General Practice Toolkit for more heart and diabetes checks and better help for smokers to quit

[Dr John McMenamin] We all know that cardiovascular disease, diabetes and smoking related illnesses are a huge health burden in New Zealand.

Too many people suffer from long term conditions and die prematurely because of them.

Although some are more predisposed than others because of their ethnicity, age or family history - these illnesses are largely preventable.    

Hi, I'm Dr. John McMenamin, I'm a GP in Whanganui and I'm the national champion for the better help for smokers to quit.

The more we can do to work with our patients at risk to help identify early health problems, the more likely they are to be able to live longer.

For the health targets, our goal is to offer 90% of our eligible patients, heart and diabetes checks and 90% of our smokers brief advice and support to quit.

[Dr Bryn Jones] All general practices in New Zealand are required to collect information about the heart health and smoking status of their patients and to participate in health target reporting.

Kia Ora,  I'm Dr. Bryn Jones. I'm a GP in Hawkes Bay and I'm also the health target champion for the more heart and diabetes checks.

The information that we collect is used in a variety of ways – including planning and funding, addressing inequalities and identifying areas in which we can work more effectively.

So that’s the big picture.

At a local level, doing more heart and diabetes checks and offering better help for smokers to quit is important for improving the health and wellbeing of our communities and encouraging people to manage their own health better.

Dr Bryn Jones: “Come on in Jim.”  

Patient (Jim): “Okay, thank you. Good morning.”  

This can feel like an obstacle to our day to day practice  but heart disease, diabetes and smoking are big problems that deserve our attention and effort. This really is an area where we can make a difference.

The good news is that there are some great IT tools available to make cardiovascular disease risk assessments and smoking cessation support much easier.

A lot of GPs and nurses are having great success with these tools – in particular the tools that remind them to ask eligible patients the right questions, that allow them to update patients’ notes quickly, and that encourage them to work with high risk patients to manage their own health better.

Many also use audit tools to identify those who are due for cardiovascular risk assessments or who should be contacted about their smoking status and offered help to quit if necessary.
    

[Dr John McMenamin] The Ministry of Health has developed a series of videos on heart and diabetes checks and better help for smokers to quit.
 

They include tips for the use of IT tools, and advice for practitioners on how to help people with heart and diabetes checks and better help for patients to quit smoking.

The focus of these videos is to help you minimise the administrative burden while maximising the clinical gain for our patients.

[Dr Bryn Jones] Cardiovascular disease is the leading cause of death in New Zealand and there are often very few warning signs before people have a heart attack or stroke.

But unlike many other long term conditions, we can predict who is most likely to develop cardiovascular disease or diabetes, and we can work with them to lower that risk.

This is particularly important for those who might not have any signs or symptoms but who are at risk of developing diabetes or cardiovascular disease in the future.

There are a number of factors which impact on a person’s risk of suffering some type of cardiovascular event.

These include age, gender, ethnicity, personal and family history, smoking status, blood pressure, pulse, waist circumference, BMI, cholesterol, and blood glucose levels.

The good news is that you are likely to already have a lot of useful patient information you can use for their cardiovascular disease risk assessments.

The more information that you have, the better - as some of these individual risk factors can increase a patient's cardiovascular risk by as much as 5%.

The essential indicators are blood pressure, blood lipid levels, blood glucose levels, and smoking status.

You can use blood pressure, serum cholesterol, and blood glucose results that have been recorded in the last five years if your patient's circumstances have not changed significantly.

If you need an up to date blood pressure measurement and the first one is elevated – for instance above 160/95 - take another and record the average of the two.

When you ask a patient to get a blood test request a non-fasting lipid profile. If their cholesterol is elevated above 8mmol/L they will need to repeat the test  and this can be fasting or non-fasting.

Many GPs and nurses say that getting patients to have a blood test is one of the most challenging aspects of getting a cardiovascular risk assessment completed  it's worthwhile to think about opportunistic  blood testing and offering  free heart and diabetes checks to patients.
 

