Essex Cardiac and Stroke Network Primary Care Clinical Advisory Group Meeting Date: 28th March 2012 Venue: Sidney House, Hatfield Peverel MINUTES Present:
1. Apologies: 2. Minutes of last meeting:
AS noted a typo on 3.2 of the previous minutes, should read Familiar Hypercholesterolaemia 3.4 Mukesh mentioned the use of clopidogrel, the group agreed its use in TIA patients as had been agreed in our own guidelines. 2.1 Declaration of interests: MH stated he has received some funds from boehringer therefore declared an interest. No other declarations were declared. 3. Matters Arising 3.1 Lipid Lowering Therapy Guidelines
It was stated that Ezetimibe had not previously been included in the guidelines, it is not
mentioned in secondary prevention re NICE, there was some discussion. It was stated
that a small group of patients do not tolerate use of a statin however it was felt that other
drugs would be the preferred option. PI confirmed that the cardiac CAG did not support
the use of ezetimibe. The PC CAG agreed ezetimibe would not be included in the
PI raised issue of prescribing Atorvastatin limited to 12months, this had been raised at the
CCAG, the PC CAG agreed that patients would remain on Atorvastation for 12months
then reviewed and given an option of Simvastatin 40/Atorvastatin 40.
SW noted that Pfizer were trying to keep patent on atorvastatin and therefore the group
agreed that the guidelines will be reviewed further at the end of May 2012 before final sign
PI PC CAG Minutes 28th March 2012 Final Action: PC CAG to re review Lipid Lowering Guidelines at the next meeting 28th May
There was some discussion regarding the retesting of cholesterol, it was agreed that
discussions with the patient re lifestyle changes would indicate whether levels had
There is mention in the additional notes re FH with a reference to NICE guidelines. It was
asked to add a link to the Essex Cardiac and Stroke Network Website and reference to the leaflet produced re FH with the availability of distribution of the leaflet to patients. Action: PI to add link to ESCN Website for FH leaflet
AS stated the top box of the guidelines stated 3-6months should be given for lifestyle
changes before medical intervention is given, AS asked if this time period should be
quantified and gave an example of a patient with highrisk where lifestyle changes would
not impact on risk score. BH responded, GP would make a clinical judgment when seeing
the patient. The PC CAG agreed that patients with a higher risk but not higher cholesterol
would not benefit from statin use in particular older patients.
3.2 Heart Failure Audit Recommendations
The HF audit was tabled, BH explained there had been an additional review.
Recommendations from the review were to encourage primary care to maximise tolerated
doses of ACE and Beta Blockers, BH stated that feedback should be given to consortia
that up titration is necessary and should be encouraged to feedback to all their practices.
MR explained that SW had used a local LES to encourage up titration. MR also mentioned the provision of HF rehab, BH commented that ECS Network was working to get HF rehab consistently within all areas. The PC CAG strongly supported the Network and their efforts
It was confirmed that medically the treatment was not just for treatment of BP but also LV.
MH stated that work was being done in NE Essex as part of the QP pathway. BH asked
how the consortia were engaged, MH explained that information was given re admissions
avoided and cost savings. MH to share model across Essex.
Action: MH to share NE Essex QP pathway model.
MH explained an audit has been carried out and demonstrated that practices were not
good at getting patients on the right level of medication, these results were discussed with
practices and a way forward was agreed. Two meetings were held across NE Essex
(Colchester and Tendring) were all practices were asked to send a nurse practitioner and
a lead GP. Proff Mike Kirby and a practice nurse from Walton practice (Tracey Stevens)
gave presentations at the meetings as the Walton practice managed it HF patients well
and had a significantly above average prevalence.
It was agreed that information would be sent out to consortia explaining this is the model
of best practice, initially participating in an audit and identify where and what education is
Action: Network to circulate Best Practice recommendation
Equip are to re-audit NE Essex 2012/13 and would be able to demonstrate what progress
MH mentioned that patients read coded as LVSD did not automatically join the HF
register. JG to ask Jill Warn to investigate further.
Action: JW to investigate read code issue
PI to add issue to next agenda for further discussion. Action: PI to add to next agenda 4. Business Items 4.1 Health Checks
AS stated that SE Essex were within target by a very small margin, AS also stated that
targets were around the volume of checks delivered. The SHA had focussed on an
offered rate of 20% and the SHA has asked for a conversion rate of 75%. AS confirmed
that SE had a conversion rate of 47.5%, West 45%, Mid 40% and NE 117%.
