Indicator. title: Indicator ref.: A similar CCG rehabilitation, considerationss for. Denominator. the NICE Committee. The HSCIC is.

Transcription

1 Indicator ref.: IND-12 Appraisal of quality of indicatorr for provisional CCG OISO Indicator title: Referrals to cardiac rehabilitation Key considerationss for the NICE Committee A similar CCG OIS indicator is in development looking at the completion off cardiac rehabilitation, the present indicator uses the same denominator, the numerator is expected to be larger in this indicator as logically more m people will be referred cardiac rehabilitation thann go on to complete a course. Figures from the t National Audit of Cardiac Rehabilitation (NACR) were unavailable at the time of testing; the suitability of the indicatorr was tested using completion figures and national figures presented in the NACRR annual report. The denominator volume for this indicator is 119,993, who hadd an acute myocardial infarction, heart failure, percutaneous coronary intervention or coronary bypass graft of which 63,477 (52.9%) are referred. The HSCIC is of the vieww that this indicator is feasible. f Rationale Cardiac rehabilitation has been shown to improve physicall and social health and decrease subsequent morbidity and mortality in people with coronaryy heart disease (CHD). There is an existing CCG OIS indicator Cardiac Rehabilitation Completion thatt this potential new indicator would complement. From NICE Cardiac Rehabilitation n Services Commissioning Guide Cardiac rehabilitation is recommended in NICE clinical guideline 172 on myocardial infarction (MI) secondary prevention as an appropriate intervention for people following a hospital admission for MI. This supports the National Servicee Framework for CHD which sets the standard that: NHS Trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to hospital suffering from CHD have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of subsequent cardiac problems and promote their return to a full and normal life Based on Quality Standard 9 Statement 8, supporting measurement too determine evidence of local arrangements to ensure the availability of a supervised group exercise-based cardiac rehabilitation programme that includes education and a psychological support for people with stable chronic heart failure. What is measured Source of data Hospital Episode Statistics (HES) National Audit of Cardiac Rehabilitation Denominator The number of peoplee admitted too hospital for acute myocardial infarction, heart failure, percutaneous coronary intervention or coronary bypass graft in the relevant year (from HES data). The following ICD-10 codes have been used to classify a primary p diagnosis of acute myocardial infarction or heart failure: I21 - Acute myocardial infarction I22 - Subsequent myocardial infarction I50 - Heart failure

2 The following OPCS-4 codes havee been used to classify a primary operative procedure of percutaneous coronary intervention or coronary bypass: K49 - Transluminal balloon angioplasty of coronary K50 - Other therapeutic transluminal operations on coronary K75 - Percutaneous transluminal balloon angioplasty and insertion i of stent into coronary K40 - Saphenous vein graft replacement of coronary y K41 - Other autograft replacementt of coronary K42 - Allograft replacement of coronary K43 - Prosthetic replacement of coronary K44 - Other replacement of coronary K45 - Connection of thoracic to coronary K46 - Other bypass off coronary Numerator Of the denominator, the number of patients from the NACRR and HES linked dataset that are referred to Cardiac Rehabilitation (as measured by NACR) ). Suitability of indicator for purpose HES data: Completeness The overall coverage of the Admitted Patient Care HES dataset is deemed to very high as it has been flowing for many years. Completeness of individual fields with valid values within the dataset is also very high. For example, in the 2012/13 final datasett the level of population with valid values is NHS number 99.2% and primary diagnosis 100%. It should be borne in mind that some of the valid values are more useful than others and vague categories such as other are valid for certain fields but not necessarily as useful. Accuracy There is no other national data sett to compare against to obtain o an overall quantitative estimate of accuracy. The data aree completed from administrative records recordedd by each Trust on their patient administrativ ve system (PAS) with the clinical information added by clinical coders based on doctors notes. The Trusts are required to complete this information to inform how much they are paid under Payment by Results and the Audit Commission run a rolling programme of audits of organisations coding to check for accuracy. Timeliness The underlying data equired for the construction of the indicator are available on a monthly basis around 4 5 months after the start of the month in which w the attendance took place. The full year annual data refresh occurs around 8 months after the financial year end. Accessibility The underlying data is held by thee HSCIC and are made available to customers via several mechanisms depending on their requirements. These include the publication of aggregated output; an extract service that covers both bespoke and routine extracts; and directt access via an interrogation tool to the underlying data for certain customers. c

