HEALTH TARGETS IN PRIMARY CARE MORE HEART AND DIABETES CHECKS BETTER HELP FOR SMOKERS TO QUIT Better Help for Smokers to Quit 90% of enrolled patients who smoke and are seen by General Practice, will be provided with advice and help to quit by July 2013. More Heart and Diabetes Checks 75% of the eligible population will have had their cardiovascular risk assessed in the last five years by July 2012. (90% by July 2014) 1
More Heart and Diabetes Checks 2
Health Target results 120% Health Targets Results over 2 years 100% Target range 80% 60% Shorter stays in emergency departments 40% Improved access to elective surgery Shorter waits for cancer treatment 20% 0% Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Increased Immunisation Better help for smokers to quit Better diabetes and cardiovascular services Q2 2010/11 Q3 2010/11 Q4 2010/11 Q1 2011/12 HEALTH TARGETS IN PRIMARY CARE 3
More Heart and Diabetes Checks Why? 4
Rates for Selected Causes 2009 Age standardised death rate per 100,000 Death Rates by Ethnicity Age Standardised Death Rates per 100,000 for Selected Causes 5
In a population of 10,000 primary care patients, every year there are about: 10 coronary & stroke deaths 1 diabetic death 1 breast cancer death 1 prostate cancer death 1 suicide every year 1 road traffic death (1 cervical cancer death every 5 years) NZHIS annual mortality statistics 6
Who has the highest risk? 45 yr old man BP 150/90 mmhg never smoker TC 6.0 mmol/l HDLC 1.2 mmol/l New diabetes 5 yr CVD risk 10% 56 yr old man BP 150/90 mmhg smoker TC 6.0 mmol/l HDLC 1.0 mmol/l No diabetes 5 yr CVD risk 25% Absolute risk of CVD over 5 years in patients by systolic BP + other risk factors 5 year CVD risk (percent) Reference category is a 50 year old nondiabetic, non-smoker female with total cholesterol 4 0 mmol/l and HDL 1 6 mmol/l. Risks are given for SBP levels of 110, 120, 130, 140, 150, 160, 170, and 180 mm Hg 12% 18% 24% 33% 44% <1% 3% 6% Reference TC Smoker HDL Male Diabetes 60 years 7mmol/L 1 mmol/l Jackson R. Lancet 2005;365:434 7
0 5 10 15 20 25 30 Clinically High Risk Adjusted CVD Risk Clinical CVD or High risk diabetes Some genetic lipid disorders Consider specialist referral Treatment Intensity Urgent + intense multifactor treatment Drug intervention directed at all risk factors General advice Lifestyle Specific advice Intensive change individual advice Drug interventions Healthy eating & physical activity CVD Risk goal Reduce risk Reduce 5-year CVD risk to < 15% Analogies What could happen if you do not wear a seat belt, observe the speed limit, or follow traffic lights, etc. It does not mean that they will die in a car crash. Similarly, wearing a seat belt, observing the speed limit, or complying with traffic lights does not mean that you won't. However, which group is more likely to crash? http://www.bmj.com/cgi/content/full/327/7417/749 The potential magnitude of the population evidence base One assessment per practitioner every other day for 46 weeks/year = 115 per year 1000 practitioners could assess more than 100,000 patients per year 8
Tobacco Health Target THE END GOAL Reduce the number of people who smoke Increase the quit rate Intermediate goal Increase the number of quit attempts Increase the likely success of quit attempts Getting Healthcare Professionals to systematically BY Trigger more quit attempts (via ABC) Recommend the use of effective treatment What is required? Encouraging uptake of ABC by HCPs Developing knowledge & clinical competencies to deliver ABC Systems to support ABC Encouraging demand for ABC by smokers 9
Cumulative chances of quitting over time when making one quit attempt per year with and without cessation treatment With medication and support With medication Without treatment Aveyard and West. Managing Smoking Cessation. BMJ 2007;335:37-41 Importance of brief advice Simply advising people to stop has an effect (increases quit rates by 1-3%) NNT = 40 Silagy C, Stead LF. Physician advice for smoking cessation. Cochrane Database Syst Rev 10
% patients making a quit attempt in 6 months following a GP visit Baseline % Patients making a quit attempt 40 35 30 25 20 15 10 5 0 20 No intervention 25 Brief advice to quit on medical grounds 35 Making an offer of treatment Aveyard et al (2011) Addiction Dec 16 Acceptance of smoking cessation treatment by readiness to quit 100 90 89 Total N=2168 80 % of smokers 70 60 50 40 30 20 10 11 52 27 24 37 % of total Accepted treatment Abstinent at end of treatment (17 weeks) 0 Ready to quit Not ready to quit Pisinger et al (2005) Preventive Medicine, 40: 278-284 11
What do patients and staff think? Quotes from Timaru hospital patients asked about their smoking status [Ken Bagnall, Timaru] "I wish they'd had this help before" (a chemo patient who doesn't feel able to quit now.) "At that price why wouldn't you try?" (a smoker on being informed about the availability of NRT and the $3 script available at discharge.) "I've quit... I think it's great you can get this help here." (an ex smoker) "No, it's a good thing... how can you be smoking if you're coming in here?" (a non smoker). Staff member Liked the fact that everyone was now being asked and that it was just a routine part of a patients care. It was clear what was expected of the nurse and what action to take. And patients were now getting used to the fact that they would be asked their smoking status so didn t take offence. What's working well Waikato practice audit by GP registrar 10% quit rate with advice/cessation 20% of those contacted by phone wanted to stop (now) An interesting problem encountered with phone calls were that some smokers took this as a targeted intervention rather than a survey, so asked for help with quitting smoking. I had the feeling that unless someone asked them they would not raise the subject with their regular doctor. The call would become a consult with advice given, referrals made and sometimes prescriptions made for pick-up. 12
Prompts and reminders Outreach letters/phone calls Secondary care information Walk in clinic Making recording easy recording enhances the delivery of effective tobacco cessation Cochrane review 2011 Referral pathway available 13
http://www.knowyournumbers.co.nz/ Common messages We educate the whole family that encourages them to quit too We view asking about smoking as important as taking your blood pressure We provide patients information on smoking addiction and NRT 14