CVD: Primary Care Intelligence Packs - GOV.UK

CVD: Primary Care Intelligence

Packs

June 2017

Version 1

NHS North Durham CCG

Contents 1. Introduction 3

2. CVD prevention

• The narrative 11

• The data 13

3. Hypertension


• The data 17

4. Stroke


• The data 28

5. Diabetes


• The data 43

6. Kidney


• The data 54

7. Heart


• The data 66

8. Outcomes 82

9. Appendix 88

2

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CVD: Primary Care Intelligence Packs

3

Introduction


4

This intelligence pack has been compiled by GPs and nurses and pharmacists in

the Primary Care CVD Leadership Forum in collaboration with the National

Cardiovascular Intelligence Network

Matt Kearney Sarit Ghosh Kathryn Griffith

George Kassianos Jo Whitmore Matthew Fay

Chris Harris Jan Procter-King Yassir Javaid

Ivan Benett Ruth Chambers Ahmet Fuat

Mike Kirby Peter Green Kamlesh Khunti

Helen Williams Quincy Chuhka Sheila McCorkindale

Nigel Rowell Ali Morgan Stephen Kirk

Sally Christie Clare Hawley Paul Wright

Bruce Taylor Mike Knapton John Robson

Richard Mendelsohn Chris Arden David Fitzmaurice


Local intelligence as a tool for clinicians and commissioners

to improve outcomes for our patients

Why should we use this CVD Intelligence Pack

The high risk conditions for cardiovascular disease (CVD) - such as hypertension, atrial fibrillation, high cholesterol,

diabetes, non-diabetic hyperglycaemia and chronic kidney disease - are the low hanging fruit for prevention in the NHS

because in each case late diagnosis and suboptimal treatment is common and there is substantial variation. High

quality primary care is central to improving outcomes in CVD because primary care is where much prevention and

most diagnosis and treatment is delivered.

This cardiovascular intelligence pack is a powerful resource for stimulating local conversations about quality

improvement in primary care. Across a number of vascular conditions, looking at prevention, diagnosis, care and

outcomes, the data allows comparison between clinical commissioning groups (CCGs) and between practices.

This is not about performance management because we know that variation can have more than one interpretation.

But patients have a right to expect that we will ask challenging questions about how the best practices are achieving

the best, what average or below average performers could do differently, and how they could be supported to perform

as well as the best.

How to use the CVD intelligence pack

The intelligence pack has several sections – CVD prevention, hypertension, stroke and atrial fibrillation (AF), diabetes,

kidney disease, heart disease and heart failure. Each section has one slide of narrative that makes the case and asks

some questions. This is followed by data for a number of indicators, each with benchmarked comparison between

CCGs and between practices.

Use the pack to identify where there is variation that needs exploring and to start asking challenging questions about

where and how quality could be improved. We suggest you then develop a local action plan for quality improvement –

this might include establishing communities of practice to build clinical leadership, systematic local audit to get a better

understanding of the gaps in care and outcomes, and developing new models of care that mobilise the wider primary

care team to reduce burden on general practice.

5 CVD: Primary Care Intelligence Packs

6

Data and methods

This slide pack compares the clinical commissioning group (CCG) with CCGs in its strategic transformation plan (STP) and

England. Where a CCG is in more than one STP, it has been allocated to the STP with the greatest geographical or

population coverage. The slide pack also compares the CCG to its 10 most similar CCGs in terms of demography, ethnicity

and deprivation. For information on the methodology used to calculate the 10 most similar CCGs please go to:

http://www.england.nhs.uk/resources/resources-for-ccgs/comm-for-value/

The 10 most similar CCGs to NHS North Durham CCG are:

NHS Lincolnshire West CCG

NHS North Staffordshire CCG

NHS Newcastle Gateshead CCG

NHS Norwich CCG

NHS Canterbury and Coastal CCG

NHS West Leicestershire CCG

NHS North East Essex CCG

NHS North East Lincolnshire CCG

NHS West Cheshire CCG

NHS Barnsley CCG

The majority of data used in the packs is taken from the 2015/16 Quality and Outcomes Framework (QOF). Where this is

not the case, this is indicated in the slide. All GP practices that were included in the 2015/16 QOF are included. Full

source data are shown in the appendix.

For the majority of indicators, the additional number of people that would be treated if all practices were to achieve as well

as the average of the top achieving practices is calculated. This is calculated by taking an average of the intervention rates

(ie the denominator includes exceptions) for the best 50% of practices in the CCG and applying this rate to all practices in

the CCG. Note, this number is not intended to be proof of a realisable improvement; rather it gives an indication of the

magnitude of available opportunity.


Benchmarking is helpful because it highlights

variation.

Of course it has long been acknowledged that some

variation is inevitable in the healthcare and outcomes

experienced by patients.

But John Wennberg, who has championed research

into clinical variation over four decades and who

founded the pioneering Dartmouth Atlas of Health

Care, concluded that much variation is unwarranted –

ie it cannot be explained on the basis of illness,

medical evidence, or patient preference, but is

accounted for by the willingness and ability of doctors

to offer treatment.

Benchmarking may not be conclusive. Its strength lies not in

the answers it provides but in the questions it generates for

CCGs and practices.

For example:

1. How much variation is there in detection, management,

exception reporting and outcomes?

2. How many people would benefit if average performers

improved to the level of the best performers?

3. How many people would benefit if the lowest performers

matched the achievement of the average?

4. What are better performers doing differently in the way

they provide services in order to achieve better outcomes?

5. How can the CCG support low and average performers to

help them match the achievement of the best?

6. How can we build clinical leadership to drive quality

improvement?

A key observation about benchmarking data is

that it does not tell us why there is variation. Some of the

variation may be explained by population or case mix and

some may be unwarranted. We will not know unless we

investigate.

The variation that exists between

demographically similar CCGs and

between practices illustrates the local

potential to improve care and outcomes

for our patients

There are legitimate reasons for exception reporting. But …….

Excepting patients from indicators puts them at risk of not receiving optimal care and of having worse outcomes. It is also

likely to increase health inequalities. The substantial variation seen in exception reporting for some indicators suggests

that some practices are more effective than others at reaching their whole population. Benchmarking exception reporting

allows us to identify the practices that need support to implement the strategies adopted by low excepting practices.

Why does variation matter?

7

Cluster methodology: your most similar practices

Each practice has been grouped on the basis of demographic data into

15 national clusters. These demographic factors cover:

• deprivation (practice level)

• age profile (% < 5, % < 18, % 15-24, % 65+, % 75+, % 85+)

• ethnicity (% population of white ethnicity)

• practice population side

These demographic factors closely align with those used to calculate

the “Similar 10 CCGs”.

These demographic factors have been used to compare practices with

similar populations to account for potential factors which may drive

variation. Some local interpretation will need to be applied to the data

contained within the packs as practices with significant outlying

population characteristics e.g. university populations or care home

practices will need further contextualisation.