3 NACR Data: Completeness Of the 285 cardiac rehabilitation programmes in England, 2712 providedd Phase II (structured exercise and rehabilitation). Data was submitted by 241 of these providers and estimated for the remaining 30. The base number of patients was taken from HES data. The NACR report states that they believe that women are under reported in the t dataset, where 39% of those who have an MI are women, whilst referrals were only made up of 30% % women and 26% of Phase III participants. Participation in the NACR is not mandatory, but is part of the British Association forr Cardiovascular Prevention and Rehabilitation (BACPR) standard. It is an established audit and it is expected thatt all providers that offer this service take part. Accuracy The accuracy of the figures is dependent on the programmes reportingg to the NACR. The provision of service may change and the NACR is dependent on programmes updating them with any changes. In the case of the 30 providers that did not submit data, their figures were estimated. The estimate is based on the median number of patients by category in the country or from extrapolating fromm the previous year s dataa after confirming that the service had not changed. Timeliness An annual report on NACR data iss released approximatelyy 18 months after the reporting period ended. Accessibility NACR is managed by a team based at the University of York, informatics and data management servicess are provided by the HSCIC. Figuress from this dataset are published in an annual report. Cardiac Rehabilitation units are able too get extractsts of their activity via a reporting tool on the HSCIC website. How data are aggregated Relevance This indicator reflects the provisionn of high quality care; CCGs can usee the information presented in this indicator to assess the quality of service they t provide to patients. This indicator would be reported as a percentage of peoplee who were admitted to hospital for acute myocardial infarction, heart failure, percutaneouss coronary intervention, or coronary bypass graft who were referred to a cardiac rehabilitation programme. Risk adjustment It is not recommendedd to standardise or risk adjust this indicator as all eligible patients who have suffered a cardiac even should be referred to a cardiac rehabilitation programme. However, the NACR notes that women are under-represented in cardiac rehabilitation programmes. Scientific validity The sample data that has been used for this testing report covers the amount of people who have had a cardiac event recordedd in the HES database (primary diagnosis of acute myocardial infarction, heart failure, percutaneous coronaryy intervention, or coronary bypass graft) and the amount of people who have been referred to a cardiac rehabilitation programme. A similar indicator is already in development that t uses thee same HES figure as its denominator. A referral is classed as when the rehabilitation unit becomes aware of the patient. The denominator volume for this indicator is 119,993 people who had a primary diagnosis of

4 acute myocardial infarction or heart failure, or had a primary operative procedure of percutaneous coronary intervention or coronary bypass graft in ,,477 (52.9%) people who were eligible for cardiac rehabilitation were referred. The denominator volume has been aggregated fromm GP level to CCG level, meaning that commissioning hubs are present in the data, however, these are not present in the numerator dataa and have been excluded from the analysis. A number of CCGs have a referral rate of over 100%; there are a couple of potential reasons for this. The data used has not been linked l between the two datasets and as such, a number of people may be appearing in the NACR dataset but not thee HES dataset, or they may have had an event in the previous HES eference period and are therefore not counted in the HES figure. A rate of over 100% could also suggest that people are being cross- centres specialisee in certain functions. The activity volumes reported r in the NACR report are generally larger than the volumes found in the sample data, this is due to the NACR count off patients looking for an acute myocardial infarction, percutaneous coronary intervention, or coronary y bypass graft in referred from other centres, regions may have differing programmes where some any position in the record. The sample data looks only in the primary diagnosis or procedure position for a wider range cardiac events, acute myocardial infarction, heart failure,, percutaneous coronary intervention, or coronary bypass graft, inn line with the methodology for CCG OIS 1.3, completion of cardiac rehabilitation. Data is collected at rehabilitation unit level, of which 241 provided Phase III rehabilitation and submitted to the NACR. Figures were estimated from the remaining 30 providers in England. GP practice is recorded on the record by the rehabilitation unit and can be used to aggregatee the data to CCG level. Cardiac rehabilitation unit level cannot be reported due to this level not being available in thee HES dataset. Aggregating unit level data to CCG level may cause issue due to the distribution of cardiac rehabilitation units, itt may end up that some CCGs contain numerous cardiac rehabilitation units whilst otherss contain none. In line with the methodology of CCG OIS 1.3 ( the number of people who completed rehabilitation), for this report, patients who have been deemed ineligible for rehabilitation and are not referred should be excluded from the denominator. The main groups that were excluded from referral protocols included; pacemakers, angina, cardiacc arrest, heart failure, and implantable cardioverter defibrillator. The 30 units thatt did not submit figures should also be excluded as the data presented may not be a validd representation of their activity; however, this will also further exacerbate any issues with the distribution of cardiacc rehabilitation units. Patients with heart failure are included in the denominator figure, as per the scope for rehabilitation in the Department off Health service specification. However, according to the NACR report, 40 rehabilitation units in the United Kingdomm in reported a policy of not accepting patients with this diagnosis. It is noted that these patientss may be cross- The referred to another programme that may be better equipped to deal with these cases. NACR do not publish the number of heart failure patients in their counts of eligible patients. The HES and NACR datasets cann be joined together usingg the NHS number; this is 99.2% complete in the HES dataset and is required when enteringg patients details in the NACR dataset. If a link cannot be obtained through this field, thenn date of birthh and postcode can also be used to ensure a match. This linked data can be used to exclude people in the denominator based on eligibility criteria and check the recorded GP practice in the NACR data. Guidelines suggest that a patient should be referred withinn three days of a cardiac event,

