Cardiovascular disease

JSNA Refresh Cardiovascular disease Overview of cardiovascular disease 1.1. Cardiovascular disease (CVD), also called circulatory disease, describes a group of diseases which are caused by blockage or rupture of blood vessels. CVD embraces a range of conditions including atherosclerosis (blocked arteries), cerebrovascular disease (stroke), aortic aneurysm (ballooning of the main artery) and peripheral vascular disease (PVD), which usually involves blockage or reduction of the blood supply to the legs.(1) 1.2. The two most important causes of death are coronary (ischaemic) heart disease (CHD) and stroke. The precursors of these include angina (chest pain) and hypertension (high blood pressure). CVD accounts for nearly one third of all deaths in Southwark and over one quarter of premature deaths, under 75 years of age, Almost 50% of CVD deaths are due to coronary heart disease and almost 24% to stroke (Figure 1.1). Figure 1.1 Causes of CVD death among people all ages Southwark (2005-07) Source: NCHOD accessed October 2009 1.3. Premature death rates (i.e. the under 75 population) are higher in Southwark than the national average for both men and women. Actual death rates are higher in men than in women. The Standardised Mortality Ratio (SMR) is the ratio of the number of deaths observed in a specified population to the number that would be expected if that population experienced the same mortality rate, age and sex structure as a reference population (in this case England). A locality with the same death rate as the standard population would have a SMR of 100. 1.4. Table 1.1 shows SMRs for men, women and persons of all ages and under-75. Death rates in Southwark women aged under 75 are 28% higher 1

than the national average and death rates in Southwark men are 12% above the national average. When we look at trends in mortality for all persons under 75 and for males under 75 it is clear that we are narrowing the gap between Southwark and England (Figures 1.2 and1.3). Conversely though female mortality is falling, the gap is widening between Southwark and England for females (Figure 1.4). Table 1.1 Standardised mortality ratios (SMR) all age and under 75 for males, females, persons 2005-07 (confidence intervals in brackets) SMR all ages SMR < 75 SMR No. deaths SMR No. deaths Males 94 (87, 101) 726 112 (100,125) 336 Females 88 (82, 95) 703 128 (110, 148) 186 Persons 91 (87, 96) 1429 117 (107, 128) 522 Source: NCHOD accessed October 2009 Figure 1.2: Mortality from circulatory disease in people under 75 Source: CSL HNA Toolkit 2

Figure 1.3: Mortality from circulatory disease in males under 75 Source: CSL HNA Toolkit Figure 1.4: Mortality from circulatory disease in females under 75 Source: CSL HNA Toolkit Cardiovascular diseases in Southwark 1.4. Table 1.2 compares the prevalence of cardiovascular diseases, reported in the Quality and Outcome Framework (QOF) for 2008/2009, with the national QoF prevalence and with expected prevalence derived from a range of models developed for the Association of Public Health Observatories. The crude prevalence (unadjusted for age) is lower than the national average for all these conditions. This might be due to Southwark s relatively young 3

population, although we cannot exclude the possibility of under diagnosis of this condition. There is a marked difference in local prevalence and expected prevalence derived from APHO modeling particularly for CHD and hypertension. The expected number with these conditions is roughly twice that recorded on registers locally. There is likely to be under diagnosis and under recording of these conditions, however whether it is great as this is questionable. Expected growth in prevalence is described in Table1.2. However the reservations described above are likely to apply here also. Table 1.2: Prevalence of CVD conditions in Southwark compared to national prevalence and expected modelled prevalence 2009 Local prevalence (number in brackets) National prevalence Expected prevalence in over 16 population(number in brackets) CHD 4757 (1.5% ) 3.5% 4.8% (10959) Stroke/TIA 2595 (0.8%) 1.7% 2.2% (5169) Heart failure 1180 (0.4%) 0.7% Hypertension 29,976 (9.7%) 13.1% 25.4% (58593) Source NHS IC QoF and APHO Prevalence models for CHD, stroke/tia and hypertension based on models developed in the department of primary care and public Health Imperial College London(October and November 2008) Table 1.3: Future expected prevalence of CHD, stroke/tia, and hypertension in those aged over 16 in Southwark 2009 2010 2015 2020 CHD 10959 (4.8%) 11087 (4.7%) 11877 (4.7%) 12862 (5%) Stroke/TIA 5169 (2.2%) 5222 (2.2%) 5516 (2.2%) 5856 (2.3%) Hypertension 58593 (25.4%) 59573 (25.5%) 64016 (25.9%) 68522 (26.6%) Source: APHO Prevalence models for CHD, stroke/tia and hypertension based on models developed in the department of primary care and public Health Imperial College London(October and November 2008) Inequalities within Southwark 1.5. It can be seen from Figure 1.5 that five wards had SMRs for men more than 50 percent above the national average (Nunhead, Peckham, Cathedrals, The Lane and Camberwell Green). Of these 5 wards all except Cathedrals have high levels of deprivation. Only 5 wards had SMRs lower than the national average: Surrey Docks (not shown because of small numbers); Chaucer; South Bermondsey and Grange although upper confidence intervals for all of these (apart from Surrey Docks) are greater than 100. SMRs for females aged under 75 (not shown) are high in Nunhead, East Walworth, East Dulwich, Camberwell Green and The Lane (in descending order). 4