Once you have all the information to complete the cardiovascular risk assessment, you can use either the New Zealand adapted Framingham Cardiovascular Risk Charts that are in the primary care handbook, or you can use a validated electronic cardiovascular risk assessment tool.

If you find a patient does have a higher chance of cardiovascular disease or diabetes, you can then take the necessary steps to help them improve their health.

This is where shared decision making comes in. The Ministry advocates a patient-centred approach to ensure patients make informed decisions about their treatment plans and have ownership of their own health.

Depending on a person’s risk level, a treatment plan might include medication, or lifestyle changes, such as improved diet or increased physical activity.

When it comes to developing a treatment plan, I try to encourage people to make a single change at a time and to opt for changes which will have the greatest impact - such as quitting smoking.

Although people with existing cardiovascular disease don’t need to have their risk calculated, it is still good practice to record their cardiovascular disease risk, which is 35%, in your patient management system. Also include recent blood pressure, blood lipid and blood glucose levels.

This way the information is accessible if you or your nursing team run heart health clinics, if you ever need to use GP2GP to transfer patient files, or when you are deciding treatment options with a patient.

[Dr John McMenamin] Smoking is the single largest cause of preventable death in the world.

The Million women study shows that on average smokers lose at least a decade of life.

It’s an addictive lifestyle choice that kills around 5,000 people in New Zealand every year and affects the quality of life of thousands more.

And although the benefits of quitting smoking are greatest at a young age, even people with advanced smoking-related diseases benefit by limiting further advancements of their disease.

The Million women study shows that stopping at any age is worthwhile - the sooner, the better.

We know most of the 450,000 people in New Zealand who smoke don’t actually want to. Nearly two thirds try to stop every year, and a third of smokers try more than once.

Knowing this, we should make it our business to know every patient’s smoking status. And to include this in every cardiovascular risk assessment that we do.

Offering patients  the chance to quit smoking can be life changing.

Of course it's not enough just to ask. We want to offer support to smokers to quit. We can refer, for example, to Quitline and other support services, and we can offer NRT and other medications.

If a patient takes you up on the offer to quit – well done, but remember that quitting smoking is hard and needs to be actively managed like any other long term condition.

[Dr John McMenamin] “Lilo, just before we finish up can I touch base with you about…”

I make it a priority to ask every patient of mine who smokes whether they are interested in becoming smoke free.

When someone says they are not interested, I say: “That’s fine. Let me keep the offer open and if you find you do become interested in quitting, let me know.”

[Dr John McMenamin] “This is not the time for you to be stopping?”

[Patient (Lilo)] “No.”  

[Dr John McMenamin] “Okay, I'll just make a note of that and maybe just touch base with you next time you're in about you're going, okay?”

When they say they have tried to quit but it didn’t work, I say: “That's okay lots of people try a few times before they are successful.”

When I have asked them about their quitting experience and they say:  “Well, I used the patches but it irritated my skin…”

Or they might say: “I tried the gum and I didn't like it…”  

Or perhaps: “It didn't work anyway…”

[Refer them to a quit coach]

[Rosie – Quit Coach] We believe with coaching and the use of NRT, we can get patients to quit.

Some of the things that come up quite regularly are that the patches itch. This is because the glue on the patches can cause some irritation.

It's good to advise your patients that wearing them on the trunk of the body - the thicker parts, even the butt, are better and irritate less. You can even wear them on your feet, especially if you are a sports person and they are likely to come off when you perspire.

It's advising as well that the patches are now for 24 hours, not the normal 16, and it's quite safe to sleep in them. If the person is a ‘first thing in the morning’ smoker, definitely recommend it.

Advise that these do cause vivid dreams but it's a myth that everybody gets nightmares.  

What we find most with the oral products is that people complain that they've had burps, wind, upset stomachs, hiccups, or a sore throat. This is often because they haven't been using the products properly.