Further detailed information including full technical methodology and a

full PDF report on each of the 15 practice clusters is available here:

https://github.com/julianflowers/geopractice.


https://github.com/julianflowers/geopractice

7

9

22

21

17

31

14

15

12

9

3

5

1

1

1

-20%-15%-10%-5%0%5%

WELLINGTON ROAD SURGERY

EMERSONS GREEN MEDICAL CENTRE

LEAP VALLEY MEDICAL CENTRE

CHRISTCHURCH FAMILY MEDICAL CENTRE

CONISTON MEDICAL PRACTICE

FROME VALLEY MEDICAL CENTRE

ST MARY STREET SURGERY

KINGSWOOD HEALTH CENTRE

CONCORD MEDICAL CENTRE

KENNEDY WAY SURGERY

BRADLEY STOKE SURGERY

THE WILLOW SURGERY

CLOSE FARM SURGERY

PILNING SURGERY

COURTSIDE SURGERY

ALMONDSBURY SURGERY

STOKE GIFFORD MEDICAL CENTRE

ORCHARD MEDICAL CENTRE

WEST WALK SURGERY

THORNBURY HEALTH CENTRE - BURNEY

The performance of every practice in the GP cluster contributes to the average of the top performing

50% of practices to form a benchmark.

The difference between the benchmark and the selected practices is displayed on this chart. The benchmark will

most likely be different for different practices as they are in different clusters, so the difference is the key measure

here. If the practice performance is below the benchmark, the difference is applied to the denominator plus

exceptions to demonstrate potential gains on a practice basis. The potential gains on a CCG basis are calculated

based on the difference between the top 5 performing closest CCGs and the selected CCG, applied to the

denominator plus exceptions.

Cluster methodology: calculating potential gains

Raw difference between the

practice value

and the average of the

highest or lowest 50% of

similar cluster practices

Potential opportunity if

the practice value was

to move to the average

of the highest 50% of

similar cluster practices

Potential opportunity if the

CCG value were to move

to the average of the top 5

performing closest CCGs


CVD prevention


CVD prevention “The NHS needs a radical upgrade

in prevention if it is to be

sustainable”

5 year Forward View 2014

The size of the prevention problem

• 2/3 of adults are obese or overweight

• 1/3 of adults are physically inactive

• average smoking prevalence is 17% but is much

higher in some communities

• in high risk conditions like atrial fibrillation, high blood

pressure, diabetes and high ten year CVD risk score,

up to half of all people do not receive preventive

treatments that are known to be highly effective at

preventing heart attacks and strokes

• around 90% of people with familial hypercholestero-

laemia are undiagnosed and untreated despite their

average 10 year reduction in life expectancy

This is because England faces an epidemic of largely

preventable non-communicable diseases, such as heart

disease and stroke, cancer, Type 2 diabetes and liver disease.

The Global Burden of Disease Study (next slide) shows us that

the leading causes of premature mortality include diet,

tobacco, obesity, raised blood pressure, physical inactivity and

raised cholesterol. The radical upgrade in prevention needs

population-level approaches. But it also needs interventions in

primary care for individuals with behavioural and clinical risk

factors.

0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12%

Unsafe water/ sanitation/ handwashing

Unsafe sex

Other environmental risks

Sexual abuse and violence

Child and maternal malnutrition

Low bone mineral density

Air pollution

Occupational risks

Low physical activity

Low glomerular filtration rate

High total cholesterol

High fasting plasma glucose

Alcohol and drug use

High systolic blood pressure

High body-mass index

Tobacco smoke

Dietary risks

HIV/AIDS and tuberculosis

Diarrhea, lower respiratory & other common infectious diseases

Neglected tropical diseases & malaria

Maternal disorders

Neonatal disorders

Nutritional deficiencies

Other communicable, maternal, neonatal, & nutritional diseases

Neoplasms

Cardiovascular diseases

Chronic respiratory diseases

Cirrhosis

Digestive diseases

Neurological disorders

Mental & substance use disorders

Diabetes, urogenital, blood, & endocrine diseases

Musculoskeletal disorders

Other non-communicable diseases

Transport injuries

Unintentional injuries

Self-harm and interpersonal violence

Forces of nature, war, & legal intervention

Percent of total disability-adjusted life-years (DALYs)

Social prescribing and wellbeing hubs offer new

models for supporting behaviour change while reducing

burden on general practice.

The NHS Health Check is a systematic approach to

identifying local people at high risk of CVD, offering

behaviour change support and early detection of the

high risk but often undiagnosed conditions such as

hypertension, atrial fibrillation, CKD, diabetes and pre-

diabetes.

Question: What proportion of our local eligible

population is receiving the NHS Health Check and how

effective is the follow-up management of their clinical

risk factors in primary care?

11 11 CVD: Primary Care Intelligence Packs

Global Burden of Disease Study 2015

Risk Factors for premature death and disability caused by CVD in England, expressed as a percentage of total disability-adjusted life-years

0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%

Other environmental risks

Low glomerular filtration rate

Air pollution

Low physical activity

High fasting plasma glucose

Tobacco smoke

High body-mass index

High total cholesterol

Dietary risks

High systolic blood pressure

Percentage of total CVD disability-adjusted life-years (DALYs)


15.3%

16.2%

16.2%

16.7%

16.9%

18.2%

18.6%

19.6%

20.0%

21.6%

23.5%

0% 5% 10% 15% 20% 25%









NHS Norwich CCG

NHS Barnsley CCG


13

Estimated smoking prevalence (QOF) by CCG

Comparison with demographically similar CCGs

Note: It has been found that the proportion of

patients recorded as smokers correlates well

with IHS smoking prevalence and is a good

estimate of the actual smoking prevalence in

local areas,

http://bmjopen.bmj.com/content/4/7/e005217.abs

tract

Definition: denominator of QOF clinical indicator

SMOKE004 ( number of patients 15+ who are

recorded as current smokers) divided by GP

practice’s estimated number of patients 15+


• prevalence of 16.2% in NHS North

Durham CCG

http://bmjopen.bmj.com/content/4/7/e005217.abstract

http://bmjopen.bmj.com/content/4/7/e005217.abstract

5.7%

7.7%

9.5%

10.5%

12.4%

13.9%

14.5%

15.0%

15.1%

15.1%

15.2%

15.5%

16.4%

17.6%

17.6%

18.0%

18.7%

19.4%

19.6%

19.7%

20.2%

20.4%

21.0%

21.8%

23.0%

23.4%

23.5%

23.7%

23.7%

23.9%

27.1%

0% 5% 10% 15% 20% 25% 30%

CLAYPATH & UNIVERSITY MEDICAL GROUP A83011

LANCHESTER MEDICAL CENTRE A83072

CHASTLETON MEDICAL GROUP A83036

CHEVELEY PARK MEDICAL CTR A83055

CESTRIA HEALTH CENTRE A83050

BELMONT & SHERBURN MEDICAL GROUP A83014

GREAT LUMLEY SURGERY A83029

QUEENS ROAD SURGERY A83049

OAKFIELDS HEALTH CENTRE A83618

MIDDLE CHARE MEDICAL GROUP A83028

CEDARS MEDICAL GROUP A83038

BRIDGE END SURGERY A83009

BOWBURN MEDICAL CENTRE A83635

COXHOE MEDICAL PRACTICE A83027

WEST RAINTON SURGERY A83024

DUNELM MEDICAL PRACTICE A83030

CONSETT MEDICAL CENTRE A83018

PELTON & FELLROSE MEDICAL GROUP A83033

THE HAVEN SURGERY A83622

DIPTON SURGERY A83076

THE MEDICAL GROUP A83022

SACRISTON MEDICAL CENTRE A83026

LEADGATE SURGERY A83636

TANFIELD VIEW MEDICAL GROUP A83016

STANLEY MEDICAL GROUP A83023

BROWNEY HOUSE SURGERY A83617

CRAGHEAD MEDICAL CENTRE A83632

ANNFIELD PLAIN SURGERY A83644

DRS LAMBERT & NG A83073

DENHOLM HOUSE A83630

PELTON FELL SURGERY A83637

GP Practice CCG

14

Estimated smoking prevalence (QOF) by GP practice

Note: This method is thought to be a reasonably

robust method in estimating smoking prevalence

for the majority of GP practices. However,

caution is advised for extreme estimates of

smoking prevalence and those with high

numbers of smoking status not recorded and

exceptions.


