‘integration’ cvd: importance and challenges · cvd risk: nice prevention guidance 4,500 7,000...
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‘Integration’ & CVD: importance and challenges
Huon GrayNational Clinical Director for Cardiac Care, NHS England
Consultant Cardiologist, University Hospital of Southampton
Integrated Care, King’s Fund, London, 1st May 2014
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Outline
• Why is CVD important?• Why should we take an integrated approach to CVD?
• What did the CVD Outcomes Strategy say?• What does the future hold?• What are the challenges?
BHF Heart Stats (2012) http://www.bhf.org.uk/publications/view‐publication.aspx?ps=1002097
CVD Mortality in England (all <75 yrs)
Source: www.statistics.gov.uk/ statbase/Product.asp?vlnk=6725
Causes of Death (England, <75 yrs)(Source: ‘Living Well for Longer’ [ONS data], 2013)
Global Burden of Disease Study. Lancet 2013;381:997‐1020
UK causes of Years of Life Lost (both sexes, all ages) 1990-2010
259 diseases and injuries & 67 risk factors
Global Burden of Disease Study. Lancet 2013;381:997‐1020 UK causes of Years of Life Lost (both sexes, all ages) 1990-2010
259 diseases and injuries & 67 risk factors
CVD………..
• 200k deaths pa (1:3 of all)• 4.9m adults have CVD (11.7% of population)• 1.4m hospital admissions in 2010/11
• 65% were patients under 75 yrs• >50% were emergencies
• Prevalence increases with deprivation - Inequalities• CVD costs NHS & UK economy £30bn pa.
“Services for the prevention of CV Disease”NICE Commissioning Guide 45. March 2012
Outline
• Why is CVD important?• Why should we take an integrated approach to CVD?
• What did the CVD Outcomes Strategy say?• What does the future hold?• What are the challenges?
“The performance of the UK in terms of premature mortality….is below the mean of the EU15+…….further progress will require improved public health, prevention, early intervention and treatment activities……and deserves an integrated and strategic response”
INTERHEART: Risk of AMI with Multiple Risk Factors (52 countries, n≈30,000)
Yusuf et al. Lancet 2004;364:937-52
INTERHEART: Risk of AMI with Multiple Risk Factors (52 countries, n≈30,000)
Yusuf et al. Lancet 2004;364:937-52
INTERHEART: Risk of AMI with Multiple Risk Factors (52 countries, n≈30,000)
Yusuf et al. Lancet 2004;364:937-52
http://www.instituteofhealthequity.org
201120112011
2013
Global Burden of Disease Study. Lancet 2013;381:997‐1020
DALYs Attributable to 20 Risk Factors (UK)
CVD Risk: NICE Prevention Guidance
4,500 7,000
190,857
88,236
178,705
80,338
9,14618,292 14,000 20,000
30,00013,000
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
CVDDeaths
CHDDeaths
CVDDeaths
CHDDeaths
CHDMortalityreduced -
more activetravel - Low
est
CHDMortalityreduced -
more activetravel -
High est
CVDDeaths
Reduced -Salt down
3g pd to 6gpd - Low
est
CVDDeaths
Reduced -Salt down
3g pd to 6gpd - High
est
CVDdeaths
reduced by1% food
energy fromIPTFAs -Low est
CVDdeaths
reduced by1% food
energy fromIPTFAs -High est
CVDdeaths
reduced byreducing
sat fat from14% to 7%of energy
intake
Smokingrelateddeaths -
CHD
2008 2010 Each year
Num
ber o
f Dea
ths
England
Physical Activity Salt Trans fats Sat fat Cigs
Baseline
OutsideScopeOf NICEGuidance
NICE Guidance – Prevention of CVD at Population Level –Potential Impact of Risk Change on Deaths – UK (& England)
Potential Future impact in reducing nos. of deaths
Source: NICE. Prevention of Cardiovascular Disease at Population Level (PH25) (NICE. June 2010)
Vascular Disease – One Event Leads to Another
Having a strokeincreases your chance of: • Heart attack by 2-3 times• Another stroke by 9
times
Having PAD increases your chance of:
• Heart attack by 4 times• Stroke by 2-3 times
Having a heart attackincreases your chance of: • Having another heart
attack by 5-7 times• Stroke by 3-4 times
Diabetes (type 2)Because of the increased risk associated with diabetes the risk is equivalent to having a heart attack
*Includes angina and sudden death. Sudden death defined as death documented within 1 hour and attributed to coronary heart disease (CHD) **Includes only fatal heart attack and other CHD death; does not include non-fatal heart attack, + Includes death ++Includes TIA
1. Adult Treatment Panel II. Circulation 1994; 89:1333–63. 2. Kannel WB. J Cardiovasc Risk 1994; 1: 333–9. 3. Wilterdink JI, Easton JD. Arch Neurol1992; 49: 857–63. 4. Criqui MH et al. N Engl J Med 1992; 326: 381–6.