Figure 1.5: SMR for CVD in males under 75 years of age by ward 2003-07, Southwark 300.0 SMR CVD males < 75,by ward,southwark (2003-07) 250.0 200.0 150.0 100.0 50.0 0.0 Camberwell Green The Lane Cathedrals Peckham Nunhead East Walworth Rotherhithe Faraday Southwark Newington East Dulwich Village Livesey Peckham Rye South Camberwell Brunswick Park College Grange South Bermondsey Chaucer Riverside Source: LHO 5

Hospital admissions 1.6 Cardiovascular disease imposes a considerable demand on acute health services. In the 2008-09 financial year admission rates for circulatory disease in Southwark were similar to the National and London average (3045 admissions). Figure 1.6: Circulatory disease admissions/1000 by PCT London SHA 2008-09 Source: NHS Comparators accessed October 09 Risk factors and inequalities 1.7.There are a range of physical and lifestyle risk factors associated with CVD. These include high levels of blood fats (lipids which include cholesterol), smoking, raised blood pressure, diabetes, obesity and low rates of physical activity. The two most important modifiable risk factors are smoking and high cholesterol. (2) 1.8. Men experience higher rates of angina, heart attacks and stroke, and more severe forms of CVD. Women are at lower risk of CVD than men until after the menopause. (1) There is also a strong association between CVD and social class, ethnicity and age. 1.9. The elderly, and more socially deprived are doubly disadvantaged generally having greater prevalence of risk factors and lower rates for early detection of cardiovascular problems.(3) National policy 1.10. The national policies and strategies concerning the prevention and management of CVD including CHD and stroke include: National Service Frameworks (NSFs) for coronary heart disease, older people, and diabetes. (4, 5, 6), Health Checks Programme, the national Stroke Strategy and Healthcare for London Stroke Strategy. 1.11. Nationally the Government is committed to reducing the gap in life expectancy between spearhead PCTs and the population as a whole by at 6

least ten percent by 2010; reducing cardiovascular disease mortality by 40 percent by 2010 from its 1997 baseline, as well as decreasing the gap in CVD mortality rates between the national average and the worst fifth of local authorities by 40 percent. 1.12. Southwark is likely to achieve its life expectancy targets and has begun to close the CVD mortality gap. Action in primary care to reduce deaths from CVD is a priority in order to achieve targets on increasing life expectancy and decreasing cardiovascular disease mortality. 1.13. Effective measures to reduce premature deaths include smoking cessation, primary prevention of CVD in hypertensives under 75 years, by antihypertensive coverage and statin therapy, as well as secondary prevention of CVD. It is important to target disadvantaged groups and ethnic groups with high prevalence. What we are doing in Southwark? 1.14. Further detail is provided in disease specific sections e.g. CHD, stroke. NHS Southwark is implementing the Health Checks Programme using 2009-10 to pilot a range of approaches using general practice, community pharmacy and community outreach via health trainers. NHS Southwark has introduced a local QoF that does not allow exception reporting and incentivises practices to reach targets in excess of those set by QoF for cardiovascular disease and diabetes The PCT has a tobacco control and smoking cessation strategy which is delivered through strong partnership working involving the local authority (trading standards and environmental health), education, the smoking cessation team, primary care and community pharmacy services, the Drug Action Team, Healthy Schools and public health. However QOF data for Southwark shows that smoking status is recorded for only 58 percent of 15 to 75 year olds. Coronary heart disease 1.15. CHD is a condition where the arteries of the heart muscle become narrowed and blocked, starving it of oxygen. CHD manifests as angina and heart attack and is the most common cause of death under 75 years in the UK and Southwark (1). There were 785 deaths from CHD in Southwark in 2006, nearly one in six of all deaths. 1.16. Premature deaths in Southwark as a result of CHD (i.e. in those aged under 75) are 11% above the national average for males (though the lower confidence interval is below 100, 26% above the national average for females and 15% above the national average for persons (Table 1.4). Seventy-two percent of premature deaths occur in men. 7

Table 1.4. Standardised Mortality Ratio (SMR) Coronary Heart Disease (CHD), all ages and age < 75, males, females, persons, Southwark PCT 2005-07 (95% confidence intervals in brackets) SMR < 75 no. deaths < 75 SMR all ages no. deaths all ages Males 111(97, 128) 205 92 (83, 102) 390 Females 126 (100, 157) 80 90 (80, 101) 285 Persons 115 (102, 129) 285 91 (84, 98) 675 Source: NCHOD accessed October 2009 1.17. Deaths from acute myocardial infarction (heart attack) are a major cause of CHD deaths. Myocardial infarction death rates in men aged under- 75 and in men aged between 35 and 64 are high in Southwark (Table 1.5). Table 1.5. Standardised Mortality Ratio (SMR) Acute Myocardial Infarction (AMI) age < 75, and age 35-64 by males, females, persons, Southwark PCT 2005-07 (95% confidence intervals in brackets) SMR < 75 no. deaths < 75 SMR 35-64 no. deaths 35-64 Males 137 (112, 165) 107 162 (125, 208) 63 Females 124 (87, 173) 35 92 (42, 175) 9 Persons 133 (112,157) 142 148 (116, 187) 72 Source: NCHOD accessed October 2009 1.18. Trends in CHD mortality showed a downward trend from 1999-2001 to 2002-04. Mortality has been increasing since then in Southwark for men and women whilst declining in London and England. (Figures 1.7, 1.8 and 1.9) Figure 1.7: Trends in mortality for CHD, 1993-1995 to 2005-07 (3 year rolling averages), males aged under 75 Source: CSL HNA Toolkit 8