• 34,996 people who are recorded as

smokers in NHS North Durham CCG

• GP practice range: 5.7% to 27.1%

Hypertension


16

The Missing Millions On average, each CCG in England has 26,000 residents with

undiagnosed hypertension – these individuals are unaware of

their increased cardiovascular risk and are untreated.

What might help? • support practices to share audit data and systematically

identify gaps and opportunities for improved detection and

management of hypertension

• work with practices and local authorities to maximise

uptake and follow up in the NHS Health Check

• support access to self-test BP stations in waiting rooms

and to ambulatory blood pressure monitoring.

• commission community pharmacists to offer blood

pressure measurement, diagnosis and management

support, including support for adherence to medication

What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement

and exception reporting?

2. how many people would benefit if all practices performed

as well as the best?

3. how can we support practices who are average or below

average to perform as well as the best in:

• detection of hypertension

• management of hypertension What do we know? • at least half of all heart attacks and strokes are

caused by high blood pressure and it is a major risk

factor for chronic kidney disease and cognitive decline

• treatment is very effective – every 10mmHg reduction

in systolic blood pressure lowers risk of heart attack

and stroke by 20%

• despite this 4 out of 10 adults with hypertension, over

5 and a half million people in England, remain

undiagnosed

• and even when the condition is identified, treatment is

often suboptimal, with blood pressure poorly

controlled in about 1 out of 3 individuals

Hypertension

High blood pressure is common and costly • it affects around a quarter of all adults

• the NHS costs of hypertension are around £2bn

• social costs are probably considerably higher


The Global Burden of Disease

Study confirmed high blood pressure as

a leading cause of premature death

and disability

0.59

0.60

0.60

0.60

0.60

0.61

0.62

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

England

NHS South Tees CCG


NHS Hambleton, Richmondshire And Whitby CCG

NHS Darlington CCG

NHS Hartlepool And Stockton-On-Tees CCG

NHS Durham Dales, Easington And Sedgefield CCG

Ratio

0.59

0.60

0.60

0.60

0.60

0.61

0.62

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

England

NHS South Tees CCG



NHS Darlington CCG



Ratio

17

Hypertension observed prevalence compared with expected prevalence by CCG

Comparison with CCGs in the STP


Note: this slide shows Hypertension prevalence

estimates created using data from QOF

hypertension registers 2014/15 and

Undiagnosed hypertension estimates for adults

16 years and older. 2014. Department of Primary

Care & Public Health, Imperial College London

• the ratio of those diagnosed with

hypertension versus those expected

to have hypertension is 0.6. This

compares to 0.59 for England

• this suggests that 60% of people with

hypertension have been diagnosed

0.55

0.58

0.59

0.59

0.59

0.60

0.60

0.60

0.61

0.61

0.62

0% 10% 20% 30% 40% 50% 60% 70%

NHS Norwich CCG









NHS Barnsley CCG


18

Hypertension observed prevalence compared with expected prevalence by CCG



0.40

0.54

0.55

0.55

0.56

0.56

0.57

0.57

0.59

0.59

0.59

0.59

0.60

0.61

0.61

0.62

0.62

0.62

0.63

0.63

0.63

0.64

0.64

0.64

0.65

0.65

0.66

0.68

0.70

0.71

0.73

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
































Ratio

GP practice CCG

19

Hypertension observed prevalence compared with expected prevalence by GP practice

• it is estimated that there are 25,983

people with undiagnosed

hypertension in NHS North Durham

CCG

• GP practice range of observed to

expected hypertension prevalence

0.4 to 0.73


79.6%

80.0%

81.4%

82.1%

82.2%

82.3%

82.7%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

England

NHS South Tees CCG




NHS Darlington CCG


79.6%

80.0%

81.4%

82.1%

82.2%

82.3%

82.7%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

England

NHS South Tees CCG




NHS Darlington CCG


20

Percentage of patients with hypertension whose last blood pressure reading (measured in

the preceding 12 months) is 150/90 mmHg or less by CCG


*Using QOF clinical indicator HYP006

denominator plus exceptions

• 39,165 people with hypertension

(diagnosed)* in NHS North Durham

CCG

• 32,135 (82.1%) people whose blood

pressure is <= 150/90

• 1,313 (3.4%) people who are

excepted from optimal control

• 5,717 (14.6%) additional people

whose blood pressure is not <=

150/90


78.8%

79.6%

79.9%

80.1%

80.5%

81.3%

81.5%

81.6%

82.1%

82.2%

82.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

NHS Barnsley CCG






NHS Norwich CCG





21

Percentage of patients with hypertension whose last blood pressure reading (measured in

the preceding 12 months) is 150/90 mmHg or less by CCG



45

43

28

59

51

110

120

88

101

210

49

108

290

250

318

110

345

199

87

658

716

295

309

180

409

462

369

346

99

89

487

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
































No treatment Exceptions reported

22

Percentage of patients with hypertension whose last blood pressure reading

(measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice

• in total, including exceptions, there

are 7,030 people whose blood

pressure is not <= 150/90



66.5%

71.2%

71.6%

72.9%

74.5%

75.9%

80.0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

England




NHS South Tees CCG


NHS Darlington CCG

66.5%

71.2%

71.6%

72.9%

74.5%

75.9%

80.0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

England




NHS South Tees CCG


NHS Darlington CCG

23

New diagnosis of hypertension who have been given a CVD risk assessment whose

CVD risk exceeds 20% and treated with statins by CCG


• 125 people with a new diagnosis* of

hypertension with a CVD risk of 20%

or higher in NHS North Durham CCG

• 89 (71.2%) people who are currently

treated with statins

• 36 (28.8%) people who are exempted

from treatment with statins

• 0 (0%) additional people who are not

currently treated with statins

*Using the QOF clinical indicator CVD-PP001



57.0%

60.3%

61.0%

64.2%

64.8%

65.8%

67.2%

68.4%

71.2%

73.6%

82.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%


NHS Barnsley CCG


NHS Norwich CCG








57.0%

60.3%

61.0%

64.2%

64.8%

65.8%

67.2%

68.4%

71.2%

73.6%

82.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%


NHS Barnsley CCG


NHS Norwich CCG








24


CVD risk exceeds 20% and treated with statins by CCG



1

1

1

2

1

1

1

1

6

4

1

2

1

1

7

2

3

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

































25


CVD risk exceeds 20% and not treated with statins by GP practice


are 36 people who are not treated

with statins



Stroke


27

Only a half of people with known

AF who then suffer a stroke have been

anticoagulated before their stroke.

Stroke is one of the leading causes of

premature death and disability. Stroke is

devastating for individuals and families, and

accounts for a substantial proportion of health

and social care expenditure.

