Improving outcomes for CVD Dr Kathryn Griffith - CVD Clinical Lead, VOY CCG Dr Maurice Pye - Consultant Cardiologist, YTHFT Shane Hayward-Giles - NHS Right Care Delivery Partner Fiona Ottewell - NHS Right Care Delivery Partner Carl Donbavand - Improvement Manager & Project lead, VOY CCG

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CVD Opportunities – CHD and Stroke Primary care & Prevention Unplanned Admissions Hospital Length of Stay Hospital Procedures Acute MI, Cerebral infarctions Cholesterol, Hypertension, AF

8 19 4,964 339 1,149 952

Cholesterol management – CCG variation

Cholesterol management - Practice variation QOF 14 - The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less

Cholesterol - What do we know? Cholesterol Treatment Trialist’s (CTT) collaborators: meta-analyses of mortality and morbidity from all relevant large-scale randomised trials of statin therapy. Per 1 mmol/l reduction in LDL-C 12% reduction in all-cause mortality 19% reduction in coronary mortality 24% reduction in the need for revascularisation 17% reduction in stroke 21% reduction in any major vascular Importantly, a similar proportional benefit was observed in different age groups, across genders, at different levels of baseline lipids [including triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C)] and equally among those with prior CAD and cardiovascular (CV) risk factors as in those without. Cholesterol Treatment Trialists’ (CTT) Collaborators. (2012). The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet, 380(9841), 581–590. http://doi.org/10.1016/S0140-6736(12)60367-5

Case Study: Bradford Healthy Hearts Highest premature mortality for CHD in England Population-based mind-set approach. Primary care led System wide engagement primary & secondary care. Included: cardiology, diabetes, lipid clinic and vascular surgeons Treatment to guidelines standards not to QOF Over 6000 on simvastatin with total cholesterol >4 mmol/l or LDL >2 mmol/l were switched to atorvastatin 40/80mg Completed switches within 3 months!

Case Study: Bradford Healthy Hearts How they did it? Clinical team from primary and secondary care developed protocols and clinical searches to identify patients not at target Template letter sent to patients explaining reasons for change Process supported by website and patient education programme Coverage in local media and press Bulk prescribing switches for all appropriate patients Primary care workload? Reported 1-2 mins per computer record review Only a handful of patients that weren't happy about the switch and needed to speak to a GP or pharmacist – Patient communication and engagement was key If done the traditional face to face way, statin switches & QRISK work would have taken up to an extra 24,000 appointments across CCG.

Case Study: Bradford Healthy Hearts Outcomes: Achieved 0.56% mmol/l reduction in LDL (and TC 0.9mmol/l) over 3 months (p<0.001) Improved mortality – including 60 less deaths last year Combined outcomes: Reduction in non-elective admissions estimated net savings £1.2M over 15 months What can we do in the Vale of York?

‘Yor-Healthy Hearts’?

Hypertension - What do we know? High BP contributes to half of all heart attacks and strokes Treatment is very effective at lowering blood pressure and at improving outcomes Every 10 mmHg drop in BP was associated with a 20% reduction in cardiovascular events BHF data for CCG

Hypertension detection – CCG variation

Hypertension Detection & Management Detection of high BP Management of high BP

What might help? Hypertension detection Maximise uptake of NHS health check Opportunistic testing / case finding in practices Support access to BP equipment / empowering patients to do home testing / consider community pharmacy Hypertension management Develop hypertension protocols (e.g. Bradford Healthy Hearts) Simple protocol following guidelines for all vascular patients used across primary and secondary care Patient led protocols for management with home monitoring Technology for diagnosis of BP with 24hr BP and home monitoring Empowering patients to make behaviour changes Education events for practitioners and patients Pharmacist follow-up

6 192 77 39

Stroke Pathway Summary: BP and AF Quality Opportunity Patients with stroke/TIA whose BP > 150/90 192 Excess Mortality from stroke under 75 years 6 High-risk AF patients not on anticoagulation therapy 77 Stroke patients treated by early supported discharge team (qtrly opp) 39

AF produces big red clots!! AF strokes are more severe strokes 25% AF strokes are fatal compared with 15% none AF strokes Increased death persists for up to 8 years Hospital admission times longer Only 20% live independently after stroke

AF – What do we know? Among those with a stroke, those with AF experienced a worse stroke with 70% increase in hospital mortality 40% reduction in relative change to discharge own home 20% increase in hospital LOS The diagnosed prevalence in our CCG is 1.9% and the estimated prevalence is 2.6%. There could be an additional 2,600 people with undiagnosed AF in the CCG. Source: Health and Social Care Information Centre (HSCIC) Quality and Outcomes Framework (QOF), 2014/15; National Cardiovascular Intelligence Network (NCVIN), 2014/15

AF – Detection

AF patients on Anticoagulation therapy: QOF data CHADS2 >1

AF patients on Anticoagulation therapy Warfarin INR 2.5-3 reduces stroke risk by 64% SSNAP (Sentinel Stroke National Audit Programme) data for period April – July 2016: 58 people in AF admitted to York Hospital with stroke. 26 had been prescribed anticoagulation prior to their stroke. 32 had a stroke without protection from an anticoagulant With 64% reduction in events 21 strokes could have been avoided with appropriate anticoagulation Over a year period there were 84 avoidable strokes from July 2015 – July 2016!

What are the barriers to detection and management of AF What are the barriers to detection and management of AF? What support would you need to change?

Are you aware of these?

Our Priorities? Primary care & Prevention Unplanned Admissions Hospital Length of Stay Hospital Procedures Acute MI, Cerebral infarctions Cholesterol, Hypertension, AF

Be Actively involved Keep me informed How can I get involved? Keep me informed Share ideas / input with solutions Be Actively involved E.g. Developing and testing out solutions, project group involvement, Training & development

Questions?

Thank you Carl Donbavand – Innovation and improvement Manager & CVD Project lead, VOY CCG Carl.donbavand@nhs.net Dr Kathryn Griffith – CVD clinical lead, VOY CCG kathryn.griffith@nhs.net Dr Maurice Pye – Consultant Cardiologist, YTHFT maurice.pye@york.nhs.uk Shane Hayward-Giles NHS Right Care Delivery Partner shane.hayward-giles@nhs.net Fiona Ottewell - NHS Right Care Delivery Partner fiona.ottewell@nhs.net