Proof of Concept: NHS Wales Atlas of Variation for Cardiovascular Disease. Produced on behalf of NHS Wales and Welsh Government

Transcription

1 Proof of Concept: NHS Wales Atlas of Variation for Cardiovascular Disease Produced on behalf of NHS Wales and Welsh Government April 2018

2 Table of Contents Introduction... 3 Variation in health services... 3 Identifying unwarranted variation in cardiovascular care... 4 From unwarranted variation to the reallocation of resources... 4 Recommendation... 5 Prevalence (%) of hypertension by GP cluster... 6 Context... 6 Magnitude of variation... 7 Options for action... 7 Prevalence (%) of coronary heart disease (CHD) by GP cluster... 9 Context... 9 Magnitude of variation Options for action Emergency admissions to hospital for people with heart failure by GP cluster Context Magnitude of variation Options for action Acknowledgements Page 2 of 16

3 Introduction Variation in health services Variation in the provision of health services is a phenomenon that has been recognised for several decades, and it occurs in health services across the world irrespective of the method of financing. There are two main types of variation in health-service provision: 1. Warranted; 2. Unwarranted (sometimes referred to as unintended). Warranted variation usually reflects differences in health-service provision based on patient-centred care and clinical responsiveness to the assessed need of the population being served. It can also reflect innovation and improvement in a particular area or organisation that has yet to be disseminated throughout a service. Wennberg defined unwarranted variation as: variation in the utilisation of health care services that cannot be explained by variation in patient illness or patient preferences. 1 Unwarranted variation helps to uncover two of the main problems in healthcare: Overuse, in particular of lower-value interventions but also in treating people who are only mildly affected and would derive little benefit from that treatment; Underuse of effective interventions which would benefit people in need. 1 Wennberg JE (2010) Tracking Medicine: A Researchers Quest to Understand Health Care. Oxford: Oxford University Press. Page 3 of 16

4 Unwarranted variation represents a waste of resources, and highlights the provision of poor-quality and lower-value healthcare. As Berwick observed: Variation is a thief. It robs from processes, products and services the qualities that they are intended to have.... Unintended variation is stealing healthcare blind today. 2 In the context of population ageing, increasing need and increasing demand for healthcare, and efficiency targets, the NHS in Wales needs to identify and reduce unwarranted variation in order to improve outcomes and increase value for individual patients and populations. Identifying unwarranted variation in cardiovascular care In the NHS Wales Heart Conditions Delivery Plan published in January 2017, unwarranted variation in practice and the delivery of services was identified as one of the key remaining challenges in cardiac care in Wales. 3 In addition, it was noted that comparisons, benchmarks and clinical audit have been difficult to establish and maintain in many areas of the country. 3 The aim in publishing this NHS Wales Atlas of Variation for Cardiovascular Disease is to identify unwarranted variation in key aspects of cardiac care and thereby to investigate the reasons for unwarranted variation, whether of overuse, underuse or both. From unwarranted variation to the reallocation of resources For indicators where unwarranted variation represents overuse, changes can be made in the allocation of resources to increase value that is, shifting resource from the overuse of interventions into: increasing the use of effective interventions currently being underused; introducing innovations of proven effectiveness; meeting currently unmet need in the population being served. 2 Berwick DM (1991) Controlling variation in health care: a consultation from Walter Shewhart. Medical Care 29: NHS Wales. Heart Conditions Delivery Plan. Highest standard of care for everyone with or at risk of a heart condition. Produced by the Heart Conditions Implementation Group. January Page 4 of 16

