Audit and Practice Survey Posters 248 – 255
248 Lipid modification in type 1 diabetic patients
Aim: To identify all T1DM patients registered at a GP surgery, and to analyse whether they are on adequate statin therapy.
Content of Presentation: NICE guidelines (August 2015) state patients diagnosed with T1DM for over 10 years or those who are over 40 years old should be on Atorvastatin 20mg or the equivalent. This audit looks at type 1 diabetic (T1DM) patients at the practise in two age categories of 20-39 years old (considered to have diabetes for >10 years) and above 40 years old, and whether they are on statins for primary prevention of cardiovascular disease (CVD).
Relevance/Impact: It is well known that diabetic patients are at increased risk of CVD and that primary prevention is a key factor to reduce the burden to the patient and the NHS. The CARDS study (Colhoun et al 2004) shows the positive impact that statins have in reducing the incidence of CVD.
Outcomes: Only 1 patient of 8 in the 20-39 age group and 52% of patients over 40 were on a statin. The average age for starting a statin was 50 years old. The type and dose of statin varied and with that only 55% of patients on a statin were on a correct dose. Of all the patients identified, 24% were on adequate statin therapy.
Discussion: More patients over the age of 40 are being put on statins and this is likely due to GPs thinking about primary prevention for CVD more as patients get older. In this practice more effort must be done to educate GPs and practice nurses on the new NICE guidelines to the increase the numbers of patients on statin therapy.
249 Shining a light on the primary /secondary care interface for people diagnosed with cancer following an emergency presentation (EP)
Aim: To identify and understand potential reasons for late diagnosis via emergency presentation and agree the necessary actions to strengthen and improve local health care systems and referral pathways.
Content of presentation: Key findings from an audit that collected qualitative data on patients who had presented as an emergency. This audit analysed over 160 GP and 35 secondary care Significant Event Audit templates and has provided good insight into the interface issues that can be improved.
Relevance/Impact: Between one four and one in five people in England are still being diagnosed with cancer via an emergency route. This audit’s findings provide an in-depth understanding into ways to improve this challenging part of the pathway. Outcomes: The underlying factors which led to why cancer was not diagnosed earlier could be grouped into three broad areas; tumour, person and /or system (including primary and secondary care). Within system factors the potential to change the route to diagnosis was considered and five themes were identified as being particularly relevant to improving the interface between primary and secondary care: tests and diagnostics, ownership of the patient, referral pathways, communication and having a holistic approach.
Discussion: Diagnosing cancer earlier is challenging for primary care. GPs need to be better supported by the health care system, specifically at the interface with secondary care. Although not all EPs can be prevented, reducing EPs has potential to improve survival.
250 Diagnosis of type two diabetes in those with a BMI over 40 in order to improve access to healthcare and bariatric surgery
Aim: To identify people with undiagnosed type 2 diabetes (T2DM) or pre-diabetes in order that they may benefit from improved care, including access to bariatric surgery. NICE guidelines CG43 lowers the BMI threshold for eligibility for those with Type 2 to 30 if recently diagnosed (35-40 if already diabetic), 40 otherwise. Under-diagnosis remains a problem.
Methods: A SystemOne search was run on all the patients with a BMI over 40, who had never had an HbA1c, of which there were 96. Letters were sent out inviting them to be tested. 23 booked in to have an HbA1c. Letters were re-sent (to those who did not respond) six months later, and the search was re-run.Results: 12 had normal HbA1cs. Eight were identified to have pre-diabetes. Two were newly diagnosed withT2DM. One already had T2DM, but no HbA1c at this practice. In addition to the letters being sent out, the practice agreed to increase opportunistic weighing, health advice and HbA1c testing to those at risk. Re-audit seven months later identified two more diabetics and two more pre-diabetics. One newly diagnosed diabetic was now pre-diabetic in the re-audit.
Conclusion: Under diagnosis of T2DM remains a problem, particularly amongst those with a BMI over 40. Diagnosis rates can improve when GPs engage patients in testing and data is up to date. By diagnosing T2DM, those individuals can potentially access weight loss surgery and other services. This audit recommends those with a BMI over 40 to be recalled annually for health education and screening, which this practice is implementing.
251 Procedural Pain from No-Scalpel Vasectomy in a Primary Care Practice
BackgroundVasectomy is a permanent, irreversible and popular form of contraception for men. The two most common surgical techniques are the scalpel method and the non-invasive technique of No-Scalpel Vasectomy. The No-Scalpel Vasectomy is an innovative technique with low rates of complications and adverse effects.
Aim The aim of this audit is to evaluate pain associated with No-Scalpel Vasectomy. By comparing the patients’ expectation of pain from the procedure to their actual experienced level of pain during the procedure and after the procedure is done.
Methods 184 underwent bilateral vasectomy, using the No-Scalpel principle and technique. Patients were given a questionnaire immediately after their appointment. Pain and satisfaction were evaluated using a 5-point scale; for pain, a score of 4 represented ‘excruciating pain’ and 0 was ‘No Pain’. The questionnaires were compiled and the data analysed with ExCel.
