Implementing MICRO‐HOPE in primary care with extra nurse support

Abstract

An audit of work to implement the MICRO-HOPE study findings in a UK rural practice is presented. Seventy-three out of an eligible group of 142 who fitted the HOPE trial criteria were not taking an ACE inhibitor. Of these, 60 were invited to a special clinic session with a visiting nurse to provide an opportunity to offer ACE inhibitor treatment and follow-up. The average age of males (n=29) and females (n=31) was 70.7 (SD 9.9) and 70.1 (SD 8.9) respectively. The mean HbA 1c of the invited group was 7.64% (CI 7.33-7.95%) and mean blood pressure was 138/75mmHg .Thirty-five (58%) patients attended and 20 (33%) started taking ramipril as a result of the intervention. In the interim, three had been started on treatment by a hospital. At 12 weeks, 14 (23%) were still on treatment from the practice. Only two (10%) achieved the target dosage of 10mg ramipril daily. Six patients (30%) had side-effects and stopped ramipril treatment. The total cost of the intervention was £3200.The nurse-led intervention increased the appropriate ACE inhibitor usage among people with type 2 diabetes from 49% to 59% over three months. The proportion of patients on either an ACE inhibitors or angiotensin II-receptor antagonists rose from a baseline of 56% to 65% at six months.For a brief intervention, this was a worthwhile effect. This audit shows that increasing ACE inhibitor use is resource intensive but its small scale may exaggerate the effect size. Clarity is needed around the issue of any 'class effect' for ACE inhibitors and how patients will cope with the increasing burden of medication. the patients again for repeat blood pressure measurement, electrolyte monitoring and dose titration. The doctor saw the patients at weeks two and three for dose titration and the nurse reviewed patients at week four for an electrolyte check and any further adjustments. The outcomes of interest were the additional number of patients successfully commenced on ramipril following practice intervention and the number achieving the target dosage of 10mg daily at three months. To asses whether the effect was sustained, the proportion of patients treated with either an ACE inhibitor or an angiotensin IIreceptor antagonist was compared at baseline and at six months. ResultsThe baseline characteristics of the invited patients are shown in Table 1. Out of 60 people invited, 35 (58%) attended the clinic.Thirty-five (58%) patients did attend and 20 (33%) of those invited were started on ramipril, but only 14 (23%) were still taking it at the point of audit in the 12th week. Three patients had been started on ramipril by a hospital physician in the time between invitation and first appointment with the nurse. The recruitment, progress of the clinic and reasons for stopping the drug are shown in Figure 1.Twelve patients who attended the clinic decided, in consultation with the doctor or nurse, not to start the drug. Some patients have since revised their opinion but in most cases it was the physician and nurse who counselled the patient not to start ramip...