5 These changes in allocation can occur: within a system of care, for instance, within the system of care for people with heart failure assessing whether the balance of expenditure is appropriate between different treatments or across the care pathway from prevention, treatment, rehabilitation to end-oflife care; across systems of care within cardiac care, that is an appropriate balance in allocation between people with coronary heart disease, people with rhythm problems and people with heart failure. In 2015/16, 7.4% of the overall budget for NHS Wales expenditure of 6.1 billion was allocated to Circulation Problems, which includes cardiovascular disease, amounting to million; this was divided into 84.6 million on Cerebrovascular Disease, million on Coronary Heart Disease and million on Other Problems of Circulation. 4 These figures gives some indication of the resources available for reallocation within and across systems of care for cardiovascular disease to increase value for people with heart problems who are in need. Recommendation Group members are invited to comment on this paper and the proposed next steps. 4 NHS Wales expenditure by budget category and year. Page 5 of 16

6 Prevalence (%) of hypertension by GP cluster 2016/17 Context Hypertension or high blood pressure (140/90 mmhg) is one of the most preventable causes of premature morbidity and mortality in the UK. At least one-quarter of adults (one in four people), and more than half of people over 60 years of age have high blood pressure. 5 Persistent hypertension increases the risk of cardiovascular disease (CVD), heart attacks, heart failure, stroke, peripheral arterial disease, kidney disease, vascular dementia and aortic aneurysm, therefore identifying and managing people with hypertension is likely to have a considerable impact on population risk for CVD and other conditions. Untreated hypertension is associated with a progressive rise in blood pressure, often culminating in a treatment-resistant state due to associated vascular and renal damage 5, which can lead to disability and death. The prevalence of hypertension is influenced by age, family history, ethnic background and lifestyle factors. In Wales, Quality and Outcomes Framework (QOF) reports on hypertension prevalence for all ages have been produced since 2004/05. QOF-Reported registers of hypertension show GP-recorded prevalence rising from 12.7% in 2005 to 15.6% in The clinical management of hypertension is one of the most common interventions in primary care. In the sub-local authority analysis of the Welsh Health Survey dated March 2012 the percentage of adults reporting they were being treated for high blood pressure ranged from 15% to 25% at upper super-output area level; the average for Wales was 19%. 7 5 NICE. Hypertension in adults: diagnosis and management. NICE guidelines [CG127]. Published date: August Last updated: November QOF Database. Wales. Prevalence. 7 Public Health Wales Observatory. Sub-local authority analysis of the Welsh Health Survey. March Page 6 of 16

7 Magnitude of variation For GP clusters in Wales, the reported prevalence of hypertension ranged from 8.4% to 19.5% (2.31-fold variation). Crown copyright and database rights 2013 Ordnance Survey The most likely reason for the degree of unwarranted variation is differences in the identification of people with hypertension in different local areas, especially among GP clusters that have similar populations demographically. Options for action Owing to the impact of hypertension on cardiovascular disease risk, it is important to prioritise the prevention, early detection and treatment of people with hypertension. This requires a partnership approach especially between the health sector and local government. Page 7 of 16

8 Outcomes of treatment by GPs can be used: to assess the degree of variation in the identification of hypertension at practice level; to identify which practices might need support in the identification of people with hypertension. In most cases, hypertension has no symptoms that would lead people to consult the GP. Therefore, in addition to screening for undetected blood pressure, it is important for primary care clinicians to undertake regular measurements of blood pressure when people attend for other reasons (opportunistic testing; also Making Every Contact Count 8 ). According to NICE guidance, drug treatment is not necessarily the first step in managing hypertension. Clinicians should advise people with hypertension about the importance and co-benefits (e.g. improved mental well-being) of: dietary change; exercise; weight reduction; modifying alcohol intake; stopping smoking; good sleep hygiene. If people with hypertension are prescribed drug treatment, primary care clinicians need to ensure that medication is titrated to achieve optimal control of blood pressure. 8 Page 8 of 16