Figure 1.8 Trends in mortality for CHD, 1993-1995 to 2005-07 (3 year rolling averages), aged under 75, persons, Southwark, London, England Source: CSL HNA Toolkit Figure 1.9: Trends in mortality for CHD, 1993-1995 to 2005-07 (3 year rolling averages), aged under 75, females, Southwark, London, England Source: CSL HNA Toolkit 9

Prevalence of CHD 1.19. In 2008/09, Southwark GP registers recorded a total of 4,757 patients with CHD, an unadjusted local prevalence of 1.5% compared to 3.5% nationally. Expected prevalence from the APHO CHD prevalence model suggests a prevalence of 4.8% (10,959 people) in 2009 In Southwark (Tables 2 and 3). Recorded prevalence has been falling in Southwark over the past 4 years. This may be due to under recording, under diagnosis or both. Whether under diagnosis is as great as that suggested by the APHO model is questionable. However patients with CHD who are not diagnosed are more likely to suffer disease progression and premature death. Figure 4.7 shows that reported CHD prevalence in practices across Southwark varies between 0.2 percent and 5.3 percent. Figure 4.8 shows the ratio between expected (based on APHO model) and reported prevalence in practices across Southwark PCT in 2007-08 and the overall ratio for Southwark and for London. The ratios for Southwark practices vary considerably from 0.18 to 0.94. This suggests that in the first practice approximately 82% of those with CHD are either undiagnosed, unregistered or a combination of the two as opposed to about 6% in the second practice. Figure 1.10 Unadjusted prevalence of CHD by practice (2008-09) Southwark CHD prevalence by practice, 2008-09, QoF 5.0% 4.5% 4.0% 3.5% prevalence 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Source: NHS Information Centre QoF 10

Figure 1.11: Comparison of registered and estimated prevalence of CHD in Southwark general practices CHD ratio of recorded prevalence (QOF) to estimated prevalence by practice (2007-08) 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Source: QOF, NHS Information Centre Inequalities within Southwark 1.20. Figure 1.12 plots the SMR for males aged less than 75 years by individual ward. The Lane, Camberwell Green and Cathedrals wards report SMRs around 50 percent above the national rate. As with CVD deaths there is no consistent association between a ward s CHD SMR and the ward rank order for deprivation. 11

Figure 1.12 SMR for CHD among males under 75 years of age by ward and ranked according to IMD 2007 score, Southwark SMR CHD persons < 75 years, Southwark (2003-07) 250.0 200.0 150.0 100.0 50.0 0.0 Newington Chaucer Faraday South Camberwell Brunswick Park Peckham Rye Southwark South Bermondsey Peckham College Livesey Nunhead East Walworth Camberwell Green Cathedrals The Lane Source: LHO 2009 1.21. No data is shown for East Dulwich, Grange, Riverside, Rotherhithe, Surrey Docks or Village wards due to small numbers. Of the wards shown only two Newington and Chaucer have an SMR below 100. Confidence intervals are very wide due to small numbers of deaths in each ward. The 95% lower confidence interval is above 100 for Camberwell Green, Cathedrals and The Lane ward this indicates that death rates are statistically significantly higher than the national average. However we cannot say that they are not significantly higher in other wards with high SMRs that have a 95% lower confidence interval below 100 as this may be due to the small numbers which cause the confidence intervals to be wide. Hospital admissions 1.22. Hospital admission rates for CHD for Southwark for 2008-09 are lower than the London and national average (824 admissions). When admissions are looked at by elective and non-elective rates are similarly low. These lower rates of emergency admissions do not support the high CHD prevalence rates suggested by the APHO model. 12

Figure 1.13. CHD hospital admission rates/1000 London PCTs, Southwark in blue. Line in black national rate, line in pale blue London rate Source: NHS Comparators accessed October 09 Treatment of heart attacks and angina 1.23. In the three year period from April 2006 to March 2009 there were 344 admissions for myocardial infarction in Southwark residents (62.8% were males). Most myocardial infarctions occur in those aged between 55 and 74 (Table 1.6). Standardised admission ratios (SAR) for myocardial infarction in Southwark are well below the national average. There is some variation across the PCT. However no wards have a SAR in excess of the national average. First line treatment of heart attack in those suitable is now percutaneous coronary intervention (PCI). This allows the blockage in the artery to be flattened with or without the insertion of a metal stent, thus restoring blood flow to heart muscle and preventing or reducing damage to the heart muscle. In order for this to happen, patients need to have the procedure performed within 3 hours of the onset of their heart attack. This data is collected as part of the MINAP audit but is not shared widely with PCTs. Table 1.7 shows the interventions received by those admitted with myocardial infarction in 2008 financial year. About 27% had a PCI type procedure. 13

