21/06/2018. MEASURING PERFORMANCE (AUDIT AND QUALITY IMPROVEMENT) Towards Reducing Inequity. What should we be measuring?

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1 MEASURING PERFORMANCE (AUDIT AND QUALITY IMPROVEMENT) Towards Reducing Inequity Dr Raewyn Fisher Cardiologist Director of Waikato Integrated Heart Failure Service What should we be measuring? At risk, prevention Incidence, diagnosis Therapy (incl. drugs, devices) Hospitalisation Outcome, re-admission, mortality. Continuum of disease Are we measuring the right things? Hospitalisation data = Stage C-D heart failure Underestimates true incidence/prevalence/burden Missing opportunities to prevent and delay disease progression Copyright American Heart Association 1

2 What do we know from NZ data? What we do know from Midland data Number of HF admissions are increasing (>1700/yr) Number of HF patients are increasing Highest number are elderly Higher rate in Maori/Pacific 5x rate in Maori/Pacific aged yrs Highest rates and number in most deprived areas What we do know from Midland data What we do know from Midland data Constant and significant re-admission rate 25% 1 year re-admission Higher rate with elderly Higher rate with high deprivation No re-adm difference with LOS No re-adm difference with ethnicity Primary care prevalence = Secondary care prevalence Maori/Pacific rate consistently > non M/P at all ages Consistently higher rate with higher levels of deprivation 2

3 What is our target HF population? Temporal trends and patterns in heart failure incidence: a population-based study of 4 million individuals Nathalie Conrad, MSc, Prof Andrew Judge, PhD, Jenny Tran, MSc, Hamid Mohseni, PhD, Deborah Hedgecott, BSc, Abel Perez Crespillo, BSc, Moira Allison, BSc, Prof Harry Hemingway, FRCP, Prof John G Cleland, MD, Prof John J V McMurray, MD, Prof Kazem Rahimi, FRCP The Lancet Volume 391, Issue 10120, Pages (February 2018) DOI: /S (17) Findings From 2002 to 2014, heart failure incidence (standardised by age and sex) decreased, similarly for men and women, by 7% (from 358 to 332 per person-years; adjusted HF incidence 7% decrease incidence ratio 0 93, 95% CI ). However, the estimated absolute number of individuals with newly New diagnosed HF pts heart failure in 12% the UK increased by 12% (from in 2002 to HF in 2014), prevalence largely due to an increase 23% increase population size and age. The estimated absolute number of prevalent heart failure cases in the UK increased even more, by 23% (from to ). Over the study period, patient age and multimorbidity at first presentation of heart failure increased (mean age 76 5 years [SD 12 0] to 77 0 years [12 9], adjusted difference 0 79 years, 95% CI ; mean number of comorbidities 3 4 [SD 1 9] vs 5 4 [2 5]; adjusted difference 2 0, 95% CI ). Age at 1 st presentation Slight increase Socioeconomically deprived individuals were more likely to develop heart failure than were affluent Co-morbidities individuals (incidence rate ratio 1 61, Increase 95% CI ), 3.4 to 5.4 and did so earlier in life than Socio-economic those from the most affluent gap group (adjusted Widened difference 3 51 years, 95% CI 3 77 to 3 25). From 2002 to 2014, the socioeconomic gradient in age at first presentation with heart failure widened. Socioeconomically deprived individuals also had more comorbidities, despite their younger age. Temporal trends in age at diagnosis of incident heart failure by socioeconomic status quintile ( ) 3

4 Focusing our resources Upping our game with Diagnosis and Treatment You re suffering from a terrible post-code Younger /prevention vs Older/multi-morbid HF patients aren t all the same But common investigation/therapy/management Patient journey + Clinical pathways Agree on pathway Implement pathway Audit pathway adherence Resource the pathway 4