What might help? • increase opportunistic pulse checking especially in over 65s

• support practices to share audit data and systematically

identify gaps and opportunities for improved detection and

management of AF - eg GRASP-AF

• promote systematic use of CHADS-VASC and HASBLED to

ensure those at high risk are offered stroke prevention

• promote systematic use of Warfarin Patient Safety Audit Tool

to ensure optimal time in therapeutic range for people on

warfarin

• develop local consensus statement on risk-benefit balance for

anticoagulants, including the newer treatments (NOACs)

• work with practices and local authorities to maximise uptake

and clinical follow up in the NHS Health Check

• commission community pharmacists to offer pulse checks,

anticoagulant monitoring, and support for adherence to

medication

What questions should we ask in our CCG? 1. for each indicator how wide is the variation in

detection, treatment and exception reporting?

2. how many people would benefit if all practices

performed as well as the best?

3. how can we support practices who are average

and below average to perform as well as the

best in detection of atrial fibrillation and stroke

prevention with anticoagulation.

Atrial fibrillation increases the risk of stroke

by a factor of 5, and strokes caused by AF are

often more severe, with higher mortality and

greater disability.

Anticoagulation reduces the risk of stroke in

people with AF by two thirds.

Despite this, AF is underdiagnosed and under

treated: up to a third of people with AF are

unaware they have the condition and even when

diagnosed inadequate treatment is common –

large numbers do not receive anticoagulants or

have poor anticoagulant control.

Stroke prevention


0.70

0.69

0.72

0.72

0.73

0.76

0.78

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

England


NHS South Tees CCG


NHS Darlington CCG



0.70

0.69

0.72

0.72

0.73

0.76

0.78

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

England


NHS South Tees CCG


NHS Darlington CCG



28

Atrial fibrillation observed prevalence compared to expected prevalence by CCG


Note: This slide compares the prevalence of

atrial fibrillation recorded in QOF in 2015/16 to

the estimated prevalence of atrial fibrillation,

taken from National Cardiovascular Intelligence

Network estimates produced in 2017. The

estimates were developed by applying age-sex

specific prevalence rates as reported by Norberg

et al (2013) to GP population estimates from

NHS Digital. Estimates reported are adjusted for

age and sex of the local population.

• the ratio of those diagnosed with atrial

fibrillation versus those expected to

have atrial fibrillation is 0.69. This

compares to 0.7 for England


atrial fibrillation have been diagnosed.


0.65

0.69

0.70

0.70

0.71

0.71

0.72

0.75

0.75

0.79

0.80

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

NHS Norwich CCG






NHS Barnsley CCG





29

Atrial fibrillation observed prevalence compared to expected prevalence by CCG



0.5

0.5

0.6

0.6

0.6

0.6

0.6

0.6

0.6

0.6

0.6

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.8

0.8

0.8

0.8

0.8

0.8

0.8

0.9

0.9

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
































Ratio

GP practice CCG

30

Atrial fibrillation observed prevalence compared with expected prevalence by GP practice


people with undiagnosed atrial

fibrillation in NHS North Durham CCG

• GP practice range of observed to

expected atrial fibrillation prevalence

0.5 to 0.9


77.9%

76.6%

81.7%

81.9%

83.5%

83.6%

83.7%

0% 20% 40% 60% 80% 100%

England


NHS Darlington CCG

NHS South Tees CCG




Optimal management No treatment Exceptions reported

31

In patients with AF with a CHA2DS2-VASc score of 2 or more,

the percentage treated with anti-coagulation therapy by CCG


• 3,748 people with atrial fibrillation*

with a CHA2DS2-VASc score >= 2 in


• 3,130 (83.5%) people treated with

anti-coagulation therapy

• 233 (6.2%) people who are

exceptions

• 385 (10.3%) additional people with a

recorded CHA2DS2-VASc score >= 2

who are not treated

*Using the QOF clinical indicator AF007



74.6%

77.3%

77.4%

77.7%

78.4%

78.7%

79.1%

80.3%

81.4%

83.5%

84.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%






NHS Norwich CCG

NHS Barnsley CCG






32

In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage

treated with anti-coagulation therapy by CCG



1

10

3

3

33

39

12

10

17

4

20

7

27

38

14

11

25

41

15

31

4

30

19

24

15

42

43

37

11

15

17

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

































33

In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated

with anti-coagulation therapy by GP practice


are 618 people with a recorded

CHA2DS2-VASc score >= 2 who are

not treated



8

6

4

10

4

11

7

10

4

1

-15%-10%-5%0%5%10%15%

OAKFIELDS HEALTH CENTRE

DIPTON SURGERY

BOWBURN MEDICAL CENTRE

BELMONT & SHERBURN MEDICAL GROUP

CEDARS MEDICAL GROUP

QUEENS ROAD SURGERY

WEST RAINTON SURGERY

CESTRIA HEALTH CENTRE

DRS LAMBERT & NG

PELTON FELL SURGERY

LEADGATE SURGERY

PELTON & FELLROSE MEDICAL GROUP

COXHOE MEDICAL PRACTICE

DUNELM MEDICAL PRACTICE

BROWNEY HOUSE SURGERY

CRAGHEAD MEDICAL CENTRE

THE MEDICAL GROUP

CONSETT MEDICAL CENTRE

SACRISTON MEDICAL CENTRE

THE HAVEN SURGERY

34 34 CVD: Primary Care Intelligence Packs

In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated

with anti-coagulation therapy by GP practice – opportunities compared to GP cluster

• using the GP cluster method of

calculating potential gains, if each

practice was to achieve as well as the

upper quartile of its national cluster,

then an additional 79 people would be

treated

Details of this methodology are available on slide

9. Click here to view them.

83.8%

83.2%

84.5%

84.8%

85.4%

85.6%

85.7%

0% 20% 40% 60% 80% 100%

England

NHS South Tees CCG




NHS Darlington CCG


Below 150/90 Not below 150/90 Exceptions reported

35

Percentage of patients with a history of stroke whose last blood pressure reading

(measured in the preceding 12 months) is 150/90 mmHg or less by CCG


*Using the QOF clinical indicator STIA003


• 5,552 people with a history of stroke

or TIA* in NHS North Durham CCG


pressure is <= 150 / 90


exceptions

• 603 (10.9%) additional people whose

blood pressure is not <= 150 / 90


83.0%

83.4%

83.9%

84.3%

84.4%

84.5%

84.5%

85.7%

85.7%

86.1%

87.4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Barnsley CCG

NHS Norwich CCG











36

Percentage of patients with a history of stroke whose last blood pressure reading




