Title: Improving the quality of care of patients with angina and heart attack
Funder: Department of Health (England)

Abstract: BACKGROUND Unacceptable variations in care for patients with coronary disease are ubiquitous, but we do not have prospective large scale outcomes research linking general practice, specialist clinic, and in-patient hospital care. In order to evaluate explanations for these variations and test new interventions which are actionable in the NHS, we propose unique new observational research and a major randomised trial. AIM To evaluate important new opportunities for improving quality of care and outcomes for patients with chronic stable angina and acute coronary syndromes (ACS), integrated across the patient journey, and at different levels of care (summarised in Figure 1) OBJECTIVES (i) To determine the cumulative impact of missed opportunities for improving patient outcome, from the beginning to the end of the patient journey, across five of the most common symptomatic coronary presentations, assessing inequalities in care and outcome. (ii) To determine at the level of the individual hospital the extent to which the organisation and processes of care have an impact on the patient journey. (iii) To establish the effectiveness and cost-effectiveness of a multi-faceted intervention targeting initial specialist management at hospital chest pain clinics of patients early in the symptomatic phase of the patient journey. (iv) To determine whether novel biomarkers are a cost-effective addition to existing clinical information in predicting the progression of chronic stable angina to acute fatal and non-fatal events. RESEARCH PLANS We define patient outcomes as death and major (including repeat) cardiovascular events, throughout the programme. (i) We will identify patients presenting with coronary disease between 2002-11, and reconstruct the longitudinal patient journey by establishing a linkage between primary care record datasets (GPRD, Q Research ~3.76 million adults), the Myocardial Infarction National Audit Project (MINAP), hospitalisation and death. We will examine missed opportunities for diagnosis, treatment and risk prediction, at multiple time points, and assess their relative impact on outcome. (ii) We will determine how each of the 230 hospitals nationally differ in terms of patient outcomes after ACS, and identify explanations for variation which are amenable to action within the NHS, using quantitative surveys and an ethnographic study of hospital care. (iii) We will randomise 50 hospital chest pain clinics (9,740 patients) to a multi-faceted intervention based on patient specific computerised decision support, education and support vs usual care, and follow patients for 3 years for the primary outcome of fatal and non-fatal cardiovascular events. (iv) Exploiting the trial population in (iii) as a risk prediction cohort, we will measure novel biomarkers (e.g. BNP) and common genetic variants, and assess any incremental prognostic information beyond conventional clinical information. Cost-effectiveness will be assessed in a decision analysis of invasive management. RESEARCH TEAM EXPERTISE IMPACTING ON SERVICE PROVISION National leadership roles, influencing NHS innovation: NICE guidelines (Chair post MI Feder, Chair chest pain Timmis), HTA methodology (Sculpher, Abrams), NHS (Medical Director Keogh), DH Policy (National Director of Heart Disease and Stroke, Boyle), MINAP Academic Group (Chair Timmis), Q-Research (Director Hippisley-Cox), European Society of Cardiology (Chair Section on Epidemiology, Hemingway). During the current RAE period applicants have published > 25 applied research papers influencing service change in high impact general medical journals (NEJM/JAMA/Lancet/BMJ/ArchIntMed) and > 30 papers in top cardiovascular journals and secured >£10m in grant funding for applied research. RESEARCH ENVIRONMENT UCLH is the co-ordinating centre for MINAP, and has a strong track record in longitudinal cardiovascular health, healthcare and inequalities research. The clinical environment of chest pain clinics presents twin opportunities of recruiting patients early in the course of symptomatic disease, and of intervention to improve a newly developed service. ANTICIPATED IMPACT ON THE HEALTH OF PATIENTS AND THE NHS Our research will provide decisive new evidence to change healthcare policy and cost-effectively improve clinical outcomes in patients with coronary heart disease at the level of general practice, chest pain clinics and acute hospital care. PUBLIC INVOLVEMENT Our Public and User Involvement Group has met quarterly since 2006 and has informed the development of our proposed programme from inception and will be involved right through to analysis and dissemination. ETHICAL IMPLICATIONS Linkage will be performed by a trusted third party, according to established governance arrangements; no identifiers will be held at UCL, where all analyses will be on anonymised data; written informed patient consent will be obtained for the trial.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: CARDIOVASCULAR