Table 1.6: Admissions for myocardial infarction by age-group (2006-2008 financial years) Age (10-year) Inpatients % 25-34 3 0.9% 35-44 12 3.5% 45-54 47 13.7% 55-64 75 21.8% 65-74 67 19.5% 75-84 81 23.5% 85+ 59 17.2% Total 344 100% Source: Dr Foster Table 1.7: Admissions acute myocardial infarction Southwark residents by intervention (2008-09 financial year) Dr Foster Procedure Number % No intervention 56 44.4% K75 Percutaneous transluminal balloon angioplasty and insertion of stent 31 24.6% K49 Transluminal balloon angioplasty of coronary artery 2 1.6% K50 Other therapeutic transluminal operations on coronary artery 1 0.8% K62 Therapeutic transluminal operations on heart 1 0.8% K63 Contrast radiology of heart 12 9.5% U20 Diagnostic echocardiography 9 7.1% U21 Diagnostic imaging procedures 3 2.4% K60 Cardiac pacemaker system introduced through vein 2 1.6% U05 Diagnostic imaging of central nervous system 2 1.6% K60 Cardiac pacemaker system introduced through vein 2 1.6% U11 Diagnostic imaging of vascular system 1 0.8% U19 Diagnostic electrocardiography 1 0.8% L74 Arteriovenous shunt 1 0.8% E85 Ventilation support 2 1.6% ALL 126 100% Source: Dr Foster 14

Quality of care in primary care 1.24. Secondary prevention (i.e. prevention of further events in those who already have a diagnosis of CHD is an effective means of reducing CHD mortality). Control of cholesterol and blood pressure are two important and complementary means of achieving this. Both of these are included in the Quality and Outcomes framework for primary care. Achievement on cholesterol control for the PCT as a whole has plateaued over the past 3 years at about 70%. However this hides considerable variation in both achievement (59.5% to 81.1%) and exception reporting by practices (from none to 22.3% - PCT average 8.6%). See Figure 1.14. Low achievement is not linked to any particular geographic area or type of practice. Figure 1.14: Percentage of patients with CHD, with well controlled cholesterol, shows those who are controlled, uncontrolled and exception reported, Southwark (2008-09) 100.00% CHD 8 (cholesterol < 5) Quality and Outcomes Framework 2008-09 exceptions not controlled control 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Source: QMAS 1.25. Likewise there is variation in blood pressure control and in exception reporting in this area also. The average for the PCT is 84.6% ranging from 69.8% to 93%. Exception reporting varies from 0% to 12.7% with an average PCT exception reporting rate of 3.8% (Figure 1.15). Good control of cholesterol and blood pressure are important in preventing further CVD events in this group of patients. 15

Figure 1.15: Percentage of patients with CHD in whom blood pressure is controlled, uncontrolled or exception reported (last reading measured in the previous 15 months) Southwark (2008-09) CHD 6 (BP<150/90) Quality and Outomes Framework 2008-09 exceptions not controlled control 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Source: QMAS What is the evidence about risk reduction? 1.26. In England and Wales, there were 68,230 fewer CHD deaths in 2000 compared with 1981. Fifty-eight percent of the decline has been attributed to reduction in risk factors, particularly a fall in smoking prevalence and the balance to improved medical and surgical treatments. Eleven percent of the decrease in mortality was due to secondary prevention the treatment of risk factors in those who already had CHD. Only four percent was attributable to angioplasty and coronary artery bypass surgery. (7, 8) 1.27,. This reinforces the importance of health promotion initiatives and primary care services for CHD. It also highlights the need for effective use of QOF data relating to diabetes, hypertension and CHD to focus evidencebased interventions that target high-risk groups. 1.28. What are we doing to address inequalities? There is close working on smoking cessation and CHD with the Southwark Tobacco Alliance. There are strong links with the Healthy Southwark Partnership through the obesity strategy group on promotion of healthy diets and physical activity. We have developed a local QoF to incentivise improved secondary prevention of CVD Implementation of health Checks Programme in Southwark 16