9 Prevalence (%) of coronary heart disease (CHD) by GP cluster 2016/17 Context Coronary heart disease (CHD) is a major cause of ill health and death in Wales: more than 1 in 7 men and nearly 1 in 10 women die from CHD. 9 Issues that need to be addressed include a reduction in risk factors and identifying how improvements can be made to reduce morbidity and mortality associated with cardiovascular disease. Premature CHD is a largely preventable condition, significantly influenced by poverty and socio-economic health determinants. Although the risk of CHD increases with age, some of the main risk factors for CHD are modifiable by individuals with the support of health professionals: smoking/tobacco use; poor diet and nutrition; high blood cholesterol; high blood pressure; insufficient levels of physical activity; overweight/obesity; diabetes; psychosocial stress; excess alcohol consumption. In Wales, Quality and Outcomes Framework (QOF) reports on CHD prevalence for all ages have been produced since 2004/05. QOF-Reported registers of CHD show little change in GP-recorded prevalence from 4.3% in 2005 to 4.2% in In 2015 the Public Health Wales Observatory modelled CHD prevalence based on self-reported treated prevalence data from the Welsh Health Survey and compared the results with the CHD register of prevalence British Heart Foundation CYMRU. CVD Statistics BHF Factsheet for Wales. Last reviewed and updated February QOF Database. Wales Public Health Wales Observatory. CHD prevalence modelling by GP cluster. Version 2a. 4 June c9ac/$FILE/CHDPrevalenceModel_AllClusters_v2a.pdf (NHS Wales Internal Access Only) Page 9 of 16

10 For every GP cluster the model predicted higher prevalence than the QOF register reported, with estimates ranging from 12% to 45% of people with CHD not on the QOF register. 12 Although these results must be interpreted with caution, GP clusters can use the results as a starting point for the investigation of case-ascertainment and equity of access to services. 12 About 119,000 people are estimated to be living with CHD in Wales. 13 The most common symptom of CHD is angina; other symptoms include heart attacks and heart failure. Most deaths from CHD are caused by a heart attack. Magnitude of variation For GP clusters in Wales, the reported prevalence of CHD ranged from 1.9% to 4.9% (2.63-fold variation). Crown copyright and database rights 2013 Ordnance Survey The National Assembly for Wales. Tackling CHD in Wales: Implementing Through Evidence. (Not dated.) QOF Database. Wales. Page 10 of 16

11 There is considerable geographical variation in the prevalence of CHD in Wales 14, both between and within communities. Reasons for the degree of variation include differences in: the prevalence of risk factors in different local areas; the level of service provision. 15 The most likely reason for the degree of unwarranted variation is differences in the identification of people with CHD in different local areas. Options for action Given that many people who present with CHD have had the disease for some years prior to presentation, GPs and primary care teams need to identify people with a high risk of developing CHD or with established CHD and offer them comprehensive lifestyle advice and appropriate treatment. A lack of treatment increases the risks of morbidity, mortality and hospitalisation for people with CHD. Clinicians need to take advantage of opportunities to assess the risk for CHD when people present for other reasons (Making Every Contact Count). For populations in which there are lower levels of identification, when compared with populations where levels meet those that are expected, it is important to obtain data on the degree of variation in identification at practice level, and ascertain which practices need support in the identification of people with CHD. The Heart Conditions Delivery Plan 16 published in January 2017 focusses on the prevention of cardiovascular disease and the development of safe and effective pathways of care for patients with CHD. 14 The National Assembly for Wales. Tackling CHD in Wales: Implementing Through Evidence. (Not dated.) 15 The National Assembly for Wales. Tackling CHD in Wales: Implementing Through Evidence. (Not dated.) 16 NHS Wales. Heart Conditions Delivery Plan. Highest standard of care for everyone with or at risk of a heart condition. Produced by the Heart Conditions Implementation Group. January Page 11 of 16

