Name
Date of Completion
of Audit
Peer review
feedback available / Yes No
Completion of sections 1 – 5 would indicate a ’5 criterion audit’.
A completed audit cycle would be indicated if sections 1 – 8 had been attempted.
As a Prescribing Support Pharmacist and during my ‘Period of Learning in Practice’ for the XXXPharmacist Independent Prescribing Course, I spent time with the Practice Health Care Assistant observing the Healthy Heart Clinic and the Nurse Practitioner (NP) Prescriber undertaking patient consultations. During this process I noticed that due to practice systems of checking cholesterol levels for all patients on statins and subsequent review of these results, some primary prevention patients were subsequently prescribed an increased statin potency where a Total Cholesterol (TC) of 5 mmol/L or less was not achieved. The NP mentioned she had already been discussing the need to change the practice system for checking cholesterol levels of patients prescribed statins for primary prevention of CVD with the General Practice Partners.
The local Formulary advises that, for primary prevention patients prescribed a statin; simvastatin 40 mg daily should be prescribed first line, cholesterol should not be checked and a higher intensity statin should not be offered. There are no cholesterol targets for primary prevention of cardiovascular disease (CVD)due to a lack of trial data and simvastatin 40 mg daily is the standard treatment choice(NICE 2008and SIGN 2007).
Therefore patients may be at risk of increased side effects at greater expense without evidence based reason.
References
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE), 2008. Lipid modification, CG67. [online]. London: National Institute of Health and Clinical Excellence. Available from: [accessed 19/3/14].
SCOTTISH INTERCOLLEGIATE GUIDELINES NETWORK (SIGN), 2007. Risk estimation and the prevention of cardiovascular disease, 97. [online]. Edinburgh: Scottish Intercollegiate Guidelines Network. Available from: [accessed 19/3/14].
1. Reason for the AuditExplain why the audit topic was chosen and that as a result of this choice there is the potential for change to be introduced which is relevant to the practice or you as an individual practitioner.
2. Audit Criteria to be MeasuredCriteria are simple, logical statements used to describe a definable and measurable an item of health care eg. Patients with type II diabetes should have a fundoscopy every 12-months. See Audit Guidance for examples of criteria if greater understanding is required. Focusing on one or two criteria makes data collection more manageable and the introduction of small changes to practice less challenging. Where available, evidence should be cited in support of criteria eg. nGMS contract or a clinical guideline. A single criterion is acceptable for Appraisal purposes.
Number of patients prescribed a statin of greater potency than simvastatin 40 mg daily* for primary prevention of CVD**
*Statins of greater potency than simvastatin 40 mg daily = simvastatin 80 mg, atorvastatin greater than or equal to 30 mg, rosuvastatin greater than or equal to rosuvastatin 10 mg daily (Bandolier 2004).
**Excludes;
~patients with a diagnosis of familial hyperlipidaemia (if there was an entry in the patients records to the effect that the patient had a bad family history or family history of hypercholesterolaemia and a baseline TC > 8 mmol/L(as per local formulary) then the patient was classed as having familial hypercholesterolaemia for the purposes of this project.
~ established cardiovascular disease or diabetes (as per local formulary)
References
BANDOLIER, 2004. Cholesterol lowering with statins. [online]. Oxford. Available from: 12/11/13].
3. Standards Set0% patients prescribed a statin of greater potency than simvastatin 40 mg daily* for primary prevention of CVD** at 12 months.
*Statins of greater potency than simvastatin 40 mg daily = simvastatin 80 mg, atorvastatin greater than or equal to 30 mg, rosuvastatin greater than or equal to 10 mg daily (Bandolier 2004).
**Excludes;
~patients with a diagnosis of familial hyperlipidaemia (if there was an entry in the patients records to the effect that the patient had a bad family history or family history of hypercholesterolaemia and a baseline TC > 8mmol/L (as per local formulary) then the patient was classed as having familial hypercholesterolaemia for the purposes of this project.
~ established cardiovascular disease or diabetes (as per local formulary).
References
BANDOLIER, 2004. Cholesterol lowering with statins. [online]. Oxford. Available from: 12/11/13].
An audit standard describes the level of care to be achieved for any particular criterion eg.90% of Patients with type II diabetes should have a fundoscopy every 12-months. Standard levels may be influenced by the target levels contained in the nGMS contract or by discussing and agreeing the desired or ideal level of care with colleagues. State how long you estimate it will take you to reach your chosen standard(s) eg. 3 months.
4. Preparation and PlanningAt the outset the audit was discussed with the Prescribing Support Pharmacist (PSP) and Nurse Practitioner (NP), including the data to be collected and the exclusions.
The PSP also checked with the Practice Manager and Administrative Staff to check there were no ‘targets’ e.g. QOF which warranted lipid levels to be checked annually for primary prevention patients.