Stroke 1.29. A stroke occurs when the blood supply to a part of the brain is suddenly cut off as a result of a blockage or rupture to a blood vessel. The resulting harm to brain cells can leave lasting damage, affecting mobility, cognition, sight or communication. (9) 1.30. A transient ischaemic attack (TIA) is a minor stroke which is less damaging. It is often an important warning sign of a more serious stroke, heart attack, or other vascular event. The risk of stroke in the first 24 hours after TIA is higher than the risk of a heart attack after an episode of chest pain. (10) 1.31. The risk of stroke increases with age but the most important risk factor amenable to intervention is hypertension. Other important risk factors include a previous TIA, atrial fibrillation, diabetes, and smoking. (11) 1.32. Southwark has a high proportion of people from Black ethnic groups, who have stroke rates twice that for White ethnic groups. On average Black people experience their first stroke at 61 years, about twelve years earlier than White people (average first stroke aged 73). (12) Mortality 1.33. Premature mortality rates for stroke are falling in Southwark. Approximately 5% of all deaths below the age of 75 are stroke-related.; the risk of premature death from stroke in Southwark is 10 percent above the national average for persons (2005-07 pooled years data). Fifty-three percent of premature stroke deaths were in males, whereas for all ages 56% were in men (Table 1.8). Table 1.8: Standardised mortality ratios (SMR) stroke all age and under 75 for males, females, persons 2005-07 (confidence intervals in brackets) SMR all ages SMR < 75 SMR No. deaths SMR No. deaths Males 87 (74, 103) 147 106 (79,141) 49 Females 73 (63, 84) 190 115 (83, 154) 44 Persons 79 (70, 87) 337 110 (89,135) 93 Source: NCHOD accessed October 2009 1.44. Mortality rates have been falling since 1996-98 with some year on year fluctuation. The gap between rates in Southwark and England began to close in the 2003-05 period and has shown signs of further narrowing. 17

Figure 1.16: Trends in standardised mortality rates for stroke, <75 years, 1993-2007. Source: CSL HNA Toolkit Incidence and prevalence of stroke in Southwark 1.45. There are estimated to be 340 strokes and 170 TIAs per year in Southwark. (13, 14) Stroke is the main cause of adult disability. (10) Applying National Audit Office rates there will be 1,060 people in Southwark with a moderate to severe stroke-related disability. There are 2,595 (0.8% prevalence) individuals on stroke registers in Southwark. There is considerable variation in prevalence across practices. Registered prevalence of stroke in Southwark is considerably lower than predicted prevalence which is 2.2% or 5169 individuals. Figure 1.17: Stroke TIA prevalence in Southwark by practice 2008-9 Southwark Stroke/TIA prevalence by practice 2008-09 (QoF) p revalen ce 1.8% 1.6% 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% Source: QoF NHSIC 18

Figure 1.18. Registered to estimated stroke/tia prevalence ration by practice 2007-08 Registered to estimated stroke/tia prevalence ratio by practice 2007-08 1.2 1 0.8 0.6 0.4 0.2 0 Source: LHO Hospital admissions 1.46. Though prevalence appears low and premature mortality is only slightly above average, standardized admission rates for stroke are the 7 th highest in London and are higher than those for London and England. During 2008-09, there were 358 hospital admissions for cerebro-vascular disease for Southwark residents. This would tend to support the view that there is significant under-diagnosis or under-recording of stroke in Southwark. Figure 1.19: Hospital admissions rates/1000 cerebro-vascular disease 2008-09 19

Source: NHS Comparators accessed 15.10.2009 1.47. A study of the South London stroke register showed that 26 percent of persons died within 28 days of their stroke, and 37 percent within 180 days. Many survivors are left with a disability such as speech or swallowing problems, mobility problems, cognitive impairment, and mood disorders. In the South London stroke register study, a fifth of patients recovered, but half were left with severe disability as measured using the Barthel Activities of Daily Living index (ADL). Most patients who make a functional recovery do so within 13 weeks of their stroke, but the more severe the stroke the longer the period of recovery. (12) Primary care service provision related to stroke in Southwark 1.48. The quality of care a patient receives in primary care has a direct impact on their risk of developing a stroke or other cardiovascular event. For patients who have had a TIA or stroke correct treatment by primary care can reduce future risk. 1.49. Blood pressure control is important in reducing risk of a further stroke or other CVD event. In Southwark 80.6% of those on stroke registers had a BP below 150/90 ranging from 57.7% to 91.8%. Exception reporting for the PCT was 5.4% and ranged from 0% to 25% though this practice only had 4 patients on the register. Figure 1.20 Blood pressure control in patients on stroke registers in Southwark 2008-9 BP < 150/90 (Stroke 6) QoF 2008-09 exceptions not controlled controlled 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 20

Evidence of what works for stroke and TIA 1.50. There is consistent evidence that the following interventions reduce stroke risk: managing hypertension so systolic blood pressure is below 140 mmhg; anti-platelet or anti-coagulant therapy for individuals with atrial fibrillation; statin therapy for all people with more than 20 per cent risk of cardiovascular disease within ten years; and smoking cessation for all individuals who have had a stroke or TIA. (9) aspirin and management of vascular risk in those with TIA carotid endarterectomy for TIA Thrombolysis (clot busting drugs) if started within 3 hours of onset of a non-haemorrhagic stroke reduce the risk of death and disability. (15,16) Stroke units reduce death and disability through the delivery of high quality, well co-ordinated multidisciplinary care and rehabilitation. (17) 1.51. Policy Health Care for London has developed a new model of care for stroke focusing on prevention, immediate management of stroke including delivery of thrombolysis in hyper-acute stroke units, rehabilitation in stroke units and well coordinated community rehabilitation post discharge (18). The National Stroke Strategy (DH, 2007) provides a quality framework for the development of stroke services in England over the next ten years. (9) ASSET is an evaluation toolkit to help NHS commissioners deliver high quality stroke services. (13,14) Both the Government s 2005 White Paper on health and social care, Our health, our care, our say and the Commissioning Framework for Health and Well-being emphasise the need to include those who have had a stroke in discussions about commissioning their care. (19, 20) Standard 5 of the Older People NSF identifies milestones to focus on the development of specialised stroke services; primary care protocols for risk management; and referral and treatment of TIA. (5) 1.52. What are we doing to address inequalities? Implementation of Health Checks programme which will detect some of those with undiagnosed hypertension as well as those with a high risk of CVD Use of a software tool by practices to identify patients with CVD who may not be included on registers. 21

