Tackling Coronary Heart Disease

Inequality in CHD services health outcomes how much? What is to be done? Population public health interventions

What conclusions can be drawn from the HLPI data about inequalities in service provision and health outcomes for CHD, across Northern and Yorkshire?

What are HLPIs? Higher Level Performance Indicators Values attributed to each Health Authority in England, recording their performance in various parameters Adjusted for age and sex NOT adjusted for social and economic characteristics of a population

Accessing HLPIs /index.htm Deaths from all Deaths from all Deaths from Deaths from SuicidesDeaths from Accident Morbidity causes age causes age cancer circulatory diseasesaccidents SpecificationSpecificationSpecificationSpecificationSpecificationSpecificationSpecification ENGLAND Avon Barking and Havering Barnet Barnsley Bedfordshire

Purpose of HLPIs allow comparisons to be made between different Health Authorities and NHS trusts reflect key Government priorities highlight areas of inequality, to be addressed by the National Plan

Drawbacks of HLPIs Difficulty interpreting the data as presented on the website Not direct measures of quality Differing data collection methods Values are averages for each HA Do not assess coping vs demand Misleading if examined alone

CHD parameters Deaths from all circulatory diseases (under 75 years only) Surgery rates for CHD Deaths in hospital within 30 days of admission for a heart attack (35-74 years only)

Deaths from all circulatory diseases by Health Authority Age/sex standardised rate per 100,000 persons aged under 75

Deaths in hospital within 30 days following a heart attack by Health Authority Age/sex-standardised rate per 100,000 persons aged years

Revascularisation rate by Health Authority Age-standardised rate per 100,000 persons aged under 75 years,

CHD trends in England from twofold variation in the death rate from all circulatory disease between the worst and best Health Authorities whilst there was a 9% increase between 1997/98 and 1998/99 in the elective surgery rates for CABG/PTCA, one third of all Health Authorities saw no increase at all

CHD trends in the Northern and Yorkshire region all except N. Yorkshire of the 13 DHA are above the England average for deaths from circulatory diseases, with 8 appearing in the top DHA are below the England average for deaths in hospital within 30 days of admission for a heart attack 9 DHA are above England average for revascularisation rates, but only Tees is nearing the 1500/million NSF goal

Revascularisation rate and circulatory disease death rate for all Health Authorities in England Age/sex standardised rate per 100,000 persons aged under 75 years,

Revascularisation rate and circulatory disease death rate for Northern and Yorkshire region Age/sex standardised rate per 100,000 persons under 75 years, some correlation between death rate and revascularisation rate high circulatory disease death rates for all Health Authorities within Northern and Yorkshire

Association between average distance travelled for revascularisation and revascularisation rate by Health Authority in England,

Townsend deprivation score 4 indicators used to assess level of deprivation 1Unemployment - percent of economically active residents aged /64 who are unemployed 2Car ownership - percent of private households who do not possess a car 3Home ownership - percent of private households not owner occupied 4Overcrowding - percent of private households with more than one person per room the higher the score, the higher the level of deprivation

Deaths from circulatory disease against Townsend deprivation score for England Age/sex standardised rate per 100,000 persons under 75 years

Circulatory disease deaths and Townsend deprivation score for Northern and Yorkshire region positive correlation between death from circulatory disease and Townsend deprivation score no significant correlation found between death within 30 days following AMI or surgery rate and Townsend deprivation scores

Conclusion inequalities within England and Northern and Yorkshire region for CHD poorer health outcomes in Northern and Yorkshire region for CHD provision of services for CHD is more in line with need in Northern and Yorkshire region than England difficult to interpret HLPI

National Service Framework for Coronary Heart Disease.

What is an NSF? Key tool for tackling major health issues and important diseases. Aims to improve health, reduce inequalities and raise the quality of care. Sets of a vision for the future. Will evolve over time.

