following use of an RA annual review template.
Discussion Without adequate incentives for GPs, co-morbid mood problems could continue to be under-recognised and undertreated, potentially leading to worse mental and physical health outcomes for patients with RA.
230 Cervical Screening Rates: The Roma Slovak a new Migrant population
Cervical screening rates: The Roma Slovak a new migrant population
Aims. To asses smear uptake rates of new migrant populations in Sheffield. Background. Women from BME backgrounds are reportedly less likely to access the NHS cervical cancer screening programme. New waves of immigration from Eastern Europe are presenting challenges in engaging those women eligible to have smears. These countries may have neither an established screening programme, nor universal HPV vaccination programmes. The Roma constitute one of the largest minorities in Europe (est. 5-10 million), historically they have been marginalised, many have low educational status and high levels of unemployment and deprivation. Roma life expectancy is 10 years lower than other EU citizens. An estimated 197,705 Roma reside in the UK (25,451 in the Yorkshire and Humber Region).
Methods. 12 month retrospective smear uptake data analysis from 5 sentinal practices in areas of highest Roma population density. Data were compared with Sheffield CCG and individual practice smear rates.
Results. The combined average of Roma Slovak smear uptake was 53.1% compared to the combined practice average of 68.6% and CCG average of 73.5%
Conclusion. Pooled Roma Slovak smear rates were 20.4 % below the CCG average. It is an NHS priority to improve uptake of cancer screening and access to early treatment in socioeconomically deprived as well as BME groups in order to address inequalities in cancer survival. Further research is warranted to investigate Roma Slovak smear rates in a larger primary care population and qualitatively investigate the women’s views in order to develop an intervention to improve smear uptake.
231 That’s not my bag baby: an audit of GPs’ bag contents
AIM: To audit what medications and equipment were carried on home visits in order to identify gaps, encourage discussion on what should be carried, and create standards across the practice.
CONTENT OF PRESENTATION: Advice from the Care Quality Commission was used to compile a provisional list of ‘standards’. Some items were omitted if they were obsolete or did not apply to the practice being audited. All the doctors’ bags in the practice were searched with their permission and the contents checked against the lists. With only four doctors 100% compliance with standards was set as the goal.
RELEVANCE: Having adequate equipment in the bag on home visits is essential for effective diagnosis, decision-making and treatment on home visits by GPs. Differences are inevitable due to the local situation but there should be a minimum standard agreed for the practice, and such a standard should improve consistency of care for patients.
OUTCOMES: 24 out of 38 standards were fully met. Through presentation of the audit at a practice meeting, the necessity of some of the items was debated and recommendations were made. Some items were considered to be unnecessary by the team, for example a personal alarm or letter-headed paper. Some items no doctor carried and it was agreed that they should be, for example alcohol gel and a sharps box. It was agreed that doctors should perform regular checks especially for essential medications such as aspirin. The list was shortened to those felt necessary.
DISCUSSION: Agreement between staff the minimum required on home visits along with standardisation across the practice should be combined with a system for regular checking and restocking of bags.
232 Monitoring of Patients on 40mg Citalopram in Primary Care
Aims/Objectives To assess monitoring of patients on high dose (40mg) citalopram in one general practice. Content of Presentation26 patients on 40mg citalopram identified on EMIS®Web electronic patient records system. Patients who were pregnant, breastfeeding or had pre-existing cardiac disease or dyspepsia not included. Consultation and medication records reviewed to assess recording of side-effects and monitoring including ECG.
Relevance/Impact The prevalence of depression and prescriptions for anti-depressants are rising in the UK, thus monitoring and treating side-effects in patients on 40mg citalopram important.
Outcomes Patients split into two age groups: >45 years, n=15 and ≤45 years, n= 11). 40% of patients over 45 had gastric side-effects documented in comparison to none in patients under 45. 46.7% of patients above 45 were prescribed gastro-protection including all those who are prescribed regular oral NSAIDs and/or steroids. 56.3% and 27.3% patients above and under 45 years old, respectively, had documented evidence of an ECG.
Discussion Selective Serotonin Re-uptake Inhibitors (SSRIs) can cause side effects including gastrointestinal ulceration and bleeding. Citalopram at high dose (40mg) is associated with arrhythmias. NICE guidance suggests that patients at high risk of GI bleeding must be considered for gastro-protection, and older patients, those with heart disease and taking 40mg citalopram should have an ECG. We found that not all patients were receiving adequate gastro-protection or ECG monitoring. The audit was discussed within the practice, and all patients on 40mg citalopram will be invited to attend a review with their GP. The audit will be repeated in one year.
233 Prescribing at the mental-physical interface: An audit of treatment of depression in patients with chronic physical health problems
Introduction Depression is 2-3 times more common in patients with chronic physical health problems. Management of these patients often falls to primary care physicians and can be complex, with each condition potentially complicating the other, and an array of possible medication interactions. NICE Guideline 91 “Depression in adults with a chronic physical health problem: treatment and management” sets out standards for appropriate care of these patients.
Aims/Objectives To identify whether patients in a large suburban GP Practice who had a diagnosis of both depression and a chronic physical health problem were being managed in accordance with NICE. There was particular focus on prescribing of anti-depressant medications alongside anti-platelets, anti-coagulants and NSAIDs.
MethodsThe medical records and repeat prescriptions of all 382 patients who met the criteria for inclusion were studied. The findings were analysed and presented at a practice meeting, where quality improvement interventions were agreed for implementation. A subsequent re-audit was undertaken.
Results Of those patients who were prescribed medications for depression, SSRIs were often prescribed alongside medications which further increase bleeding risk, including aspirin or NSAIDs (55%), warfarin (62.5%) and heparin (100%). When SSRIs and NSAIDs or aspirin were co-prescribed, 22% were not on gastroprotective medications. Mirtazapine would have been an appropriate alternative drug choice, but it was prescribed in only a minority of cases. Adherence to NICE standards had improved at re-audit.
Discussion This work highlighted prescribing errors at the complex mental-physical interface. Educating and supporting prescribers proved paramount in improving adherence to NICE standards.
234 Are hypertensives managed appropriately? An audit within primary care assessing compliance to recent NICE clinical guidance (2011)
By 2025, global prevalence of hypertension is expected to exceed 1.5 billion. The primary care setting is crucial in both diagnosing and treating the majority of hypertensive patients. This study assessed a health centres application of ‘The National Institute for Health and Care Excellence (NICE)’ guidance regarding the management of primary hypertension. Our objectives were to determine whether this pro forma had been utilised correctly concerning (1) ambulatory blood pressure monitoring (ABPM), (2) initiation of first-line pharmaceutical agents, and (3) the Framingham cardiovascular risk assessment tool. All patients registered as having primary hypertension between the following dates, 31/5/13 to 31/5/14 were reviewed during this three week project. A total of 31 patients were identified of which 10 were excluded on the basis of incorrect coding.
Retrospective analysis of patient documentation found that 80.9% (17 out of 21) of individuals were appropriately diagnosed and staged following ABPM. Furthermore, identical results (80.9%) were obtained regarding correct administration of first-line antihypertensive agents (either calcium channel blockers or angiotensin-converting enzyme inhibitors) in respect to patient age and ethnicity. Lastly, cardiovascular risk assessment was applicable to 17 patients of which only 11 (64.7%) underwent evaluation. Therefore, this audit demonstrated varied implementation of the recent NICE clinical guidance. Moreover, particular issues were raised around patient coding, appraisal of knowledge and risk assessment usage, all of which were addressed through appropriate recommendations. Overall, this project emphasised the significance of primary care in initiating innovative strategies imperative to the diagnosis and treatment of hypertension.