Background
Heart failure clinical audit and patient reviews were identified as an area of opportunity by the NHS in East Riding of Yorkshire (formerly the Clinical Commissioning Group (CCG) area) in December 2021. Local winter access funding was available to all practices who registered for the opportunity.
To improve patient outcomes, the CCG identified the need to conduct a clinical audit and patient review to ensure that heart failure coding accuracy and management of patients with Heart Failure with Reduced Ejection Fraction (HFrEF) were optimised. The aim of the audit was to highlight the importance of diagnostic accuracy in primary care notes, reflect accurate prevalence data for practices, and improve the care and management of patients with HFrEF in the region.
Data revealed that there were more than 500 emergency admissions per year in the area with 20% of patients being admitted more than once during that period1 . The audit identified a need for better coding practices to support the recall of patients for reviews.
Practices that required additional support contracted with Oberoi Consulting.
Oberoi Consulting provided expert data stratification through the Oberoi Disease Management Digital Audit platform for Heart Failure and where required clinical resource – Oberoi heart failure nurse specialists (OHFNS) to validate the registers and optimise patients within the budget available.
How was the support delivered?
Following an introductory meeting with participating practices, clinical system resources were deployed to stratify patients, which included searches, pop-up alerts and an integrated review form.
The numeric data generated from the searches populated the practices’ baseline and re-audit reports and on-line dashboards, which were available on https://www.oberoi-dm.co.uk/.
This was key to stratify the patients to enable the OHFNS to prioritise their clinical time.
The OHFNS started with validating the existing HF registers in 9 practices. This process ensured those patients with an overarching heart failure diagnosis had an accurate sub category code (i.e., type of HF) in addition to the HF diagnostic code. Patients that did not have objective evidence of a HF diagnosis were flagged to the lead health care professional and removed from the register if appropriate. Where diagnoses were missed or additional sub category codes required, these were added to the patient’s record. In addition, those patients who had a sub category code (for example, HFrEF) who were not on the practice HF register were added where appropriate to the HF register. The second step of initial data validation ensured those codes ‘relating to heart failure’ were checked for missing cases and those found to have confirmed HF were added to the register.
The OHFNS then conducted clinical notes checks to ensure appropriate patients were recalled for virtual HF clinics to optimise as many patients on the four pillars of HFrEF management²
Early Impact Results:
Impact on Data Quality
619 records were reviewed during the data validation process, the impact of the code cleansing is detailed below.
HF Registers
For the 5 practices within Bridlington, the number of patients with heart failure coded increased from 762 (2.18% prevalence) to 833 (2.39% prevalence) which equates to an increase of 71 patients.
For the 4 practices within Harthill, the number of patients with heart failure coded increased from 267 (1.11% prevalence) to 332 (1.39% prevalence) which equates to an increase of 65 patients.
HFrEF
For the 5 practices within Bridlington, the number of patients coded with HFrEF increased from 491 (64.44% of the heart failure register) to 616 (73.95% of the heart failure register) which equates to an increase of 125 patients.
For the 4 practices within Harthill, the number of patients coded with HFrEF increased from 132 (49.44% of the heart failure register) to 226 (68.07% of the heart failure register) which equates to an increase of 94 patients.
HFpEF
For the 5 practices within Bridlington, the number of patients coded with HFpEF increased from 49 (6.43% of the heart failure register) to 124 (14.89% of the heart failure register) which equates to an increase of 75 patients.
For the 4 practices within Harthill, the number of patients coded with HFpEF increased from 15 (5.62% of the heart failure register) to 37 (11.14% of the heart failure register) which equates to an increase of 22 patients.
Virtual Clinics
215 digital clinical notes were reviewed and suitable patients were identified to attend a virtual clinic consultation with the OHFNS. In total 9 clinics were implemented with 129 patients being reviewed by the end of the project. Medication optimisation recommendations were discussed with the lead health care professional from each practice and changes made aimed at life prolonging therapies and improved symptom control and quality of life. Feedback from practices and patients was positive.
Across the 9 practices, the number of patients with HFrEF on all 4 pillars of treatment increased by 36 patients. In addition, the number of patients on triple therapy increased by 21 patients and a number of patients were started on an ACE/Beta Blockers, reducing the number of patients with HFrEF missing the 3 therapies by 19.
Conclusion:
The heart failure clinical audit and patient reviews conducted by Oberoi Consulting improved practice coding considerably and patient management by supporting the recall of patients for reviews and assessments. This case study demonstrates the value of clinical audits in improving patient care and outcomes and highlights the need for ongoing monitoring and review to ensure that improvements are sustained over time.
References
1) Local Business Intelligence Tool RAIDR
2) Straw et al (2021) Four pillars of heart failure: contemporary pharmacological therapy for heart failure with reduced ejection fraction. British Medical Journal. http://dx.doi.org/10.1136/openhrt2021-001585 (last accessed March 2023)