5 NICE Pathway Chronic heart failure Implementing NICE guidance The NICE chronic heart failure pathway covers the diagnosis and management of chronic heart failure in adults in primary and secondary cares NICE clinical guideline 108 NZ Cardiac Network recommendations for referral and access to secondary care for common cardiac conditions Cardiology referral not necessarily appropriate, for patients consider in whom declining intervention referral. by secondary care will influence management Cardiology referral appropriate Auditable standard. All patients should have an assessment, initial investigation and management plan within 4 months of referral. Priority for more urgent assessment is expected. Indication for an echocardiogram with a verified report from an accredited cardiologist or CSANZ level 1 trained physician) Non Acute Chest Pain Suspected Heart Failure Patients with low cardiovascular risk and atypical symptoms Patients with symptoms consistent with angina regardless of CV risk Patients with uncertain symptoms and increased 1. cardiovascular Ensure that referred risk patients where appropriate have been adequately assessed with either non-invasive testing to a level that can satisfactorily rule out prognostic coronary artery disease or referred for invasive angiography 2. Perform above within an audited clinical governance structure that includes Acute an Chest accredited Pain cardiologist. All patients presenting with possible acute coronary syndrome 1. Assess with an accelerated chest pain pathway 2. 70% of appropriate patients admitted with acute coronary syndrome receive angiography within 3 days Confirmed ST elevation myocardial infarction 1. Primary percutaneous intervention if it can be reliably delivered within 120 minutes from first medical contact 2. In patients who cannot receive timely primary percutaneous intervention thrombolysis as soon as possible unless contraindicated 3. When rescue percutaneous intervention would be considered in the event of failed thrombolysis the patient should be transferred immediately to a PCI If LV function centre not known to assess left ventricular function in all patients with ACS. To occur before discharge in all patients at higher risk Secondary Prevention for IHD Primary and Secondary Care are expected to work together to provide a community and evidence based prevention programme tailored to individual needs and geographic location for patients with ACS Patients with non-limiting symptoms and normal cardiac biomarkers (when not on treatment), normal ECG and normal chest X-ray Symptomatic patients with elevated cardiac biomarkers, abnormal Chest X-ray or ECG Timely assessment including early echocardiography A clinical governance structure that includes a multidisciplinary heart failure service Optimisation of Heart Failure medication phase: at the end of (approx. 3 months) the titration phase, post revascularisation and or post MI when initial EF suspected to be <35% in order to determine future management including device implantation. Follow up: if change in clinical status or cardiac exam Baseline and serial re-evaluation in a patient undergoing therapy with cardiotoxic agents Atrial Fibrillation Patients with uncomplicated AF and clearly defined embolic risk Rhythm control or cardioversion is considered Heart rate not adequately controlled, ongoing symptoms, or treatment intolerance Abnormal resting ECG (other than AF) or significant finding on echocardiogram Echocardiography appropriate for 1. New diagnosis of atrial fibrillation 2. Change in clinical status 3. Suspected underlying structural heart disease or LV dysfunction Access to cardiology assessment, appropriate investigation and evidence based treatment within an appropriate time frame Palpitations /syncope/arrhythmia Patients with infrequent symptoms non-limiting symptoms and low probability of cardiac disease Symptoms consistent with sustained tachycardia Syncope consistent with cardiac cause Exercise induced pre syncope/palpitations Access to cardiology assessment, appropriate investigation and treatment within an appropriate time frame Echocardiography for suspected valve/ structural /inherited/ heart disease A persistent heart murmur which Cannot be explained by fever, anaemia, high output, pregnancy. Is associated with new or changing symptoms Is associated with a raised BNP, abnormal ECG or Chest X-ray Screening of first-degree relatives for inherited Follow-up cardiomyopathy Echocardiography for known heart valve disease Monitoring for potential treatment related cardiotoxicity Valve pathology Aortic/Mitral regurgitation Aortic Stenosis Mild Moderate Severe Not necessary Vmax m/s 3-5 years 1-2 years 6/12-1 y Vmax m/s 1-2 years Vmax > 4.0 m/s 6/12-1 y MVA > cm2 < 1.0 cm2 Mitral cm2 1-2 years 1y Stenosis Follow up 3-5 echocardiography years for prosthetic valves Bioprosthetic Mechanical < 2y not necessary <3y not necessary 2-3y for first 10y then annually 3-5y Repaired Log of echocardiographic <5y not activity 5y collected line with these standards necessary NZ Cardiac Network recommendations for referral and access to secondary care for common cardiac conditions for patients in whom intervention by secondary care will influence management Cardiology referral not necessarily appropriate, consider declining referral. Cardiology referral appropriate Auditable standard. All patients should have an assessment, initial investigation and management plan within 4 months of referral. Priority for more urgent assessment is expected. Indication for an echocardiogram with a verified report from an accredited cardiologist or CSANZ level 1 trained physician) Suspected Heart Failure Patients with non-limiting symptoms and normal cardiac biomarkers (when not on treatment), normal ECG and normal CXR Symptomatic patients with elevated cardiac biomarkers, abnormal Chest X-ray or ECG Timely assessment including early echocardiography A clinical governance structure that includes a multi-disciplinary heart failure service Optimisation of Heart Failure medication phase: at the end of (approx. 3 months) the titration phase, post revascularisation and or post MI when initial EF suspected to be <35% in order to determine future management including device implantation. Follow up: if change in clinical status or cardiac exam Baseline and serial re-evaluation in a patient undergoing therapy with cardiotoxic agents 5

6 Focusing our resources on earlier stages of HF Identify at risk Timely and correct diagnosis Pt awareness GP access BNP + signs/symptoms Access to diagnostics and expert care BPAC etc Audit Electronic Medicine Focusing our resources on management Appropriate evidence based Rx Prescription, dispensing and adherence Longterm Rx Dosage/uptitration Updating Rx, devices Palliative care 6

7 The Message Prescribe evidence based therapies unless contra-indicated ACE/ARB + BB : IF NOT, WHY NOT? Up-titrate therapy to maximum tolerated Titration Guidelines for CNS Beta-blockers ACE inhibitors/arbs Diuretics Monitor Rx (and CV risks) regularly MRA s Device Therapy for HF Relative contra-indications = K+ > 5 Creat > 221 egfr < 30 7

8 MEASURING MANAGEMENT OUTCOMES 2018 REGISTRY DATA COMPLETION REG NO. BRIEF FORM DATA TRENDS OVER TIME BRIEF VS FULL FORMS BRIEF 2016 FULL %HFrEF BB ACE/ARB MRA 0 NUMBER %HFrEF BB ACE/ARB MRA BRIEF FORM PTS : LOWER IN-HOSPITAL DEATH AND SHORTER LOS 8

9 MIDLAND VS NATIONAL THAMES/COROMANDEL N=363 referred N=162 HFrEF MIDLAND NATIONAL N=116 with repeat echo 20 0 %FULL FORM %HFrEF BB ACE/ARB MRA N=65 (56%) EF improved N=34 (29%) EF stable N=17 (15%) EF worsened (2016 FULL FORM DATA) 36 FOR DISCUSSION FOCUSING RESOURCE Know what resource we have (and don t have) Questions??? MEASURING OUTCOMES HF Management rather than hospital admissions/discharges IMPROVED CARE, REDUCED INEQUITY COMMUNITY/PRIMARY CARE INTERFACE Earlier diagnosis, appropriate management 9