Development of a local QoF focusing on CVD (including hypertension), diabetes and CKD Inclusion of CVD and diabetes in the performance monitoring framework for primary care 1.53. Guy s and St. Thomas Charity funded a major programme to support the improvement of stroke services across Southwark and Lambeth (Stroke Modernisation Initiative). The project was driven forward by a partnership across Southwark and Lambeth PCTs, KCH and GSTFT, as well as users. A number of new initiatives have resulted: Public awareness campaign on hypertension, clinical and organisational and changes in primary care to improve the detection and management of hypertension (in the most culturally diverse/deprived area in Southwark). Introduction of thrombolysis drugs for patients whose stroke is caused by a clot; an acute response service to improve the early management of stroke; and better access to specialist TIA clinics, which has reduced waiting times by 14 days. (21) The redesign of community therapy services has improved the handover of care from hospital to community services. Initiatives include: better discharge planning; intensive rehabilitation at home; and regular review by a multidisciplinary team, including specialist stroke consultants. Further development of community stroke rehabilitation services 22

1.54. Coronary heart disease and stroke summary CVD accounts for one third of all deaths and one quarter of premature deaths The premature mortality rate for CVD, CHD and myocardial infarction is higher than the national average and CVD premature mortality rates are particularly high in some parts of Southwark The prevalence of CHD and stroke is lower than expected, indicating under registration or under diagnosis. There is wide variation in quality of care for secondary prevention and some evidence of plateauing in achievement in the management of cholesterol It is not clear what proportion of patients with acute myocardial infarction are eligible for percutaneous coronary interventions (PCI) or patients with non-haemorrhagic strokes eligible for thrombolysis 1.55. Recommendations for the JSNA process Investigate high rates of premature death from myocardial infarction Improve recording of ethnicity data in primary care Closer monitoring of exception reporting in primary care, explore setting a limit to exception reporting Monitor quality of care in general practice and support practices to improve their detection and management of CVD Investigate whether apparently low rate of PCI intervention appropriate. Investigate reasons why rates might be low Ensure acute trusts provide timely data relating to minimum dataset for HfL stroke model of care 1.56. Service priorities Continue health promotion interventions in smoking cessation, physical activity and diet Implement Health Checks programme Develop a better understanding of the low prevalence of CHD in Southwark Continue to improve the management of CVD using QOF data to highlight areas of concern Implement Health Care for London Stroke Model of Care 23

Hypertension 1.57. What is hypertension? Hypertension (high blood pressure) is a disorder in which the pressure in the arteries is too high. Once it has developed it tends to last for life. (22) 1.58. Why is it important? Hypertension is the most common long-term condition both locally and nationally. It is a highly important modifiable risk factor for heart disease, stroke and kidney failure. In turn, these conditions are associated with high NHS and social care costs for treatment and rehabilitation. It is a leading underlying cause of premature death due to associated complications such as stroke and heart disease. It is strongly related to health inequalities in Southwark. Undetected and uncontrolled hypertension has a negative impact on achieving the national health inequality targets in Southwark. It is an important cause of heart failure, peripheral vascular disease, macular degeneration (eye disease) and a risk factor for types of dementia. (22) Risk factors in the Southwark population 1.59. The prevalence of hypertension increases with age in both sexes and is higher in Black Caribbean and Black African ethnic groups. In these groups hypertension appears at a younger age, and with an increased risk of death from stroke and end stage renal failure. (22) This is particularly relevant for Southwark as our biggest ethnic minority group is people of Black African and Caribbean origin. Family history is also a risk factor for hypertension. However, studies in developing countries and in various ethnic groups suggest that genetic predisposition is relatively weak compared with the powerful influences of lifestyle and environment. (23, 24, 25) Deprivation 1.60. Similar to other long-term conditions, there is evidence of a marked social class gradient for hypertension and its consequences. (26) Lifestyle factors 1.61.Excess dietary salt, low dietary potassium, physical inactivity, overweight and obesity and psychological stressors are all modifiable risk factors. Hypertension is more prevalent among patients with diabetes irrespective of their weight and this is mostly a consequence of kidney damage (22). Many of the above risk factors co-exist in the local population in Southwark, putting them at great risk of developing hypertension. All of these risk factors are amenable to prevention, detection and effective treatment. Effectiveness of lifestyle interventions 1.62. A range of lifestyle changes can be effective in reducing systolic and diastolic blood pressure. The results from experimental trials are shown below. Small decreases in blood pressure (BP) can produce significant reductions in risk of stroke and coronary heart disease (Table 1.9). 24