2

3

2

3

11

12

9

24

9

15

15

22

25

16

34

39

37

6

12

31

8

33

59

46

48

11

49

106

42

43

20

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

































37

Percentage of patients with a history of stroke whose last blood pressure reading (measured

in the preceding 12 months) is not 150/90 mmHg or less by GP practice


are 792 people whose blood pressure

is not <= 150 / 90



91.8%

92.5%

92.9%

93.3%

93.7%

93.9%

94.4%

0% 20% 40% 60% 80% 100%

England


NHS South Tees CCG

NHS Darlington CCG





38

Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA,

who have a record in the preceding 12 months that an anti-platelet agent, or an

anti-coagulant is being taken by CCG


*Using the QOF clinical indicator STIA007



• 3,725 people with a stroke shown to

be non-haemorrhagic* in NHS North

Durham CCG

• 3,444 (92.5%) people who are taking

an anti-platetet agent or anti-

coagulant


exceptions

• 121 (3.2%) additional people with no

treatment

90.6%

90.8%

91.0%

91.4%

91.9%

92.4%

92.5%

92.7%

92.8%

92.9%

93.4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%




NHS Barnsley CCG




NHS Norwich CCG





39


who have a record in the preceding 12 months that an anti-platelet agent,

or an anti-coagulant is being taken by CCG



2

1

1

1

1

2

5

8

2

7

8

8

3

6

15

31

19

13

6

7

12

15

10

11

17

7

9

7

16

5

26

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

































40


who do not have a record in the preceding 12 months that an anti-platelet agent,

or an anti-coagulant is being taken by GP practice



are 281 people who are not taking an

anti-platelet agent or anti-coagulant


Diabetes


Type 2 Diabetes in numbers • diagnosed prevalence – 3.0 million

• undiagnosed diabetes – 900,000

• non-diabetic hyperglycaemia (high risk of diabetes) – 5 million

What might help • ensure universal participation by practices in the National

Diabetes Audit (NDA)

• benchmark practice level data from the NDA – and support

practices to explore variation

• increase support for patient education and shared

management

• maximise uptake of the NHS Health Check to aid detection of

diabetes and Non Diabetic Hyperglycaemia

• maximise uptake of the NHS Diabetes Prevention Programme

What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and

exception reporting?

2. how many people would benefit if all practices performed as well

as the best?

3. how can we support practices who are average and below

average to perform as well as the best in:

• detection of diabetes

• delivery of the 8 care processes and achievement of the 3

treatment targets

• identification and management of Non-diabetic hyperglycaemia

Type 2 diabetes is often preventable People at high risk of developing type 2 diabetes

can be identified through the NHS Health Check,

and the disease can be prevented or delayed in

many through intensive behaviour change support.

Complications of diabetes are preventable Diabetes is a major cause of premature death and

disability and greatly increases the risk of heart

disease and stroke, kidney failure, amputations and

blindness. 80% of NHS spending on diabetes goes

on managing these complications, most of which

could be prevented. There are 8 essential care

processes, in addition to retinal screening, that

together substantially reduce complication rates.

Despite this, around a half of people with diabetes

do not receive all 8 care processes, and there is

widespread variation between CCGs and practices

in levels of achievement

Diabetes prevention and management


Diabetes costs the NHS

£9.8 billion per year – and the

prevalence is rising

0.77

0.66

0.76

0.78

0.84

0.84

0.86

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

England


NHS South Tees CCG



NHS Darlington CCG


0.77

0.66

0.76

0.78

0.84

0.84

0.86

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

England


NHS South Tees CCG



NHS Darlington CCG


43

Diabetes observed prevalence compared with expected prevalence by CCG



Note: This slide compares the prevalence of

Diabetes recorded in QOF in 2015/16 to the

expected prevalence of Diabetes in 2016 taken

from the NCVIN diabetes prevalence model

produced in 2015.

• 0.86 ratio of observed to expected

diabetes prevalence in NHS North

Durham CCG, compared to 0.77 in

England

• this suggests 86% of people have

been diagnosed

0.67

0.73

0.77

0.80

0.81

0.82

0.82

0.83

0.84

0.86

0.87

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

NHS Norwich CCG







NHS Barnsley CCG




44

Diabetes observed prevalence compared with expected prevalence by CCG



2.3%

5.8%

6.0%

6.2%

6.3%

6.4%

6.5%

6.6%

6.7%

6.7%

6.8%

6.8%

7.0%

7.1%

7.1%

7.4%

7.6%

7.7%

7.7%

7.8%

8.0%

8.3%

8.3%

8.4%

8.5%

8.9%

9.4%

9.5%

9.5%

9.6%

10.1%

0% 2% 4% 6% 8% 10% 12%
































GP practice CCG

45

Diabetes prevalence by GP practice

• GP practice range of observed

diabetes 2.3% to 10.1%

• there are an estimated 2,446 people

with undiagnosed diabetes in NHS

North Durham CCG


Note: The estimated number of undiagnosed

people with diabetes has been calculated by

multiplying the estimated prevalence rate to the

2015/16 QOF list size and subtracting the

number of people on the diabetes register.

6.5%

6.8%

6.4%

6.7%

7.1%

7.7%

6.0%

1.9%

1.2%

1.8%

2.1%

1.4%

1.5%

3.1%

11.2%

11.1%

11.0%

11.2%

11.5%

11.7%

12.6%

0% 5% 10% 15% 20% 25%

England



NHS South Tees CCG

NHS Darlington CCG



Diabetes prevalence Undiagnosed diabetes prevalence

Expected non-diabetic hyperglycaemia prevalence

6.5%

6.8%

6.4%

6.7%

7.1%

7.7%

6.0%

1.9%

1.2%

1.8%

2.1%

1.4%

1.5%

3.1%

11.2%

11.1%

11.0%

11.2%

11.5%

11.7%

12.6%

0% 5% 10% 15% 20% 25%

England



NHS South Tees CCG

NHS Darlington CCG



Diabetes prevalence Undiagnosed diabetes prevalence

Expected non-diabetic hyperglycaemia prevalence

46

Expected total prevalence of diabetes and non-diabetic hyperglycaemia

• the estimated total prevalence of

diabetes in NHS North Durham CCG

is 8.0% (diagnosed and undiagnosed)

• in addition, there are an estimated

11.1% of people in NHS North

Durham CCG who are at increased

risk of developing diabetes (i.e. with

non-diabetic hyperglycaemia)

Note: Prevalence estimates of non-diabetic

hyperglycaemia were developed using Health

Survey for England (HSE) data. Five years of

HSE data were combined, 2009- 2013. The

estimates take into account the age, ethnic group

and estimated body mass index of the population.

These estimates were produced using the GP

registered population.


