Improving Compliance to NICE guidelines for the Identification of Familial Hypercholesterolaemia in General Practice (FAMCHOL)

Problem

Familial Hypercholesterolaemia (FH) affects up to 1 in 500 individuals in the UK and, left untreated, can lead to premature coronary heart disease. This can be prevented by statins but 80% of individuals still are not being identified in primary care. The FAMCHOL study team sought to develop an intervention which could improve identification and management of this condition in primary care.

Approach

The FAMCHOL intervention development study was a before and after non-randomised intervention study over 6 month period in six general practices which patients with cholesterols over 7.5 mmol/L were assessed for possible FH (in line with NICE FH guidelines) opportunistically through computerised screen reminders and systematically by postal invitation. Over the six month study period, 831 eligible patients from six practices were identified as having total cholesterol over 7.5 mmol/L, which included 127 patients who were recruited directly to the study. NICE guideline compliance for identifying FH was assessed by analysing data extracted from general practice computer records before and after the study period. These guideline compliance measures included: conducting repeat cholesterol tests, diagnoses and investigations of secondary causes of raised cholesterol, taking a detailed family history, documenting clinical signs and symptoms of FH, and treatment of raised cholesterol (i.e. prescribing statins, giving lifestyle advice, reducing total/LDL cholesterol). These measures were evaluated as the change from baseline to follow-up using multivariate mixed-effects regression analysis accounting for differences between individuals, practices, and recruitment modes (opportunistic or systematic) as random effects.

Findings

From 127 participants recruited, data from 118 (95%) patients were available for analysis. Seven patients were excluded from the analysis due to transferring from their general practice. In these 118 patients, there was significant decrease in the mean total cholesterol of (0.24 mmol/L, 95% CI -0.44 to -0.04), borderline significant decrease in LDL-cholesterol (0.19 mmol/L, 95% CI -0.40 to 0.01), and significant decrease in proportion of patients with raised cholesterol (AOR 0.43 95% CI 0.25 to 0.76). GPs also significantly increased repeating cholesterol tests (AOR 54.67, 95% CI 24.23 to 118.87), and improved diagnosis of secondary causes (AOR 3.24, 95% CI 1.09 to 9.61), family history recording of coronary heart disease (AOR 4.39, 95% CI 1.14 to 16.97), statin prescribing (AOR 21.18, 95% CI 10.21 to 43.93), and giving smoking cessation advice (AOR 3.86, 95% CI 1.96 to 7.61).

Consequences

The FAMCHOL study demonstrated that with a relatively short six-month follow-up period, improving GP compliance to NICE FH guidelines could be achieved, potentially improving the diagnosis of FH to prevent premature heart disease. In addition, collection of patient clinical data through GP computer records was able capture key compliance data without burdening patients with data collection forms, which could potentially increase attrition and loss of outcome measures.