Table 1.9. Lifestyle interventions for people with hypertension Intervention Average reduction in systolic/diastolic BP Percentage reducing systolic BP by 10 mmhg or Healthy weight-reducing diet 5-6 mmhg 40 Regular aerobic exercise 2-3 mmhg 30 Combined diet & exercise 4-5 mmhg 25 Relaxation techniques 3-4 mmhg 33 Alcohol within recommended limits 3-4 mmhg 30 Salt reduction below 6g per day 2 mmhg 25 Source: Management of hypertension in Adults in Primary Care (NICE Guideline) 2004 (27) Patient factors 1.63. MORI survey reported poor baseline knowledge relating to hypertension within the local population. (28) There is anecdotal evidence that poor local compliance with lifestyle advice and treatment are key issues relating to levels of hypertension. Prevalence in Southwark 1.64. March 2009, there were 29,976 adults registered with GP practices in Southwark who were diagnosed with hypertension. This represents nearly one in ten of the adult population of Southwark. Applying APHO prevalence estimates to the Southwark population suggests that only half of the expected number of patients in Southwark is currently diagnosed. There is wide variation in the prevalence between individual practices. (Figure 1.21). In general practices in the Peckham and Camberwell areas which have high levels of deprivation and the highest proportion of people from Black ethnic groups tend to have higher prevalence of hypertension. Figure 1.21 Prevalence of hypertension in Southwark, unadjusted rates, 2009 Southwark hypertension prevalence by practice 2008-09 (QoF) 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 25

Source QoF 2008-09 Information Centre Figure 1.22: Registered to expected prevalence ratio by practice 2007-8 Registered to expected prevalence ratio by practice 2007-08 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Source: LHO Quality of care in GP practices 1.65. Data from the Quality and Outcomes Framework (QOF) from general practices show that there is wide variation in the quality of care delivered by individual practices. On average 70% of those on hypertensive registers have a blood pressure below 150/90. However there is marked variation between practices both for blood pressure control and for the proportion of patients who are exception reported (ranging from just over 60% in the poorest practice to 87% in the best performing practice. Figure 1.23 Percentage of GP registered hypertensive patients with blood pressure < 150/90 in Southwark, 2009 BP 5 - % BP < 150/90 (QoF 2008-09) not controlled not exception reported exceptions BP controlled 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Source: NHS Information Centre, Quality and Outcomes Framework 26

What are we doing to address inequalities? 1.66. A multi-disciplinary Hypertension Working Group was established in Southwark in November 2006. The main gaps identified through stakeholder consultation were related to lower detection and inadequate control of blood pressure. This was due to a lack of consistency in clinical practice, patient factors and the need for improvement in organisational systems in primary care. Links were established with relevant groups across the voluntary and statutory sectors to improve patient care. 1.67 Clinical actions A local QoF has been developed which will incentivise practice to reach a threshold in excess of that set by QoF and which will not allow exception reporting. Use of software (Practice Focus) to identify those who have hypertension who are not on registers New National Institute of Clinical Excellence and British Hypertension Society algorithms on hypertension were sent to all GPs and pharmacists by medicines management team and public health. All practices were updated on their prevalence and performance in January 2007 and were offered support on data quality issues. Practice leads for hypertension were identified. Local hypertension guidelines were developed and disseminated. Two hypertension-training events were held for District Nurses, Practice Nurses and Health Care Assistants. 1.68 Community actions The Men s Health team, who offer community based blood pressure testing as part of their MOT health checks focus on specific groups including Black men from deprived communities. All pharmacies and general practices have been sent hypertension information packages and hypertension related leaflets to facilitate their awareness campaigns. The Human Resources Department of Southwark Council with Public Health ran sessions to check the blood pressure of employees. 1.69 Suggested future action Use the Health Checks programme to raise awareness of undetected hypertension particularly in groups who are at high risk of hypertension and building on previous awareness raising work carried out as part of the Stroke and Kidney Disease Modernisation Initiative Develop nurse led hypertension clinics in primary care. Develop the role of health care assistants and reception staff within 27

Support practices to audit recalls for blood pressure checks and improve the recording of ethnicity in order to target interventions. Commission local research into social, cultural and environmental factors which affect compliance with lifestyle advice and drug treatment. Provide innovative, culturally sensitive and structured education to encourage people to come for blood pressure checks and comply with their medication. Ensure hypertensive patients are signposted to local leisure services as part of the hypertension management pathway. 1.70. Hypertension summary Hypertension is an important risk factor for a number of conditions One in ten of adults in Southwark have diagnosed hypertension Only half of the expected patients are diagnosed Prevalence tends to be higher in Peckham and Camberwell practices, which have the highest proportion of black ethnic groups and highest deprivation. Control of hypertension is variable 1.71. Recommendations for the JSNA process Improve data management in primary care, including auditing of blood pressure checks and recording of ethnicity Analysis of exception reporting and how this affects health gain and inequalities. 1.72. Recommendations for improving clinical care Improve case finding in primary care Improve management of diagnosed hypertensives Increase workforce training Undertake research into how we may attain better concordance with treatment and managing lifestyle interventions in the context of Southwark s population. 28