• this means that 19.1% of the

population in NHS North Durham

CCG are estimated to have diabetes,

or at high risk of developing of

diabetes

52.6%

52.6%

52.6%

58.6%

63.0%

63.0%

65.3%

0% 10% 20% 30% 40% 50% 60% 70%

England

NHS South Tees CCG





NHS Darlington CCG

52.6%

52.6%

52.6%

58.6%

63.0%

63.0%

65.3%

0% 10% 20% 30% 40% 50% 60% 70%

England

NHS South Tees CCG





NHS Darlington CCG

47

People with diabetes who had eight care processes by CCG 2015/16

• overall practice participation in the

2015/16 audit was 81.4% in England

• data on care processes and treatment

targets are taken from the National


• in NHS North Durham CCG, 26 out of

31 practices (83.9%) participated in

the NDA. Data is not available for the

remaining practices


• 63.0% of people with diabetes (of

practices who participated in the

audit) had the eight recommended

care processes in NHS North Durham

CCG, compared to 52.6% in England

39.7%

42.5%

48.7%

51.0%

55.4%

55.4%

58.6%

60.2%

60.4%

60.7%

61.3%

61.6%

61.6%

63.2%

63.6%

64.1%

64.3%

65.0%

66.3%

67.4%

67.4%

68.7%

72.1%

73.9%

76.7%

78.9%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
































GP practice Average of practices in the CCG who participated in the audit

48

People with diabetes who had eight care processes by GP practice, 2015/16


• achievement - 8 care processes: in

practices who provided data via the

NDA, between 39.7% and 78.9% of

patients received all 8 care processes

• at least 4,729 people did not receive

the eight care processes

39.0%

35.3%

36.4%

37.1%

39.7%

41.0%

41.0%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

England

NHS Darlington CCG



NHS South Tees CCG



39.0%

35.3%

36.4%

37.1%

39.7%

41.0%

41.0%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

England

NHS Darlington CCG



NHS South Tees CCG



49

People with diabetes who met all 3 treatment targets by CCG, 2015/16


• 37.1% of people with diabetes (of

practices who participated in the

audit) met the three treatment targets

in NHS North Durham CCG,

compared to 39.0% in England

28.1%

30.4%

30.4%

30.6%

31.9%

32.3%

33.2%

35.8%

37.6%

37.7%

38.0%

38.0%

38.1%

38.2%

38.4%

39.5%

40.5%

40.7%

40.9%

42.7%

43.4%

43.7%

43.9%

46.1%

47.8%

48.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
































GP practice Average of practices in the CCG who participated in the audit

50

People with diabetes who met all 3 treatment targets by GP practice, 2015/16


• achievement - 3 treatment targets: in

practices who provided data via the

NDA, between 28.1% and 48.3% of

patients achieved all 3 treatment

targets

• at least 7,322 people did not meet the

three treatment targets

60

76

61

19

61

167

71

14

33

22

38

52

25

14

7

6

7

-20%-15%-10%-5%0%5%

COXHOE MEDICAL PRACTICE




BRIDGE END SURGERY

THE MEDICAL GROUP

TANFIELD VIEW MEDICAL GROUP

PELTON FELL SURGERY

DRS LAMBERT & NG

LEADGATE SURGERY

STANLEY MEDICAL GROUP




CHEVELEY PARK MEDICAL CTR

GREAT LUMLEY SURGERY

QUEENS ROAD SURGERY

THE HAVEN SURGERY

LANCHESTER MEDICAL CENTRE

ANNFIELD PLAIN SURGERY

51

People with diabetes who met all 3 treatment targets by GP practice, 2015/16

- opportunities compared to GP cluster






then an additional 889 people would

be treated



Kidney


Chronic Kidney Disease can

progress to kidney failure and it

substantially increases the risk

of heart attack and stroke.

Chronic Kidney Disease (CKD) is common.

It is one of the commonest co-morbidities and affects a third

of people over 75. In 2010 it was estimated to cost the NHS

around £1.5bn. Average length of stay in hospital tends to

be longer and outcomes are considerably worse:

approximately 7,000 excess strokes and 12,000 excess

heart attacks occur each year in people with CKD

compared to those without.

Individuals with CKD are also at much higher risk of

developing acute kidney injury when they have an

intercurrent illness such as pneumonia What might help • Support practices to share audit data and systematically

identify gaps and opportunities for improved detection

and management of CKD.

• Promote uptake of and follow up from the NHS Health

Check to aid detection and management of CKD

• Offer local training and education in the detection and

management of CKD


achievement and exception reporting?

2. how many people would benefit if all practices

performed as well as the best?

3. how can we support practices who are average and

below average to perform as well as the best in:

• detection of CKD

• more systematic delivery of evidence based care

Late diagnosis of CKD is common. Around a third of people with CKD are undiagnosed. More

opportunistic testing and improved uptake of the NHS

Health Check will increase detection rates.

Evidence based guidance from NICE highlights CVD

risk reduction, good blood pressure control and

management of proteinuria as essential steps to reduce the

risk of cardiovascular events and progression to kidney

failure. Despite this there is often significant variation

between practices in achievement and exception reporting.

Management of chronic kidney disease


0.68

0.57

0.59

0.64

0.70

0.71

0.72

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8

England


NHS South Tees CCG




NHS Darlington CCG

Ratio

0.68

0.57

0.59

0.64

0.70

0.71

0.72

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8

England


NHS South Tees CCG




NHS Darlington CCG

Ratio

54

Chronic kidney disease (CKD) observed prevalence (2015/16) compared

with expected prevalence (2011) by CCG


Note: This slide compares the prevalence of CKD

recorded in QOF in 2015/16 to the expected

prevalence of CKD produced by the University of

Southampton in 2011. A small number of CCGs

have a ratio greater than 1. It is unlikely that all

people with CKD will be diagnosed in any CCG

and therefore a ratio greater than 1 suggests that

the figures are underestimating the true CKD

prevalence in the area. These ratios should be

taken as an indication of the comparative scale of

undiagnosed CKD rather than absolute figures.

• the ratio of those diagnosed with

chronic kidney disease versus those

expected to have chronic kidney

disease is 0.71. This compares to

0.68 for England


chronic kidney disease have been

diagnosed


0.55

0.58

0.60

0.66

0.71

0.72

0.73

0.82

0.89

0.92

1.00

0.0 0.2 0.4 0.6 0.8 1.0 1.2


NHS Norwich CCG






NHS Barnsley CCG




Ratio

55

Chronic kidney disease (CKD) observed prevalence (2015/16)

compared with expected prevalence (2011) by CCG



1.1%

3.0%

3.0%

3.1%

3.6%

3.7%

3.9%

3.9%

4.0%

4.2%

4.5%

4.5%

4.6%

4.9%

5.1%

5.2%

5.2%

5.4%

5.5%

5.6%

5.6%

5.6%

5.8%

5.9%

5.9%

6.1%

6.2%

6.2%

7.3%

7.6%

7.8%

0% 1% 2% 3% 4% 5% 6% 7% 8% 9%
































GP practice CCG

56

CKD prevalence by GP practice, 2015/16

Note: CCG estimates for the estimated

number of people with CKD are based on

applying a proportion from a resident based

population estimate to a GP registered

population. The characteristics of registered

and resident populations may vary in some

CCGs, and local interpretation is required.


people with undiagnosed chronic

kidney disease in NHS North Durham

CCG

• GP practice range of observed CKD:

1.1% to 7.8%


74.4%

73.9%

75.2%

75.4%

75.8%

76.2%

78.1%

0% 20% 40% 60% 80% 100%

England

NHS South Tees CCG


NHS Darlington CCG





57

Percentage of patients on the CKD register whose last blood pressure reading (measured in

the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15


*Using the QOF clinical indicator CKD002

denominator plus exceptions. Note: as

the CKD002 indicator was removed from

the QOF in 15/16 this is historic data

taken from the 2014/15 QOF.