Remember to advise them that you chew a couple of times and then park between the gum and the cheek and this is how the oral product is designed. Nicotine is not designed to go into the gut.

[Dr John McMenamin] Although I see most of my smoking patients at least once a year, I record all brief advice I give. I find using a prompting tool makes it quick and easy  alternatively, you can directly input  data into your patient management system.

You can access the smoking cessation READ codes either by right clicking your mouse after typing ‘smoke’ or bringing up a new classification tab, typing ‘smoke’ and hit enter.

If your patient management system allows you to refer patients to Quitline electronically – you’ll receive a receipt of the referral and be sent regular quit status updates if you want them.

By recording brief advice, we can better identify who haven’t we reached in our enrolled population. We can then use an audit tool to make a list of patients to contact.

I find using an audit tool and contacting my patients on that list by text gets great results.

This text was sent out recently and had a 37% response rate – that’s over a third of people who wanted help to quit smoking.

We also found another 20% had already quit and the general practice didn’t know. So, proactively offering support is a great way to update your records too.

People actually do expect us to talk with them about their smoking and are often disappointed if they are not advised about how to quit.

When a patient refuses an offer of support, make sure you record it in your patient management system so you know to follow up on it next time you see them.

Even if they decline your offer today, they might be ready to quit next time you ask.

[Patient (Lilo)] “Okay, that sounds great.”

[Dr Bryn Jones] The most effective way to identify the people at risk of heart disease and diabetes is to consistently and systematically assess eligible people and ask everyone about their smoking status during normal consultations.

Of course it’s important to concentrate on the reasons for their visit, but using the tools available and making the process attractive for patients there is a lot you can do.

Dr Bryn Jones: “So you can reduce your risk or heart attack or stroke by not smoking.”

People love stories they can relate to – they think ‘yes, that’s me’.

You might need to wait for results to come back to calculate cardiovascular risk. You can always discuss those results at a later consultation or by the phone to follow up.

At a minimum for eligible patients always record a person’s blood pressure, blood lipid levels, blood glucose levels and smoking status.

And always use the same READ codes, tabs and fields in your patient management system when you are inputting data.

If you’re unsure how to do this, discuss the options with your PHO or your IT vendor.

To make your life easier on a day to day basis, appointment scanners, prompting tools, PMS data entry short cuts, and the Heart Foundation Your Heart Forecast tool can be very helpful.

    
[Dr John McMenamin] A good way to remind yourself about who needs cardiovascular risk update or who might need advice about smoking is to review your appointment list each day.

Check if your patient management system has got an appointment scanner function that will allow you to bring up cardiovascular and smoking fields to help identify who needs risk assessment that day and who might benefit from smoking cessation support.

By running a scan you might, for instance, identify that 5 of the 30 patients you are due to see in a day have important information missing from their records that prevents you from assessing their cardiovascular risk - like a recent blood lipid or HBA1C test, an up to date blood pressure measurement, or smoking status.

By knowing the information gaps in advance, you can factor these into an appointment before a patient even enters your consultation room.

You can also set up an additional reminder for yourself in your waiting room pop up window just before an appointment.

My admin team do this function for me. They run the appointment scanner first thing in the morning, late morning, and early in the afternoon.     

[Dr Bryn Jones] A prompting tool is the most effective way to remind you to assess a patient’s cardiovascular and diabetes risk, and to input the relevant information into your patient management system.

I always have a prompting tool open alongside my patients’ clinical notes. If you need help to set this up if you ask your PHO or your IT vendor to help with this they'll be able to.

At the beginning of a consultation, check if your patient is eligible for a cardiovascular disease risk assessment and whether you have recorded their blood pressure, blood lipid and blood glucose results and a smoking status in the last 12 months.
 

If you have this information – you may need to just ask a few additional questions to be able to calculate their cardiovascular risk.

If not, it’s a great reminder to measure their blood pressure, ask them about their smoking status, and to print them a blood test lab form during the consultation.

It can take a bit of multi-tasking but it does become second nature.

