‘Integration’ CVD: importance and challenges · CVD Risk: NICE Prevention Guidance 4,500 7,000 190,857 88,236 178,705 80,338 9,146 18,292 14,000 20,000 30,000 13,000 0 20,000

‘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



“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





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



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


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


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


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



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



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


• Challenges to better integration:– System change across existing boundaries & defining scope




• 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.


• Challenges to better integration:– System change across existing boundaries & defining scope




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Documents

‘Integration’ CVD: importance and challenges · CVD Risk: NICE Prevention Guidance 4,500 7,000 190,857 88,236 178,705 80,338 9,146 18,292 14,000 20,000 30,000 13,000 0 20,000