• 9,126 people with CKD (diagnosed*)

in NHS North Durham CCG


pressure is <= 140 /85


exceptions

• 1,569 (17.2%) additional people

whose blood pressure is not <= 140 /

85


71.5%

72.9%

74.0%

74.1%

74.5%

74.9%

76.0%

76.2%

76.6%

77.8%

79.4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Norwich CCG

NHS Barnsley CCG











58

Percentage of patients on the CKD register whose last blood pressure reading (measured

in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15



6

8

16

35

50

23

18

36

35

52

101

55

20

64

88

61

59

26

46

111

106

63

59

106

110

36

160

239

30

245

104

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

KHAN CF A83630







PARK HOUSE SURGERY A83072


THE SURGERY GREAT LUMLEY A83029





PELTON AND FELLROSE MEDICAL GROUP A83033





GROUP PRACTICE SURGERY A83028


WOODS AND PARTNERS A83027










Not below 140/85 Exceptions reported

59

Percentage of patients on the CKD register whose last blood pressure reading (measured in

the preceding 12 months) is not 140/85 mmHg or less by GP practice, 2014/15



pressure is not <= 140 / 85



43

13

85

14

21

45

60

17

16

27

-20%-15%-10%-5%0%5%10%


PELTON FELL SURGERY

THE MEDICAL GROUP


LEADGATE SURGERY



WOODS AND PARTNERS


GROUP PRACTICE SURGERY

BELMONT & SHERBURN MEDICAL GROUP


STANLEY MEDICAL GROUP

DIPTON SURGERY

PARK HOUSE SURGERY

DRS LAMBERT & NG


QUEENS ROAD SURGERY

THE HAVEN SURGERY

KHAN CF

60

Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding

12 months) is not 140/85 mmHg or less by GP practice, 2014/15 – opportunities compared to GP cluster






be treated




75.4%

76.1%

77.1%

78.0%

78.3%

80.1%

80.6%

0% 20% 40% 60% 80% 100%

England

NHS South Tees CCG





NHS Darlington CCG

Recorded Not recorded Exceptions reported

61

Percentage of patients on the CKD register whose notes have a record of a

urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15


• 9,126 people with CKD (diagnosed*)

in NHS North Durham CCG

• 7,306 (80.1%) people who have a

record of urine albumin:creatinine

ratio test


exceptions

• 1,422 (15.6%) additional people who

have no record of urine

albumin:creatinine ratio test

*Using the QOF clinical indicator CKD004

denominator plus exceptions. Note: as

the CKD004 indicator was removed from

the QOF in 15/16 this is historic data

taken from the 2014/15 QOF.


72.2%

73.8%

74.8%

76.1%

76.9%

77.6%

78.3%

78.6%

79.2%

80.1%

83.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Barnsley CCG


NHS Norwich CCG









Recorded Not recorded Exceptions reported

62

Percentage of patients on the CKD register whose notes have a record of a

urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15



14

16

7

20

7

13

13

32

44

64

24

53

75

36

102

44

63

55

20

58

87

41

24

125

30

71

114

214

107

211

36

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


WOODS AND PARTNERS A83027


PARK HOUSE SURGERY A83072

KHAN CF A83630





PELTON AND FELLROSE MEDICAL GROUP A83033








THE SURGERY GREAT LUMLEY A83029









GROUP PRACTICE SURGERY A83028





Not recorded Exceptions reported

63

Percentage of patients on the CKD register whose notes do not have a record of a

urine albumin: creatinine ratio test in the preceding 12 months by GP practice, 2014/15


are 1,820 people who have no record

of urine albumin:creatinine ratio test



Heart


Coronary Heart Disease is one of the principal causes of

premature death and disability. The key elements of management for

an individual who has already had a heart attack or angina are

symptom control and secondary prevention of further cardiovascular

events and premature mortality. There is robust evidence to support the

use of anti-platelet treatment, statins, beta-blockers and angiotensin

converting enzyme inhibitors or angiotensin receptor blockers. There is

also robust evidence to support good control of blood pressure. Each of

these interventions is incentivised in QOF but variation in achievement

and exception reporting at practice level shows that there is often

considerable potential for improving management and outcomes.

What might help 1. roll out of GRASP-Heart Failure audit tool

that identifies people with heart failure who

are undiagnosed or under treated

2. education for health professionals to

promote evidence based management of

CHD and high quality measurement of

blood pressure

3. ensure access to rapid access diagnostic

clinics and specialist support for

management of angina and heart failure

4. ensure access to cardiac rehab for

individuals with CHD and heart failure


achievement and exception reporting?

2. how many people would benefit if all

practices performed as well as the best?

3. how can we support practices who are

average and below average to perform as

well as the best in:

• more systematic delivery of evidence

based care for people with CHD

• improved detection and management

of heart failure

Heart failure is a common and an important complication of

coronary heart disease and other conditions. Appropriate treatment

including up-titration of ace inhibitors and beta blockers in heart failure

due to LVSD can significantly improve symptom control and quality of

life, and improve outcomes for patients. Despite this, around a quarter

of people with heart failure are undetected and untreated. And amongst

those who are diagnosed, there is significant variation in the quality of

care.

Management of Heart Disease


Premature death and disability in people with

CHD can be reduced significantly by systematic

evidence based management in primary care

0.76%

0.82%

0.89%

0.90%

0.95%

1.21%

1.42%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6%

England

NHS South Tees CCG





NHS Darlington CCG

0.76%

0.82%

0.89%

0.90%

0.95%

1.21%

1.42%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6%

England

NHS South Tees CCG





NHS Darlington CCG

66

Heart failure prevalence by CCG


• prevalence of 0.89% in NHS North

Durham CCG compared to 0.76% in

England


0.66%

0.67%

0.75%

0.78%

0.80%

0.82%

0.89%

0.89%

0.90%

0.94%

1.02%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2%



NHS Norwich CCG





NHS Barnsley CCG




67

Heart failure prevalence by CCG



0.3%

0.5%

0.6%

0.7%

0.7%

0.8%

0.8%

0.8%

0.9%

0.9%

0.9%

0.9%

0.9%

0.9%

0.9%

0.9%

0.9%

0.9%

0.9%

1.0%

1.0%

1.0%

1.1%

1.1%

1.1%

1.2%

1.4%

1.5%

1.6%

1.6%

1.7%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8% 2.0%
































GP practice CCG

68

Heart failure prevalence by GP practice

• 2,264 people with diagnosed heart

failure in NHS North Durham CCG



84.7%

83.0%

85.7%

87.8%

88.1%

88.9%

89.3%

0% 20% 40% 60% 80% 100%

England

NHS Darlington CCG


NHS South Tees CCG




Treatment No treatment Exceptions reported

69

Percentage of patients with heart failure due to left ventricular systolic dysfunction

(LVSD) who are treated with ACE-I / ARB by CCG


• 897 people with heart failure* with

LVSD in NHS North Durham CCG

• 797 (88.9%) people treated with ACE-

I or ARB


exceptions

• 3 (0.3%) additional people who are

not treated with ACE-I or ARB

*Using the QOF clinical indicator HF003



81.7%

82.4%

83.0%

83.4%

85.1%

85.8%

86.1%

86.7%

87.0%

87.9%

88.9%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Norwich CCG







NHS Barnsley CCG





70


(LVSD) who are treated with ACE-I / ARB by CCG



1

2

1

1

3

3

2

10

7

12

5

1

9

7

1

2

2

4

7

2

7

3

4

4

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

































71


(LVSD) who are not treated with ACE-I / ARB by GP practice



with ACE-I or ARB



77.7%

75.4%

76.2%

81.3%

83.9%

86.5%

87.3%

0% 20% 40% 60% 80% 100%

England





NHS Darlington CCG

NHS South Tees CCG


72

Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD)

who are treated with ACE-I / ARB and BB by CCG


• 797 people with heart failure* with

LVSD treated with ACE-I/ARB in NHS

North Durham CCG

• 607 (76.2%) people treated with ACE-

I/ARB and BB


exceptions

• 43 (5.4%) additional people who are

not treated with ACE-I/ARB and BB

*Using the QOF clinical indicator HF004



66.6%

75.0%

75.5%

76.0%

76.2%

77.1%

78.5%

78.7%

81.9%

83.6%

85.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Norwich CCG


NHS Barnsley CCG










73

Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD)