Heart failure 1.73. Heart failure occurs when the heart becomes less efficient at pumping blood around the body. The commonest causes of heart failure are coronary heart disease and hypertension. Other causes include valvular disease and cardiomyopathies (enlargement of heart muscle). Heart failure can give rise to symptoms such as breathlessness, impaired exercise tolerance and ankle swelling. It is commoner in older people and is often diagnosed late. Early diagnosis and treatment can improve the prognosis of heart failure. Until recently heart failure has tended to be managed mostly in the acute hospital setting. Prevalence 1.74. The prevalence of heart failure in Southwark (0.4%) is lower than expected and varies across practices from 0.1% to 1.2%. Expected prevalence is about twice that of detected prevalence. Most practice prevalence is lower that expected prevalence apart from 4 practices. The quality of care in practices is difficult to assess. Heart failure is included in the quality and outcomes framework, but the indicators relate to recently diagnosed patients or sub-groups of patients so it is difficult to assess if any patients have been exception reported. Figure 1.24: Prevalence of heart failure in Southwark General Practices 2008-2009 Southwark heart failure prevalence by practice 2008-09 (QoF) 1.2% 1.0% 0.8% prevalence 0.6% 0.4% 0.2% 0.0% Source: QoF NHSIC 29

Figure 1.25: Registered/ expected prevalence of heart failure in Southwark general practices 2008-9 Registered to expected prevalence ratio heart failure by practice Southwark PCT 2007-08 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Source: LHO Evidence for what works 1.75. NICE has issued guidance on the management of Heart Failure (29). Heart failure Admissions 1.76. In 2007-08 heart failure admissions in Southwark at 87/100,000 were 10 th highest in London (215 admissions) HES Atlas. Admissions fluctuate from year to year however the overall trend looks relatively stable. Local Services 1.77. A Community heart failure programme has been developed which is part funded by the PCT and Guy s & St Thomas Charity. The objective of the programme is to diagnose patients earlier in their disease, improve management in the community, and reduce out-patient and in-patient admissions. 1.78. Recommendations Prevalence is likely to increase given the make up of our population if we do not focus more on the diagnosis and management of hypertension and CHD. Use Practice Focus to identify patients who may have heart failure who are not included on registers Use of ACE inhibitors and angiotensin inhibitors in those who have had MI Ensure community heart failure programme evaluate 30

Atrial fibrillation 1.79. Atrial fibrillation is a disorder of the rate and rhythm of the heart. Prevalence increases with age and it is associated with a number of other conditions including coronary heart disease, hyperthyroidism and high blood pressure. Atrial fibrillation increases the risk of developing clots within the heart which can break off and cause blockages in arteries in the brain thus causing strokes. Generally treatment of atrial fibrillation slows the heart rate but it can also restore it to a normal rhythm. PCT prevalence of atrial fibrillation is 0.6% and varies from 0.1 to 1.5% (Figure 1.26). The ratio of registered to expected prevalence for the PCT is 0.745 which suggests that about 25% of our population may have undiagnosed atrial fibrillation (Figure 1.27) Figure 1.26: Prevalence of diagnosed atrial fibrillation by practice Prevalence of atrial fibrillation by practice 2008-09 (QoF) 1.6% 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% 31

Figure 1. 27 Registered to expected prevalence atrial fibrillation by practice 2007-08 1.4 1.2 1 0.8 0.6 0.4 0.2 0 1.81 Evidence for what works: NICE has issued guidance on the management of atrial fibrillation. (National Institute of Clinical Excellence). Those who are deemed to be at high of stroke should be offered anti-coagulation (usually with warfarin). Those at moderate risk can be offered warfarin or aspirin and those at low risk aspirin. This reduces their risk of having an embolic stroke. The level of risk depends on the patient s age and the range of other risk factors they have for stroke (30). Quality of care: Almost 90% of those on atrial fibrillation registers are on anti-coagulant or anti-platelet therapy. This ranges from 60 to 100% (Figure 28). Exception reporting ranges from 0 to 25%. It is not clear whether patients are on the most appropriate therapy. 32

Figure 1.28 100.0% AF3. % with atrial fibrillation currently treated with anti-coagulation or anti-platelet therapy by practice 2008-09 (QoF) AF3 not treated not exception AF3 exception treated 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 1.82 Summary CVD is an important cause of premature mortality in Southwark and certain parts of Southwark have particularly high rates. Premature CHD mortality rates remain high. The gap between CHD mortality rates in women aged under 75 is widening between Southwark and England Premature mortality rates in men from myocardial infarction are high in Southwark There appears to be under diagnosis / under-recording of a range of CVD conditions 1.83. Summary of recommendations We need to further investigate the high premature mortality in men from myocardial infarction and the widening gap in CHD mortality between women in Southwark and in England We need to focus on primary prevention particularly the detection and management of hypertension in Black and Ethnic Minority Communities, and need to ensure that the Health Checks programme targets those with greatest need. We need to continue to address the issue of under-recording / underdiagnosis for the whole range of CVD conditions It is essential that we improve secondary prevention (particularly cholesterol control) and reduce variation amongst practices. We have very limited data on treatment of myocardial infarction and stroke in the acute phase as well as management of stroke 33

The implementation of the local QoF will need to be monitored and evaluated, particularly uptake in areas with high premature CVD mortality. 34