1. Secondary Prevention of CHD in Primary Care. Nurse Led Clinics by Susan Neal Nurse Practitioner North Street Medical Care

2. Why Do It? u HIMP Targets around setting up CHD clinics u National Service Framework u Audit revealed care gaps

3. North Street Medical Care u 12,500 patients u Six partners. u Three practice nurses u One nurse practitioner u Paperless, fully computerised u Computer held CHD register of 418. u Opportunistic approach

4. Results u Performance in risk factor modification variable u Recording of advice given poor (except smoking) u Half on medication they should be u Cholesterol management fair, lipid prescribing low.

5. Evidence Base u HA Guidelines u Aspirin u Ace Inhibitors u Advice u Beta Blockers u Cholesterol u Risk Factors including Blood pressure

6. Evidence Base u Systematic, dedicated approach is beneficial (BMJ 1998, 316: 1434-7 Campbell et al, study of 1173 patients across 19 practices)

7. Systematic Approach u Aims of dedicated consultations u Support to patients u Identification of uncontrolled symptoms u Modification of risk factors

8. Organisation u Dedicated nurse time u Extended Model of Practice u Guided by evidence based protocol u Computer based call and recall u Clerical support

9. Outcomes u 82 consultations, 50% uptake u 10 patients prescribed/advised aspirin u 1 commenced beta blockers u 20 patients required cholesterol check u 9 subsequently required action u 24 required BP check u 14 subsequently required action

10. Case Study u 48 year old male u 1990 raised cholesterol u 1992 MI u 1992 2 vessel CABG u Dipyridamole u No surgery contact u 1998 called for check

11. u Risk factors identified u Symptom deterioration u No medication u Cholesterol 7.5 mmols/l u BP 140/100

12. Lessons from Experience u Key is organisation with evidence based, focused, approach. u Extended model of practice. u ? Concept of dedicated “clinic” u Patient response u Needs resourcing