Additional pop up boxes are also great for updating missing information quickly and should be designed to link directly to your patient management system.

Most prompting tools can be tailored to suit your needs - so talk with your colleagues about what you most want from a prompting tool and discuss it with your IT vendor or PHO to set it up for you.
    

[Dr John McMenamin] If you want to record data directly into your patient management system there are some wonderful shortcuts that you can use.

For instance, if you use a MedTech PMS, open the classifications tab select the right READ code to record someone’s smoking status for example, current smoker, never smoked,  or ex-smoker.

Another option is to start typing smoking or tobacco in the clinical notes field and then right click the partial word to bring up the right READ codes for you to select.

When it comes to recording smoking advice, select from a list of READ codes in the classifications tab
To add a patient’s blood pressure result use the screening tab.

You can also type the blood pressure result in the clinical notes field after \BP entry which will then directly transfer to the right field in your screening tab.

Use the history tab to update any medical history of relevance.

If a patient has a history of cardiovascular disease they won’t need a cardiovascular risk assessment.

Just type \cvr101 in the clinical notes field – which will directly transfer to the right field in your screening tab.

Alternatively, enter 35% as their risk percentage in screening every year when you review their treatment plan.

If there is a family history of heart disease record this in the history tab too.

And once you input blood lipid and HBA1C results that come back from the lab a patient’s cardiovascular risk percentage should be automatically updated in the screening tab.

If you want to do this manually, go to screening, select new entry and then select CVD risk as the screening code and add the percentage you have calculated in the box.

You can also type it in the clinical notes field after \cvr – which will directly transfer it to the right field in your screening tab.  

A diabetes diagnosis can be made if an asymptomatic patient has two results above the diagnostic cut-off – that’s:

HbA1c ≥50 mmol/mol                           
Fasting plasma glucose ≥7.0 mmol/L; or
Random plasma glucose ≥11.1 mmol/L

This information is summarised in the New Zealand Primary Care Handbook.

People with diabetes can usually be coded using either Diabetes type 1 Or Diabetes type 2.
    

[Dr Bryn Jones] If you calculate that someone has a 10 – 20% cardiovascular risk, then you or someone in your team will need to discuss this with the patient and consider lifestyle options and medications.

Make sure that the patient is well informed about their risk and promote their involvement in any decision making.

People with a risk of 20% or more will need to be prescribed medication.

This could be done in a follow up consultation or in a heart health clinic run by your practice.  

If you opt for a follow up consultation, the Heart Foundation’s ‘Your Heart Forecast’ tool is really helpful in explaining the results of the assessment to your patient.

Dr Bryn Jones: “What this says here is your heart age is 75.”

It is a visualisation tool that helps you communicate cardiovascular risk to your patients. It uses a dynamic graphical story showing their current and future cardiovascular disease risk and the benefits that lifestyle changes might have.

The trajectory of risk can be a real eye opener for patients.

And we know it can make a really big difference to patients when a health professional talks to them about their cardiovascular risk and what they can do to reduce their chances of having a future heart attack or stroke.

[Dr Keith Abbott] Kia Ora, I’m Dr Keith Abbott, GP advisor for the Southern PHO and a GP here in Dunedin.

Audit tools can help general practices improve care for patients and maximise funding.

They act as safety nets to find patients who have fallen through the gaps, taking away all that hard work to identify those who need seeing the most.

That’s because they automatically run queries and retrieve data from your practice management system for you.

If you want to identify eligible patients overdue for a cardiovascular risk assessment or with important data missing from their medical records, like smoking status, an audit tool is ideal.

You can then contact them via text, phone or mail and invite them to come in for a risk assessment or ask them whether or not they do smoke.

When choosing an audit tool, consider how user friendly you find it and whether it allows you to review previous audits to track progress.  

It’s also useful if the financial impact of missing information is shown. I find this a real motivator.

Southern PHO is currently sponsoring practices who wish to adopt Dr Info as part of a cardiovascular risk assessment project.