Why does CHD need targeting? Every year >1.4 million people suffer from angina. 300,000 people have heart attacks each year 135,000 patients die of heart problems. 35 million days are lost each year due to CHD. Inequalities in prognosis.

CHD 22% All causes 78% CHD All causes CHD as a proportion of deaths from all causes in England and Wales in 1998

NSF for CHD Published in March 2000 Aimed at transforming the prevention, diagnosis and treatment of CHD. Ensures services are available to everyone who can benefit. Over a ten year period will save 20,000 lives/year. Sets out 12 standards of system reform and expansion.

Principles underpinning the NSF. Reducing the burden of CHD requires action across society, not just the NHS. Quality of care depends on: –access to appropriate services –interaction between clinicians and patients. –Quality of the organisation and environment. Simple things done at the right time. Structured and systematic care.

Making it happen. Local health communities and delivery plans. National and regional systems and strategies to support this. National CHD implementation group. Regional offices of the NHSE to monitor performance.

Health Outcomes NSF established 12 standards for –prevention –diagnosis –treatment of CHD Remain relevant for 10 years (or more!)

Standards Reduce heart disease in the population –reduce prevalence of risk factors –reduce inequalities of risk factors –reduce prevalence of smoking Prevent CHD in high risk patients –identify people with established CHD –identify people at significant risk

Heart attack and other acute coronary syndromes –receive expert help within 8 minutes of calling for help –assessed professionally, and receive aspirin –protocols be put in place by NHS trusts

Stable angina –receive appropriate investigations and treatment

This guy goes on!

Stable angina –receive appropriate investigations and treatment Revascularisation –urgent referral to cardiologist –hospital-wide system of care

Heart failure –appropriate investigations or alter diagnosis –identify cause and treat Cardiac rehabilitation –multidisciplinary programme offered

Inequality in CHD services health outcomes how much? What is to be done? Population public health interventions

Services Population Smoking cessation High risk prevention Primary care clinics Acute coronary syndromes Quick hospital care Stable angina Ix and Rx protocols Revascularisation Protocols for Ix Targets for Rx Heart failure Community support Dedicated hospital clinics Rehabilitation Lifestyle interventions Education

Inequalities Resources Health Action Zones Prevention or cure? Re-enforcing inequalities? Evaluation Primary Care Trusts shifting the balance of power

The NSF has a strong NHS focus to tackling CHD. What wider public health initiatives might improve CHD health outcomes at a population level?

Saving Lives:Our Healthier Nation Target: to reduce the death rate from coronary heart disease and stroke and related diseases in people under 75 years by at least two fifths by 2010-saving up to 200,000 lives in total

Smoking Kills: White paper reduce illegal sales of cigarettes monitor the advertising ban encourage media advocacy reduce smoking in public places work to support any national media campaigns develop smoking cessation services.

Smoking cessation services identify smoking status of patients provide advice and info on NRT access to smoking cessation services including back-up of intensive services provision of NRT, free for one week to poorer smokers Don’t Give Up Giving Up

Specialist Health Promotion Services Smoking Cessation Services Number of people setting a quit date2284 Number of people quit at 4weeks1260 Number of people not quit at 4weeks599 Number of people not known/lost to425 follow up Target for 2000/

Healthy diet National School Fruit Scheme Five-a-day programme work with food industry a reform of the welfare foods programme hospital nutrition policy involvement of family and friends

Physical inactivity regular exercise aim to encourage adults to build into daily routine, half an hour of moderate exercise prevent or delay hypertension control diabetes and regulate weight

Physical inactivity promotes safe, healthy travel to school National Healthy Schools Standard which includes physical activity Exercise referral Health Walk Programme

Overweight/obesity for overweight people(BMI 25+) or obese(30+), a 10% weight loss can confer significant health benefits central obesity gives higher risk dietary advice combined with physical activity support

Summary Government cannot succeed through its actions alone. It needs to work in partnership with local players such as the NHS, local authorities, schools and employers.