Data is increased risk vs general population (%)
Having Chronic Kidney Disease increases your chance of:
• Heart attack by 2 times
• Stroke up 50%
Renal Function & Risk of CV Events
Go AS. N Engl J Med 2004; 351: 1296
40
35
30
25
20
15
10
5
0
2.11 3.65
11.29
36.60
≥60 45–59 30–44 15–29 <15Estimated GFR (ml/min/1.73 m2)
No. of events 73,108 34,690 18,580 8809 3824
21.80
Age-standardised rate of cardiovascular events(per 100 person-y)40
35
30
25
20
15
10
5
0
2.11 3.65
11.29
36.60
≥60 45–59 30–44 15–29 <15Estimated GFR (ml/min/1.73 m2)
No. of events 73,108 34,690 18,580 8809 3824
21.80
Age-standardised rate of cardiovascular events(per 100 person-y)
Explaining the fall in CHD deaths in England 1980-2000
Treatments -43%AMI treatments -8%Secondary prevention -11%Heart failure -12%Angina: CABG/PCI -4%Angina: drugs -5%BP treatment -3%
Risk factors worse +13%Obesity +3.5%Diabetes +4.8%Less physical activity +4.4%
Risk factors better -70%Smoking -41%Cholesterol -9%Popul’n BP fall -9%Deprivation -3%Other factors -8%
0
-20,000
-40,000
-60,000
-80,000
1980 2000
IMPACT model; Redrawn fromUnal, Critchley & Capewell Circulation 2004;109(9):1101-7
68,230 fewer deaths in 2000
Outline
• Why is CVD important?• Why should we take an integrated approach to CVD?
• What did the CVD Outcomes Strategy say?• What does the future hold?• What are the challenges?
Andrew Lansley, SoS for HealthUK Stroke Forum Glasgow, 1 Dec 2011
• “In the New Year, work will begin on an Outcomes Strategy for cardiovascular disease. This will create a joined-up approach across the NHS, public health and social care, to secure the improved care set out in the Outcomes Frameworks.”
• “It will build on current strategies and the quality standards covering CVD….”
Scope“To improve outcomes for people with, or at risk of developing, CVD”Context• Increased Government focus on “the outcomes that matter
most to people” • Evidence based & cost neutral or saving• Need to create a joined-up approach to CVD across the three outcomes
frameworks (with shared implementation)
CVD Outcomes Strategy (2012‐13)
NHS Public Health Adult Social Care
Top ten priorities from professionals and charities
Better integration – primary secondary tertiary and social care 184
Government/societal approach to lifestyle/risks/ Regulation of industry e.g. food policy
138
Improve Primary Prevention 115
Self management – enable/empower 110
Use data/audit to drive quality 91
Early detection, diagnosis, risk management 83
Patient engagement / awareness empowerment 74
Improved rehabilitation services 77
Clinical Networks aligned to support new CVD Strategy implementation 70
Equal access / Reduce variation in Primary Care 47
Top ten priorities from professionals and charities
Better integration – primary secondary tertiary and social care 184
Government/societal approach to lifestyle/risks/ Regulation of industry e.g. food policy
138
Improve Primary Prevention 115
Self management – enable/empower 110
Use data/audit to drive quality 91
Early detection, diagnosis, risk management 83
Patient engagement / awareness empowerment 74
Improved rehabilitation services 77
Clinical Networks aligned to support new CVD Strategy implementation 70
Equal access / Reduce variation in Primary Care 47
INTEGRATION
★
★
★
★
★
★
★
Top ten priorities from patients and carers
1. Communication – between all health sectors & including social care– between professionals, patients and carers
– treat me as a person / respect and dignity2. ‘Joined up services’ – coordination of care at all
levels, particularly for people with comorbidities3. Continuity – seeing the same doctor / health
professional and not different people each time4. Support for patients and carers – psychological,
emotional – starting with those at risk e.g. obese5. Prevention - to include starting early – education in
schools