It allows practices who use the tool to monitor their progress in terms of eligible patients and  target achieved.

It can also run a range of queries to help practices with accurate coding, for example it can find patients who have been prescribed smoking cessation medication but have not had their smoking status recorded.

Practices can also monitor their performance against other practices using this audit tool.

Within the Bulk CVD tab, general practices identify eligible patients who have all the required data in their electronic health record to have their cardiovascular risk assessed.

With the click of a button they can generate a list of patients that can be virtually assessed for cardiovascular disease – this is known as a non face-to-face cardiovascular disease risk assessment.

The tool also auto-inserts the risk percentage into the right patient record in their patient management system.

As part of the project, Southern PHO is providing vouchers for general practices to send to patients who have been virtually assessed as having a risk above 10%. These vouchers offer free face to face assessment, covered by the PHO.

We are also encouraging practices to review the Clinical CVD tab to see which of their patients who have had a cardiovascular event have not had their blood pressure measured in the last 12 months.

These are people who need monitoring and should be recalled to discuss their treatment plans regularly.

We’ve had great success with Dr. Info in the past three months. Half of the practices in the Southern PHO have been using the tool. We've noticed a huge increase in the number of cardiovascular risk assessments being done, which must correlate to improved patient care.

[Barbara Homer] Hi, I’m Barbara Homer and I'm employed by the Southern PHO as a practice manager support person.

A common question I am asked by other practice managers is: “How can we fit in more heart and diabetes checks and help people to quit smoking in our everyday practice?”

The days are crammed full as they are. And the last thing anyone wants is more paper work or data entry.

Despite consistent time pressures, the general practices I work with do want to offer the best care for their patients and are generally happy to comply with the Ministry of Health’s reporting requirements – so long as they know how to take the hassle out of doing so.

The first thing I recommend is setting up your patient management system and IT tools to prioritise cardiovascular risk assessment and smoking quit support. Make it easy for your clinical staff to record the right information in the right places.

If you need extra support, ask your PHO or your IT vendor to help.  Check out what's on offer in the way of training and support from the Ministry of Health, Heart Foundation and organisations like Quitline.

[Dr Keith Abbott] “Just check your pulse if that's okay?”

Your clinical team, including locums, do need to play their part. Life is easier for everyone when they use the right READ codes and consistently and systematically record all their assessments. A practice IT user manual can be a great way to support them and promote consistency across the practice.

Some practices appoint their own health target champions. They keep the team focused, enthused and up to date with best practice approaches. It's a great way to keep heart and diabetes checks and help for smokers to quit on the agenda.

There are a few simple things your admin team can do as well. Like making sure all new patient enrolment forms include a smoking status question.

They can also help set expectations with patients by displaying posters, pamphlets and material about heart disease and smoking for patients to look at or take with them.

Perhaps your best kept secret though is your nursing staff. Make the most of their skills and make sure they receive the training and incentives they need.

General practice nurses with access to audit tools can undertake behind the scenes data clean ups, and use hospital discharge information to keep patient files up to date. They can also use audit tools to identify eligible patients due for a cardiovascular risk assessment or who smoke and are eligible for smoking quit support. Contacting people using a mix of letters, email, phone calls and text messages can work well.

Finally, many practices do well with nurse-led clinics. if the clinics are free to patients – even better. It's a constant challenge getting people to come in if they feel fit and healthy and removing the cost barrier will help.

It also helps if you’re flexible with appointments and take a patient-centred approach. This might include having free early morning appointments before work, and  running evening and weekend clinics. These are times when people are more likely to be willing and able to attend.

Some general practices like to invite eligible patients who have not been risk assessed to come in for a free appointment during Heart Week or offer  incentives like a free cookbook or chance to win supermarket or petrol vouchers to get them to the clinic.

Others advertise their clinics through practice newsletters or in local newspapers. Homemade posters in your reception area and on community notice boards are cost effective and work surprisingly well.