PI PC CAG Minutes 28th March 2012 Final
It was agreed that outcomes need to be reviewed. NE Essex have audited outcomes and
results would be available from Equip wc 2/4/12, it was agreed that the audit would be
shared and decisions re further audits be made. Results to be discussed at the next
Action: PI to add NE Essex outcomes audit to May agenda 4.3 Progress with AF Management
KR mentioned that a GRASP-AF tool was being launched which will enable practices to
identify patients at high risk. The group had a brief discussion re QOF v GRASP. BH
stated that a LES would be useful in addition to QOF as a LES can stipulate a higher
percentage of patients to be identified.
MH mentioned the availability of 2% funding and suggested the PC CAG put a bid
together for some funding for AF identification. There was some discussion regarding
which would be the most effect way of commissioning a services and it was agreed that
pulse check incorporated within a Flu LES would be the most advantageous. MH noted
NE Essex had previously commissioned this LES at £2 per patient and the rate had
covered the costs incurred. The PC CAG asked PI to write the bid via the Network on
Action: PI/Network to complete 2% Transformation Bid 4.4 Medicines 4.4.1 Dabigatran
SW informed the group that SE Essex had decided that all prescribing would remain as
the current situation until a national event had taken place (30th April 2012). SW confirmed
that in SE Essex Dr Paul Gyler (clinical lead) would controlling initiation of the drug to
ensure there was pharmacy control and prescription were only for high risk patients. SW
Essex prescribing of the drug was controlled within haematology and prescribing occurred
within secondary care. SW confirmed that approximately 12 of the 68 practices in SE
Essex had prescribed the drug and the stroke physician felt it would be prescribed within
secondary care at a rate of approximately 1-2 patients per month.
MT stated that if prescription requests were non-valvular AF it was a reasonable approach
for the medicines management team to check and go back to the GP. MT confirmed
approximately 6 of the 44 practices in NE Essex had prescribed the drug and most of the
requests to prescribe were outside of NICE recommendations.
It was agreed that all primary and secondary care specialists should be encouraged to
attend the event on 30th April. MT confirmed that other drugs i.e. Ticagrelor would also be
discussed at the event. The PC CAG agreed that local guidelines should be re-
emphasised to CCGs. Attendees to the event on 30th April are to feedback at the next
Action: PI to add 30/4/12 event to May agenda
4.5 National Guidelines No new guidelines were reported. KS stated that alcohol questions would be incorporated within the Health Check LES from April 2012. 4.6 Update from each Sub-Economy It was stated that West Essex, PAH would like to follow CHUFT lead re ICDs. 5 Information Items: 5.1 Summary of HC Event 5.2 Horizon Scanning
MH raised issue re Stable Angina and whether it should be tabled at the PC CAG. MH felt
the issue had not been discussed enough and more involvement should be engaged with
the management of symptom control, not all patients were under the care of secondary
MH noted that NICE guidelines recommend up to two angina drugs being prescribed but
he did not know how the guidance was being implemented. It was agreed the NICE
guidelines would be tabled at the next meeting and discussed further.
Action: PI to Angina Nice Guidelines to be added to May agenda PI PC CAG Minutes 28th March 2012 Final
CCG groups were discussed, attempts are ongoing to encourage all CCG representatives
to attend the PC CAG. Regularity of meetings will be discussed at the May 2012 meeting. BH thanked MR on behalf of the PC CAG and ECSN for his work and wished him a happy retirement. Date of next meeting: Wednesday 30th May 2012.
Planned Primary Care CAG dates for 2012 30th May 26th September 25th July 28th November PI PC CAG Minutes 28th March 2012 Final
Prof. Robert F. Schmidt Ausgewählte Publikationen (ältere Arbeiten, bis einschließlich 1999) Schmidt, R.F. : Physiologie kompakt. 3. Auflage, Heidelberg: Springer, pp 1-347 Heppelmann, B., Pawlak, M., Schmidt, R.F: Projection areas of the posterior articular nerve in the rat cortex. Europ J Physiol Suppl 437: R131 Schmidt, R.F. : Neurophysiologie. In: Berlit, P. (Hrsg.) Klinische
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