Top ten priorities from patients and carers
1. Communication – between all health sectors & including social care– between professionals, patients and carers
– treat me as a person / respect and dignity2. ‘Joined up services’ – coordination of care at all
levels, particularly for people with comorbidities3. Continuity – seeing the same doctor / health
professional and not different people each time4. Support for patients and carers – psychological,
emotional – starting with those at risk e.g. obese5. Prevention - to include starting early – education in
schools
INTEGRATION
Top ten priorities from patients and carers
6. Discharge planning & follow up when home, including appropriate rehabilitation
7. Access to financial and practical support –e.g. rails fitted
8. Long term care, planned management and support for rest of life as required
9. Access to services particularly transport, convenient times for appointments
10.Education of staff (especially primary / community) in specialist aspects of care
Top ten priorities from patients and carers
6. Discharge planning & follow up when home, including appropriate rehabilitation
7. Access to financial and practical support –e.g. rails fitted
8. Long term care, planned management and support for rest of life as required
9. Access to services particularly transport, convenient times for appointments
10.Education of staff (especially primary / community) in specialist aspects of care
INTEGRATION
July 2012
March 5th, 2013
https://www.gov.uk/government/publications/improving‐cardiovascular‐disease‐outcomes‐strategy
Contents
Outline
• Why is CVD important?• Why should we take an integrated approach to CVD?
• What did the CVD Outcomes Strategy say?• What does the future hold?• What are the challenges?
CVD Risk: Ageing Population
England – Population Projections (Principal) –% Growth to 2012, 2017 & 2022
1% 1% 2%
7%
3%
6%
2%
5%
2%
6%
20%
10%
22%
6%
10%
4%
7%
21%
31%
44%
10%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
0‐19 20‐44 45‐64 65‐74 75‐84 85 plus All Ages
Projected % In
crease in
Pop
ulation
2010‐2012 % Increase2010‐2017 % Increase2010‐2022 % Increase
Source: ONS Population Projections. 2010‐Based
65‐74 to growBy 20% 2010‐2017
85 plus to growBy 44% 2010‐2022
2.6 3.0 2.7 2.4
8.19.6 8.4
7.0
15.1 16.1 15.3 15.118.2
20.3 21.422.8
5.0 5.7 5.2 5.2
0
5
10
15
20
25
1994 1998 2003 2006 1994 1998 2003 2006 1994 1998 2003 2006 1994 1998 2003 2006 1994 1998 2003 2006
45-54 55-64 65-74 75 Plus All Ages
Pre
vale
nce
of IH
D (%
)
England – CHD PrevalencePersons – by Age – 1994,1998, 2003 & 2006 (Health Survey for England)
FallSince 2000
FallSince 2000 Fall
Since 2000
FallSince 2000
Source: Health Survey for England – Adult Trend Tables 2006
Identifying & Managing CVD & Risk in the Community: CHD Prevalence
Long Term Conditions: Heart Failure Prevalence
Men Women Men Women Men Women Men Women Men Women0-44 45-54 55-64 65-74 75 plus
England 0.0% 0.0% 0.2% 0.1% 0.9% 0.4% 3.1% 1.6% 13.7% 12.5%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
Prev
alen
ce o
f Hea
rt Fa
ilure
(%)
England – Heart Failure – Prevalence (%) by Age & Sex ‐ 2009General Practice Research Database 2010
Source: General Practice Research Database 2010, reported in British Heart FoundationCoronary Heart Disease Statistics . 2010 Edition
Long Term Conditions: Heart Failure ‐ Future Prevalence
2012 2017 202245 Plus
Women 371,156 398,461 453,129Men 344,728 387,815 450,342
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
Estim
ated
Pre
vale
nt C
ases
of H
eart
Failu
re
WomenMen
England – Heart Failure – Prevalence Cases – Projected Numbers to 2022 – Based on General Practice Research Database 2010
Source: General Practice Research Database 2010, reported in British Heart Foundation Coronary Heart Disease Statistics . 2010 EditionHeart Failure rates by Age/Sex applied to ONS Population Projections.