Results 66.9% of men expected their experience of pain to be ≥2; 13.1% anticipated excruciating pain. Intraoperatively, 56% only rated procedural pain as ≤1; 16.6% experienced no pain (score of 0). Postoperatively, 89.7% scored ≤ 1 in pain; 59.4% selected a score of 0.
Conclusion Overall the audit indicated that the No-Scalpel vasectomy is a safe and the acceptable approach to achieving permanent contraception for men, with lower levels of pain than would be expected. The overwhelmingly positive results from the practice would facilitate counselling processes, in order to allay any fears patients may have about the procedure.
252 Statin prescribing in patients with chronic kidney disease
Aaisha Farida Akhter
The aim of this audit was to identify if patients with chronic kidney disease (CKD) had been started on a statin for prevention of cardiovascular disease (CVD) as recommended by NICE guidelines. If statins weren’t tolerated, ezetimibe should of been considered as an alternative treatment in these patients especially if they had hypercholesterolemia. For this audit, CKD stage 3 and above patients who weren’t currently on a repeat prescription of statin were identified. From this search of 135 patients, a small cohort (n=30) were chosen randomly and the notes retrieved to determine if; a statin had been discussed and whether ezetimibe was offered to those in which statin was contraindicated in view of hypercholesterolemia. Overall it was found that only a small proportion of patients were on an acute statin prescription. Of the remaining CKD patients not on a statin (n=28), only half of these patients had been offered a statin by the GP during their consultation. The remaining 50% of CKD patients not currently on a statin had either refused to start statin after being provided with the information by the GP or were unable to tolerate the side effects. In patients who were unable to tolerate statins and with recent bloods showing hypercholesterolemia, ezetimibe had not been offered. The outcome of this audit enabled us to identify an area within the practice that could easily be improved. Firstly, it was important to distribute the audit to healthcare professionals at the practice so they were updated on current guidelines. A key point was to discuss options of CVD prevention with CKD patients during consultations and discuss statin use and consider ezetimibe if needed.
253 Preventing HIV drug interactions in primary care
Aims/Objectives This project aims to contribute to improved care for patients living with HIV. Specific objectives are to evaluate communication between primary and secondary care, and improve the safety of prescribing in the community, for patients taking antiretroviral therapy (ART).
Content of Presentation A clinical audit gives insight into information sharing between primary and secondary care, and drug interactions involving ART. Results will be discussed in light of current literature regarding the changing role of General Practice (GP) in UK HIV-care. Recommendations will provide innovative solutions to improve HIV-care in the community.
Relevance/Impact Historically HIV-care was separated from routine care for reasons of patient confidentiality. HIV-care continues to be provided by specialist centres taking responsibility for ART prescribing and monitoring. Successful ART means patients living with HIV may have other chronic diseases requiring management by their GP. GPs may not be aware of the ART medications their patients are taking thus exposing patients to risk of significant adverse events including ART failure.
Outcomes Audit outcomes are 1) rates of patients with accurate ART records available in GP, and 2) rates and severity of drug interactions involving ART in GP. Audit standards relate to the British HIV Association (BHIVA) Standards of Care.
Discussion Drug interaction prevalence and severity will be displayed using a traffic-light system, informed by reliable online-resources and a specialist HIV pharmacist. Adequacy of information sharing will be considered in relation to historical boundaries of HIV-care. Concepts of confidentiality and stigma will help understand current practice. Recommendations will provide innovative solutions to improve patient safety, opening channels between primary and secondary providers of HIV-care.
255 Recognising antibiotic resistance in urinary tract infections
Antibiotic resistance is a significant problem in primary care. Trafford is one of the highest prescribers of broad spectrum antibiotics across Manchester. The aim of this project was to audit the management of uncomplicated urinary tract infections (UTIs) in primary care. 195 patients treated in a six month period were analysed at St John’s Medical Centre, Altrincham. 31% (31/97) resistance to Trimethoprim and 14% (9/65) resistance to Nitrofurantoin was found when given first line. 34% (14/42) of second line prescriptions were Cefalexin, a broad spectrum antibiotic. This means that one in three patients given Trimethoprim required re-treatment. As a result there were increased financial costs to the NHS, additional appointments needed and a longer duration of symptoms for the patient. Trafford microbiology has identified a need to reduce Cefalexin prescriptions to combat antibiotic resistance, which were being prescribed second line to Trimethoprim. Therefore we recommended the use of Nitrofurantoin rather than Trimethoprim as first line treatment for uncomplicated UTIs in the Trafford area. Following our results, the Trafford Clinical Commissioning Group published a Prescribing Alert stating that; “Nitrofurantoin should be used first line for uncomplicated UTI in women unless contra-indicated” in order to reduce treatment failures and subsequent Cefalexin prescriptions.