General

Q1: How do I calculate LDL Cholesterol?

LDLc can be calculated, if the result is not available from the laboratory by using the Friedwald formula below:

LDL Cholesterol = Total Cholesterol - HDL - (Fasting TG divided by 2.2)

Note: Fasting TGs are necessary if TGs greater than 4.

Q2: The version of the Friedewald Formula in the Heartwatch reference guide is different from that in the ESH Task Force document. Which should I use?

These are identical as can be seen from the following worked example where total cholesterol is 4.9, HDL is 0.06 and Triglyceride is 1.51 mmol/l:

Using ESH Task Force version we get: LDL cholesterol = 4.9 - 0.06 -(0.45 X 1.51) = 4.1605 mmol/l

Using the HEARTWATCH version we get: LDL cholesterol = 4.9 - 0.06 - (1.51/2.2) = 4.1536 mmol/l

Here is the description of the above as it appears in the ESH Task Force document:

Most laboratories measure cholesterol, triglycerides and the part of cholesterol carried in HDL, namely HDL cholesterol. With these three measurements, the part of cholesterol carried in LDL can be calculated according to the Friedewald formula: In mmol/l^-1:
LDL cholesterol = total cholesterol - HDL cholesterol - (0.45 x triglycerides)

In mg/dl^-1:
LDL cholesterol = total cholesterol - HDL cholesterol - (0.2 x triglycerides)

The calculation is based on the assumption that triglycerides are less than 5mmol/l^-1 (450mg/dl-1).
The accuracy of this estimation of LDL cholesterol can be reduced due to a summation of possible analytical errors in the various lipid measurements. For the time being, however, the Friedewald calculation is cheaper and more reliable estimation of LDL cholesterol than commercially available direct measurements of LDL based on immunoseparation^[383].

Reference:
^[383] Yu HH, Ginsburg GS, Harris N, Rifai N. Evaluation and clinical application of the direct low-density lipoprotein cholesterol assay in normolipidemic and hyperlidemic adults.
Am J Cardiol 1997; 80: 1295-9.

Here is the description of the above as it appears on page 19 of ICGP HEARTWATCH reference guide which was supplied on CD to participating practices:

LDLc can be calculated, if the result is not available from the laboratory by using the Friedwald formula below:

LDL Cholesterol = Total Cholesterol - HDL - (Fasting TG divided by 2.2)

Note: Fasting TGs are necessary if TGs greater than 4.

Q3: When will I get paid for patient visits?

Payment for patient visits will be made by the GMS Payments Board approximately 6 weeks following the data returns.

If you take October payment as an example:

• Any data returned up to and including 30th September will be paid in October.
• Any data returned in the month of October and up to and including 31st October will be paid in November.
• 7th of every month: Instruction of payment sent to the GMS Payments Board
• 14th of every month: Payment sent to GP

Q4: Is there a deadline for the registration of the 15 patients?

There is no deadline for the registration of the 15 patients. GPs will receive their bonus payment of €1250, regardless of the time span of their patient registration whether they register all 15 over a month or over the space of 6 months. The patients must be registered complete with Continuing Care Forms.

Q5: Do I require a minimum of 15 patients registered before I receive any payment at all?

You do not need to have 15 patients registered in order to receive any payments. You will receive payment for each patient registered (complete with Continuing Care Form) regardless of whether or not you have reached the minimum of 15, you will not receive the bonus payment until you have registered the minimum of 15.

Q6: Do I need to test all Diabetic Patients for Microalbuminuria?

Testing for Microalbuminuria is only mandatory in the MHB region. While we strongly recommend that GP's test for it, it is not compulsory and if GP's think it is too expensive then they are permitted to leave it out. Testing for Protinuria should be carried out on all diabetic patients.

Q7: What age should be taken into account when calculating the worst ever Risk Factor Index on the registration form?

When calculating the worst ever risk factor, take the age of the patient 'today'. The reason for this is that the patient can be told that this is what their risk factor index would be, if they did not improve their status with regard to smoking, cholesterol, BP etc.

Q8: If a patient is sent for an ECG regardless of location, is this still considered a clinical event?

We only want an ECG record as an event if they are referred outside the practice as we only want this information to detail the number of referrals made. ECGs within the practice should not be included.

Q9: Are GPs required to complete the personal record card that is found in the Heartwatch Information Folder?

This is optional, it is at the discretion of the GP whether or not to complete the Personal Record Card.

Q10: If cholesterol is normal on the first visit and does not need to be checked on the second visit, what should the practice input in the mandatory field for cholesterol in the Interim Tool?

The practices may enter the value 29.99 if the cholesterol does not need to be checked on the patients second visit.

Q11: If fasting glucose is not captured in non-diabetic patients on the first visit, does the practice have to recall the patient?

Fasting Glucose can be measured on the second visit. Alternatively if it has been measured within the previous three months, then use this figure.

Q12: What values should be entered in R2 if targets are met on the 1st Visit?

If targets are met on the 1st visit, the test will not have to be done again on the 2nd visit. However, most fields in R2 are mandatory.

Q13: If a patient dies at home, how should this be recorded on the Interim Tool Release 2?

If a patient dies at home the events form should be completed by entering the local hospital, then under hospital admission click the "no" box. In this way we will be able to ascertain which deaths occurred outside the hospital.

Q14: If the medication of a patient is changed to another drug in the same class, how should this be captured?

If the medication of a patient is changed to another drug in the same class then the reason for the change should be assessed. If the reason for changing is that the control of the individual risk factor is sub optimal and a more potent response is being sought then the change of the drug should be recorded as an "increased dose". If the response is because of side effects but the patient is adequately controlled then this should be recorded as "dosage maintained".

Q15: When should Angina be captured as an event?

Angina should be captured as an event if its of clinical significance ie new onset angina, unstable angina, angina episode needing hospital admission. Therefore, if the patient is known to suffer with angina and has an episode managed in the GP surgery or at home this should not be recorded as an event.