Up 10%Over 2012
Up 26%Over 2012715,884
786,276
903,470
CVD Risk: Future trend Obesity
England – Impact of Rising Trend in Obesity ‐ Predicted Increase in Cardiovascular Disease Prevalence over & above Impact of Ageing
Diabetes Coronary Heart Disease Hypertension Stroke2010 2% 1% 1% 1%2020 15% 8% 5% 5%2030 38% 20% 13% 11%2040 68% 33% 23% 18%2050 98% 44% 34% 23%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pred
icted % In
crease in
Disease Prevalence
20102020203020402050
Source: National Heart Forum. A Prediction of Obesity Trends for Adults & their Associated Diseases (NHF. February 2010)
CVDOS Recommended Actions• Seeing CVD as one condition (‘family of diseases’)• Integration of services• Risk factors, NHS Health Check• Case finding in 10 care• Better management in, and support for, 10 Care• Inherited cardiac conditions (incl. FH)• Improve survival from OHCA (CPR, AEDs, First Responders,
Education, Registry)
• Raising awareness• 24 x 7 CV Services• Care planning (phys & psych support, self care, EOL care)• Information (CVIN, Benchmarking – those at risk, quality of care)
• Researchhttps://www.gov.uk/government/publications/improving‐cardiovascular‐disease‐outcomes‐strategy
CVDOS Recommended Actions• Seeing CVD as one condition (‘family of diseases’)• Integration of services• Risk factors, NHS Health Check• Case finding in 10 care• Better management in, and support for, 10 Care• Inherited cardiac conditions (incl. FH)• Improve survival from OHCA (CPR, AEDs, First Responders,
Education, Registry)
• Raising awareness• 24 x 7 CV Services• Care planning (phys & psych support, self care, EOL care)• Information (CVIN, Benchmarking – those at risk, quality of care)
• Researchhttps://www.gov.uk/government/publications/improving‐cardiovascular‐disease‐outcomes‐strategy
INTEGRATION
Outline
• Why is CVD important?• Why should we take an integrated approach to CVD?
• What did the CVD Outcomes Strategy say?• What does the future hold?• What are the challenges?
Conclusions
• CVDOS stresses an integrated approach to prevention & care
• Challenges to better ‘integration’:– System change across existing boundaries & defining scope
– Recent major organisational change & financial constraints
– Activating levers for change (commissioning, benchmarking, QOF, CCG OIS, Tariff, NHSIQ, NICE, Networks etc.)
• Successful implementation will require collaboration
Conclusions
• CVDOS stresses an integrated approach to prevention & care
• Challenges to better integration:– System change across existing boundaries & defining scope
– Recent major organisational change & financial constraints
– Activating levers for change (commissioning, benchmarking, QOF, CCG OIS, Tariff, NHSIQ, NICE, Networks etc.)
• Successful implementation will require collaboration
• Government• NHS England• Public Health England• Health Education England • Local Authorities • NICE• NHS Improving Quality • Strategic Clinical Networks • Commissioners • Primary Care• Academic Health Science Networks • Charities • Specialist Societies • Royal Colleges • NHS Trust Development Agency • Monitor • Care Quality Commission etc.
Conclusions
• Government• NHS England• Public Health England• Health Education England • Local Authorities • NICE• NHS Improving Quality • Strategic Clinical Networks • Commissioners • Primary Care• Academic Health Science Networks • Charities • Specialist Societies • Royal Colleges • NHS Trust Development Agency • Monitor • Care Quality Commission etc.
• CVDOS stresses an integrated approach to prevention & care
• Challenges to better integration:– System change across existing boundaries & defining scope
– Recent major organisational change & financial constraints
– Activating levers for change (commissioning, benchmarking, QOF, CCG OIS, Tariff, NHSIQ, NICE, Networks etc.)
• Successful implementation will require collaboration
http://www.kingsfund.org.uk/audio‐video/joined‐care‐sams‐story
http://www.kingsfund.org.uk/audio‐video/joined‐care‐sams‐story