Cardiovascular risk in high secure environments

1. Cardiovascular risk in high secure environments Professor Julia Hippisley-Cox University of Nottingham

2. Acknowldegments • West London Mental Health Trust • Clinical staff at three hospitals • R&D and MREC • EMIS • TPP • Vision • QResearch

3. Objectives • Compare CVD risk factor recording and CVD risk in SEMI patients in each of the 3 hospitals with SEMI patients in QResearch

4. Background • NICE PH15 - identify & reduce risk premature mortality • NICE CG68 - identify & reduce CVD risk • DRC enquiry -poor physical health of patients with SEMI

5. Key findings DRC report: Community patients with SEMI • Higher risk of CHD • Higher levels risk factors • smoking • obesity • diabetes • Less likely to be offered interventions • Less likely to report symptoms • Less likely to take prescribed medicines • Less likely to reach targets for lipids

6. NICE guidelines (2008, CG67) • Lipid modification guidelines • Identify patients at increased CVD risk • Quantify increased risk using QRISK2 or similar • Modify risk factors • weight loss • Blood pressure control • Lipid control • Smoking cessation

7. New study 2012 • Comparison of CVD Risk in four groups with SEMI • Broadmoor hospital - EMIS • Rampton hospital • Ashworth hospital • QResearch – community sample • R&D and MREC approval • Extraction of pseudoymised patient level data

8. Data items collected

9. Used www.qrisk.orgto assess CVD risk

10. Recording of family history lower in hospital Hospital A 9% Hospital B 3% Hospital C 4% QResearch 14%

11. Variation in recording of ethnicity Large variation Hospital A 48% Hospital B 0% Hospital C 97% QResearch 84%

12. Recording of body mass index Generally higher and more recent in hospital patients

13. Obesity levels very high Over half all hospital patients obese c.f. 29% in QResearch

14. Type 2 Diabetes also very high One in 5 hospital patients have diabetes Twice as high as community 5 times as high as non-SEMI

15. Diabetes by age Marked risk with increasing age – 29% patients over 50 have diabetes

16. Fasting blood glucose testing Huge variation in FBS testing but doesn’t explain high prevalence of diabetes in all hospital settings

17. SBP control < 150/90 Overall most patients meeting BP targets

18. Cholesterol < 5 mmol/l Overall many patients meeting cholesterol targets Better than QResearch

19. Recording 7 QOF SEMI register Patients with QOF code for SEMI have higher risk factor recording rates e.g. 87% with QOF code have glucose recorded cf 37% without QOF code

20. CVD risk results Hospital patients more than twice as likely to have high CVD risk compared with community patients

21. Summary: hospital vs community • Some good examples of recording • Some variation between the three hospital • Twice the CVD risk c.f. general population • More than half have obesity • One in five have diabetes • Diabetes twice as high as SEMI in community • Diabetes five times as high as general population

22. Summary recommendations Recommendation 1: • urgent need to commission services for weight loss including diet, exercise & medication review Recomendation 2: • Interventions to lower diabetes risk Recommendation 3: • Use of QOF SEMI codes to identify patients and make use of computer QOF audit facilities

23. Recommendation4 • Hospitals to use GP computer system for prescribing • Identify patients on medication for monitoring (eg lithium) • Identify patients not on medication who need it (eg statins) • use of inbuilt safety alerts in computer systems eg for drug interactions • Data for research into medication effects

24. Recommendations 5-8 • Use of computer templates to improve recording of family history • All patients to have ethnicity recorded • Update records for smoking status • Identify patients with high glucose values but without diagnosis of diabetes recorded

25. Thank you for listening • Report published at www.qresearch.org • Any questions