5 however the wait between the event and the start of rehabilitation can be much longer. Due to this length of time, there t could be cases where people are a referred towards the end of a referencee period and beginning rehabilitation in the following period. These cases could be identified through the use of linkedd data in a wider reference period andd included. Interpretation A high percentage of people beingg referred to cardiac rehabilitation is desirable. Equality assessment Variation by age, gender, geography, deprivation, ethnicityy etc. where feasible and appropriate. The following fields are available in HES whichh would support analysiss by the following equality dimensions: Age Gender Ethnicity Deprivation (using Index of Multiple Deprivation linked fromm postcode) The following fields are available in NACR for analysis of equality e dimensions Date of Birth Sex Ethnic Group Postcode Use, follow-up investigation and action The data could be analysed by thee equality dimensions to investigate iff there are specific issues within certain groups. HSCIC will assess the options for this analysis as part of further development and checkingg for data quality issues. Publication P of the indicator broken down by the equality dimensions may be restricted due to suppression, but CCGs could also undertakee local analysis. A potential perverse incentive hass been identified in that inn order to remove peoplee from the denominator; hospitals may recordd a patient as belonging to a group that would be excluded from referral protocols. Feedback from the consultation raised the potential issue that patients may be referred even if they are not well enough on o dischargee in order to improve i the CCGs figures. Feedback from HSCIC consultation Question N Organisation 4 Well defined 3 Well- constructed 3 Yes, significant issuess Data Quality issues 3 Other (25%), Clinical Commissioning Group (75%) Strongly Agreee Agree Disagree Strongly Disagree Don't Know % Yes, minor issues Response (%) 33.3% No Issues 10 Don't Know

6 Highlyy likely Quite likely Quite unlikely Highly unlikely Don t know Likely service improvements 3 10 Resultss group dependant Likely perverse incentives % % If you do not agree that the indicator is suitably constructed please describe how you think the construction could be improved. Denominator - What about people who die? - maybe discharged? If you expect that there will be data quality issues associated withh this indicator please provide more detail as too what you think these might be. Referral will take place some time after the initial diagnosis: d guidance is needed as to when the data should be collected. If you think that it is likely perverse incentives may occur please explain what kinds of issuess you think may arise. Not all patients will be well enough for rehabilitation on discharge but could be referred anyway to meet the stats. Could be referred later by community services or consultant. Could be referred more than once in a year. Sample data Below is unlinked HES and NACR data. As this data has not yet been linked, a number of potential issues may arise. For example, people may appearr in the numerator but not the denominator, and people that are to be excluded from the denominator will still be present due to being ineligible, and the dataa is unable to track which patients that have been referred to which unit. CCG Denominator Numerator Percentage CCG Denominator Numerator Percentage CCG CCG202 1,618 1, % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG % CCG %