PSP ran a Vision search to identify all patients with an active repeat prescription for a statin of greater potency than simvastatin 40 mg daily*.
The list was reviewed by the PSP to determine which patients were prescribed a statin of greater potency than simvastatin 40 mg daily for primary prevention.
After discussion of the findings with the NP, a summary of the data was disseminated by the PSPto all prescribers and the practice manager in the practice for discussion at the next Practice Prescribing Support Meeting in April 2014.
*Statins of greater potency than simvastatin 40 mg daily = simvastatin 80 mg, atorvastatin greater than or equal to 30 mg, rosuvastatin greater than or equal to 10 mg daily (Bandolier 2004).
References
BANDOLIER, 2004. Cholesterol lowering with statins. [online]. Oxford. Available from: 19/3/14].
Explain briefly who was involved in discussing and planning the audit, how the data were identified, collected, analysed, and disseminated and who gave you assistance at any stage of the project, eg. with a literature review or with collecting or analysing data if this was required.Teamwork is essential to audit and evidence of this should be provided in the report.
5. Data Collection 164 patients had a repeat prescription for a statin of greater potency than simvastatin 40 mg daily*. Of the 64, 7 (11%) patients were prescribed a statin of greater potency than simvastatin 40 mg daily* for primary prevention of CVD** This does not meet the target of zero (0%) patients.
The PSP advised all prescribers in the practice of the details of the 11 primary prevention patients prescribed a statin of greater potency than simvastatin 40 mg daily* for primary prevention of CVD.
*Statins of greater potency than simvastatin 40 mg daily = simvastatin 80 mg, atorvastatin greater than or equal to 30 mg, rosuvastatin greater than or equal to 10 mg daily (Bandolier 2004).
**Excludes;
~patients with a diagnosis of familial hyperlipidaemia (if there was an entry in the patients records to the effect that the patient had a bad family history or family history of hypercholesterolaemia and a baseline TC > 8mmol/L (as per local formulary) then the patient was classed as having familial hypercholesterolaemia for the purposes of this project.
~ established cardiovascular disease or diabetes (as per local formulary).
References
BANDOLIER, 2004. Cholesterol lowering with statins. [online]. Oxford. Available from: 19/3/14].
Initial data collected should be presented using simple descriptive statistics as part of the text, in table format or using graphs (bar charts, pie charts etc.) Remember to quote actual numbers (n) as well as the percentage (%). There is no need to quote irrelevant data (eg. age, gender, or past medical history) if it bears no relation to your chosen audit criteria. Compare and contrast your initial data with the standard(s) you set.
6. Reason for the AuditThe outcome of the audit was discussed at the Practice Prescribing Support Meeting (23rdApril 2014) and the following actions were agreed;
As new dyslipidaemia NICE guidelines are due out in July 2014 and the consultation period is ongoing with possible changes to the guidelines for when to treat for primary prevention and what to prescribe, it was agreed to await these and the subsequent NHSX response before making changes to current practice policy and individual patient’s treatment.
Meantime, the individual patient cases were reviewed and discussed by all prescribers in conjunction with the PSP, and prescribers will consider the audit results and current systems in place for measurement of lipids.
The essence of audit is to change practice in order to improve patient care and services. This section should adequately describe any change(s) that was discussed, agreed and introduced by you. The role of others in this process should also be described. An example of the change introduced should be attached in evidence as an appendix to the report, where this is possible eg. a new or amended protocol or flow chart, or a letter that is sent to a group of patients inviting them in for a review.
7. DATA COLLECTION 2To follow 1 year from agreed practice changes/ individual patient reviews ~July 2015.
Presentation of data should be as Data One. In this section, compare and contrast the results of the second data collection with data collection one and the standard(s) you originally set. Has your standard been met or surpassed? If not, comment on why you think that is the case.
8. ConclusionsThe final section should briefly and simply summarise what the audit achieved, and what were the main learning points gained from this exercise. In doing this, the benefits achieved through the audit should be discussed along with any problems encountered with the process or findings. Some thought should also be given as to whether the audit will be repeated in future and if so when.
The audit identified that there is a small proportion of patients (11%) prescribed a statin of greater potency than simvastatin 40 mg daily for primary prevention against evidence based local and national guidelines. Prescribers considered these results carefully, and it clarified whether the suspected problem was in fact a real one and to what extent.
It was agreed (following a discussion with prescribers and the PSP) to delay discussing/ changing relevant practice processes and individual patient treatment until the updated NICE dyslipidaemia guideline due out in July 2014 (with a suggested higher potency of statin for primary prevention) and NHS board response to this are available. Around one year after practice changes are agreed and implemented the audit will be repeated, although criteria may need to change depending on the new guidelines.