12 Emergency admissions to hospital for people with heart failure by GP cluster 2016/17 - Directly Standardised by Age Context Heart failure is a clinical syndrome characterised by a complex of symptoms and signs that suggest impaired efficiency of the heart muscle caused by a structural and/or functional abnormality of the heart. 17 The most common cause of heart failure in the UK is coronary heart disease (CHD), with many people having had a myocardial infarction. 18 Other main conditions that can cause heart failure include: hypertension; cardiomyopathy; arrhythmias, such as atrial fibrillation; damage to or other problems with the heart valves; congenital heart disease. Heart failure can also be caused by anaemia, cardiotoxic drugs/radiation, excessive consumption of alcohol, hyperthyroidism and pulmonary hypertension. The incidence and prevalence of heart failure increase with age. Prevalence is likely to increase in future due to the population ageing, improved survival of people with ischaemic heart disease and increased effectiveness of treatments for heart failure. 19 A GP will care for 30 people with heart failure on average, and suspect a new diagnosis of heart failure in about 10 people a year. 19 The misdiagnosis of heart failure however is common, and people with heart failure may not be recognised or treated appropriately. 20 Over 32,000 people in Wales have been diagnosed with heart failure NICE. Chronic heart failure in adults: management. Clinical guideline [CG108]. Published date: August NHS Wales. Heart Conditions Delivery Plan. Highest standard of care for everyone with or at risk of a heart condition. Produced by the Heart Conditions Implementation Group. January British Heart Foundation CYMRU. CVD Statistics BHF Factsheet for Wales. Last reviewed and updated February Page 12 of 16

13 The most common symptoms are breathlessness, fatigue and swollen ankles and legs. People with heart failure can experience acute exacerbations of their condition which may require emergency admission to hospital. Acute heart failure can also present as new-onset heart failure in people without known cardiac dysfunction. 21 In the UK heart failure accounts for 5% of all emergency medical admissions to hospital. 22 Acute heart failure is a common cause of admission to hospital in England and Wales, and is the leading cause of hospital admission in people aged 65 years and older. 18 In Wales, the aim is to set up Local Heart Failure Teams comprising a lead consultant cardiologist or physician with a special interest in heart failure, a lead heart failure specialist nurse, a clinical physiologist and a pharmacist to serve GP clusters. Each of these teams will link to a Tertiary Heart Failure Team able to provide specialist diagnosis and care. 21 NICE. Acute heart failure: diagnosis and management. Clinical guideline [CG187]. Published date: October The National Assembly for Wales. Tackling CHD in Wales: Implementing Through Evidence. (Not dated.) Page 13 of 16

14 Magnitude of variation The rate of emergency admissions to hospital for people with heart failure ranged from 80.8 to per 100,000 population (3.21-fold variation). Crown copyright and database rights 2013 Ordnance Survey Reasons for the degree of variation observed include differences in: prevalence and severity of heart failure in different local areas; identification of, and referral rates for, people with suspected heart failure; timely access to diagnostic tests; access to local heart failure teams and specialist care; access to rehabilitation programmes specifically designed for people with heart failure; the level of care and support in the community; competency for self-care among people with heart failure. Page 14 of 16

15 Options for action To reduce the rate of emergency admissions to hospital for people with heart failure, it is necessary: To increase the rates of diagnosis of heart failure by use of natriuretic peptides and echocardiography; To improve access to these tests in the community; To improve access to specialist advice and treatment, including optimising medical and device treatments for patients with confirmed heart failure; To improve access of patients to community heart failure specialist nurses to improve people s ability to manage their heart failure symptoms; To improve access to palliative care specialist teams. Further guidance is available from The European Society of Cardiology 23 and the National Institute for Health and Care Excellence The European Society of Cardiology guidelines on the management of heart failure: EHJ 2016;37: NICE guidelines Page 15 of 16

16 Acknowledgements This document has been produced for NHS Wales and Welsh Government, with the help and support of Better Value Healthcare Ltd, NHS Wales Health Collaborative, Wales Cardiac Network, Welsh Cardiovascular Society and the NHS Wales Informatics Service. Special thanks goes to the working group who supported the development of this proof of concept: Dr Jonathan Goodfellow Welsh Cardiovascular Society Heidi Dobbs Wales Cardiac Network Ricky Thomas Wales Cardiac Network Gareth John NHS Wales Informatics Service Erica Ison Better Value Healthcare Ltd Professor Sir Muir Gray Better Value Healthcare Ltd Page 16 of 16