who are treated with ACE-I / ARB and BB by CCG



1

1

11

5

1

6

4

7

2

6

4

1

7

2

9

10

3

2

3

3

6

20

32

20

5

3

5

2

9

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

































74

Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who

are not treated with ACE-I / ARB and BB by GP practice



with ACE-I or ARB



88.2%

88.6%

88.6%

89.0%

89.3%

89.4%

91.0%

0% 20% 40% 60% 80% 100%

England

NHS Darlington CCG

NHS South Tees CCG






75

Percentage of patients with CHD whose blood pressure reading



*Using the QOF clinical indicator CHD002


• 11,014 people with coronary heart

disease* in NHS North Durham CCG


pressure <= 150 / 90


exceptions

• 870 (7.9%) additional people whose

blood pressure is not <= 150 / 90


86.1%

86.9%

88.1%

88.2%

88.7%

89.1%

89.2%

89.4%

89.4%

90.0%

90.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Barnsley CCG


NHS Norwich CCG










76





5

7

6

5

14

19

13

23

34

13

11

41

15

12

25

52

22

10

59

50

45

45

53

46

123

15

144

72

22

70

100

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
































Not below 150/90 Exceptions reported

77


(measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice



pressure is not <= 150 / 90



54

11

33

7

28

22

44

16

14

33

2

0

-12%-10%-8%-6%-4%-2%0%2%4%6%




PELTON FELL SURGERY

CESTRIA HEALTH CENTRE


THE MEDICAL GROUP

MIDDLE CHARE MEDICAL GROUP

BRIDGE END SURGERY


CHASTLETON MEDICAL GROUP

DRS LAMBERT & NG




GREAT LUMLEY SURGERY

THE HAVEN SURGERY


CHEVELEY PARK MEDICAL CTR


78

Percentage of patients with CHD whose blood pressure reading (measured

in the preceding 12 months) is not 150/90 mmHg or less by GP practice –

opportunities compared to GP cluster






be treated




91.8%

92.4%

92.5%

92.5%

92.9%

93.3%

94.1%

0% 20% 40% 60% 80% 100%

England



NHS South Tees CCG


NHS Darlington CCG



79

Percentage of patients with CHD with a record in the preceding 12 months that aspirin,

an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG


*Using the QOF clinical indicator CHD005


• 11,014 people with coronary heart

disease* in NHS North Durham CCG

• 10,233 (92.9%) people who are

taking aspirin, an alternative anti-

platelet therapy, or an anti-coagulant


exceptions

• 442 (4%) additional people who are

not taking aspirin, an alternative anti-

platelet therapy, or an anti-coagulant


90.4%

90.6%

91.1%

91.3%

91.4%

91.5%

92.0%

92.6%

92.8%

92.9%

93.7%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


NHS Norwich CCG



NHS Barnsley CCG








80

Percentage of patients with CHD with a record in the preceding 12 months that aspirin,

an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG



3

3

4

7

14

15

19

27

6

12

23

13

5

31

7

65

8

73

42

32

35

33

49

27

58

14

53

44

15

22

22

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

































81

Percentage of patients with CHD without a record in the preceding 12 months that aspirin,

an alternative anti-platelet therapy, or an anti-coagulant is being taken by GP practice


are 781 people are not taking aspirin,

an alternative anti-platelet therapy, or

an anti-coagulant



Some data on outcomes for people with

cardiovascular disease


0

100

200

300

400

500

600

700

800

900

1000

2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16

Ag

e s

tand

ard

ise

d r

ate

(p

er

100

,00

0)

NHS North Durham CCG England

83

Hospital admissions for coronary heart disease for all ages 2002/03 – 2015/16

Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved

• in NHS North Durham CCG, the

hospital admission rate for coronary

heart disease in 2015/16 was 566

(1,366) compared to 527.9 for

England


0

50

100

150

200

250

2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16

Age s

tandard

ised r

ate

(p

er

100,0

00)


84

Hospital admissions for stroke for all ages 2002/03 – 2015/16

Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved

• in NHS North Durham CCG, the

hospital admission rate for stroke in

2015/16 was 202 (475) compared to

172.8 for England


293.0%

753.5%

445.8%

81.3%

150.0%

108.6%

136.8%

291.9%

751.1%

618.1%

98.7%

122.9%

83.3%

124.7%

0% 100% 200% 300% 400% 500% 600% 700% 800%

RRT

Minor amputation

Major amputation

Stroke

Heart failure

Heart Attack

Angina


85

Additional risk of complications for people with diabetes, three year follow up, 2013/14

Note: This slide uses data from the National


• The risk of a stroke was 98.7% higher

and the risk of a heart attack was

83.3% higher compared to people

without diabetes. The risk of a major

amputation was 618.1% higher.


0

20

40

60

80

100

120

2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15

Ag

e s

tand

ard

ise

d r

ate

(p

er

100

0,0

00

)


86

Deaths from coronary heart disease, under 75s

Source: Office for National Statistics (ONS) mortality data 2002 - 2015

• in NHS North Durham CCG, the early

mortality rate for coronary heart

disease in 2013-15 was 38.9,

compared to 40.6 for England


0

5

10

15

20

25

30

35

2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15

Ag

e s

tand

ard

ise

d r

ate

(p

er

100

,00

0)


87

Deaths from stroke, under 75s

Source: Office for National Statistics (ONS) mortality data 2002 - 2015

• in NHS North Durham CCG, the early

mortality rate for stroke in 2013-15

was 14.4, compared to 13.6 for

England


88

Appendix Data sources

• Quality and Outcomes Framework (QOF), 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights

reserved

• Non-diabetic hyperglycaemia prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/nhs-diabetes-

prevention-programme-non-diabetic-hyperglycaemia

• Diabetes prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/diabetes-prevalence-estimates-for-

local-populations

• CKD Prevalence model, G.Aitken, University of Southampton , 2014 https://www.gov.uk/government/publications/ckd-

prevalence-estimates-for-local-and-regional-populations

• Hypertension prevalence estimates for local CCG populations. Created using data from: QOF hypertension registers 2014/15

and; Undiagnosed hypertension estimates for adults 16 years and older. 2014. Department of Primary Care & Public Health,

Imperial College London https://www.gov.uk/government/publications/hypertension-prevalence-estimates-for-local-populations

• NHS Stop smoking services Copyright © 2014, NHS Digital

• Norberg J, Bäckström S , Jansson J-H, Johansson L. Estimating the prevalence of atrial fibrillation in a general population

using validated electronic health data. Clin Epidemiol 2013 ; 5 475 – 81.

• National Diabetes Audit, 2013/14 and 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights

reserved

• Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights

reserved

• Office for National Statistics (ONS) mortality data 2002 – 2015, Copyright © 2017, Re-used with the permission of the Office for

National Statistics. All rights reserved


https://www.gov.uk/government/publications/nhs-diabetes-prevention-programme-non-diabetic-hyperglycaemia














https://www.gov.uk/government/publications/diabetes-prevalence-estimates-for-local-populations











https://www.gov.uk/government/publications/ckd-prevalence-estimates-for-local-and-regional-populations
















https://www.gov.uk/government/publications/hypertension-prevalence-estimates-for-local-populations












89

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Published June 2017

Gateway number 2017095

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