Ten years of the CHD NSF Professor Roger Boyle CBE National Director for Heart Disease and Stroke...
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Transcript of Ten years of the CHD NSF Professor Roger Boyle CBE National Director for Heart Disease and Stroke...
Ten years of the CHD NSF
Professor Roger Boyle CBENational Director for Heart Disease and Stroke
Department of Health
Frustration
• Poor performance• Lack of teamwork• Inability to innovate –
new ideas stifled• Poor management
– Financial and general
• Poor results (outcomes)
• Increasing frustration
Modernising care
Networks
Improvement programme
CHD Partnership
CHD Collaborative
Heart Improvement Programme
NHS Improvement
Standards 1 & 2: Reducing heart disease in the population1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of
coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.
SMOKING PREVALENCE• All adult smoking rates have reduced over the period from 28% in 1998
to 21% in 2008.• Smoking in the routine & manual groups has reduced from 31% in 2001
to 29% in 2008.• In 10 years the number of smokers fell by one fifth (2 million fewer
smokers).
England – Smoking Rates & TargetsAll Adults & Routine & Manual Groups – 1998 - 2008
Standards 1 & 2: Reducing heart disease in the population1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of
coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.
England – Smoking Rates & TargetChildren Aged 11-15 years – 1996 - 2008
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000S
mo
kin
g C
es
sati
on
Se
rvic
e N
os.
Se
wtt
ing
Qu
it D
ate
& S
top
pin
g
Set Quit Date
Stopped Smoking
Set Quit Date 361,224 529,567 602,820 600,410 680,289 671,259
Stopped Smoking 204,876 298,124 329,681 319,720 350,800 337,054
2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Record Annual Year/Q (All)
Financial Yr
Data
England – Smoking Cessation Services – 2003/04 - 2008/09People Setting a Quit Date & Stopped Smoking at 4 Weeks
Year % Stopped2003/04 57%2004/05 56%2005/06 55%2006/07 53%2007/08 52%2008/09 50%
SMOKING RATES IN CHILDREN
• Smoking rates in children aged 11-15 years have reduced from 13% to 6% in the period 1996 to 2006.
• These reductions are well ahead of target.
• This is encouraging news for the future.
IMPACT - SMOKING CESSATION SERVICES
• There has been an increase in the numbers of people attending Smoking Cessation services & setting a quit date from 361,000 in 2003/04 to 671,000 in 2008/09.
• Numbers of people successfully stopping have risen from 205,000 in 2003/04 to 337,000 tin 2008/09.
0
10
20
30
40
50
60
70
80
90
100
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
19
93
19
94
19
95
19
96
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97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
Men Women
% o
f th
e P
op
ula
tio
n
Underweight d
Normal e
Overweight f
Obese g
Data Years (All) HSE Table (All) HSE Topic BMI Age All Ages
Gender Data
Measure
Health Survey for England – % Obese, Overweight, Normal & Underweight – Males and Females – 1993 - 2008
Trend since 2000Trend since 2000
Standards 1 & 2: Reducing heart disease in the population1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of
coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1997 1998 2003 2004 2006 2008
% o
f th
e P
op
ula
tio
n
Low activity
Medium activity
High activity
Data Years (All) HSE Table (All) HSE Topic Physical Activity Gender Persons Age All Ages
Data
Measure
Discontinuous Years
High activity = Meeting recommended levels
Health Survey for England – Physical Activity –All Ages – 1993, 1998, 2003, 2004, 2006 & 2008
Less Physical Activity accounted for a 4.4% increase in CHD Mortality 1980-2000 (Capewell et al)
Trend since 2000
26 28 30 32 3335
26 28 29 30
36 36
29 28 30 3235 34
24 25
31 3034 32
19 1823
20
27 28
8 913 14 16 17
5 3 3 4 4 6
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
1997
1998
2003
2004
2006
2008
1997
1998
2003
2004
2006
2008
1997
1998
2003
2004
2006
2008
1997
1998
2003
2004
2006
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1997
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2003
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2006
2008
1997
1998
2003
2004
2006
2008
1997
1998
2003
2004
2006
2008
16-24 25-34 35-44 45-54 55-64 65-74 75 Plus
% o
f th
e P
op
ula
tio
nLow activity
Medium activity
High activity
Data Years (All) HSE Table (All) HSE Topic Physical Activity Gender Women
Age Data
Measure
Health Survey for England – Physical Activity –All Ages – 1993, 1998, 2003, 2004, 2006 & 2008
Less Physical Activity accounted for a 4.4% increase in CHD Mortality 1980-2000 (Capewell et al)
PHYSICAL ACTIVITY – ALL AGE TREND
• Participation in physical activity which meets recommended levels has risen slowly since 2000.
• It still remain at around one third of people who meet the recommended levels.
PHYSICAL ACTIVITY – TREND BY AGE
• The increasing trend is most evident in the under 35s and those aged 65-74.
• There is, however, evidence in the latest Health Survey for England that people are over-optimistic about the duration of self-reported exercise compared with electronic monitoring.
Standards 1 & 2: Reducing heart disease in the population1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of
coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.
5.4
7.46.8
8.0 8.3
6.36.8
6.3 6.2 6.3
20.1
19.018.1
16.9 17.1
6.0
7.9 7.88.4
9.2
7.78.1
7.2 7.0 7.0
15.8
11.4
12.813.6
12.3
0
5
10
15
20
25
2003 2005 2006 2007 2008 2003 2005 2006 2007 2008 2003 2005 2006 2007 2008
Hypertensive controlled Hypertensive uncontrolled Hypertensive untreated
% o
f th
e P
op
ula
tio
n
Men
Women
Data Years (All) HSE Table (All) HSE Topic Blood Pressure Age (All)
Measure Data
Gender
Health Survey for England – Blood Pressure – % Population with Hypertension Controlled, Uncontrolled & Untreated – 2003, 2005, 2006, 2007 & 2008
Population BP fall accounted for a 9% reduction in CHD Mortality 1980-2000 (Capewell et al)
Steady reduction in the % of Males with untreated Hypertension
Steady but modest increase in the % of
Males & Females whoHave their Hypertension
Controlled
HYPERTENSION• There has been a steady but modest
increase in the % of males & females who have their hypertension controlled.
• There has been a steady reduction in the % of males who have their hypertension untreated.
HYPERTENSION UNTREATED & UNCONTROLLED
• People with hypertension untreated & hypertension treated but uncontrolled continue to be at risk.
• Between 2003 & 2008 – the % of men at risk due to
untreated & uncontrolled hypertension reduced from 26.3% to 23.4%
– The % of women at risk due to untreated & uncontrolled hypertension reduced from 23.5% to 19.4%.
• 23.4% of men & 19.4% of women continue to be at risk.
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2003 2005 2006 2007 2008 2003 2005 2006 2007 2008
Men Women
% o
f th
e P
op
ula
tio
n
Hypertensive untreated
Hypertensive uncontrolled
Data Years (All) HSE Table (All) HSE Topic Blood Pressure Age (All)
Gender Data
Measure
England – Hypertension Uncontrolled & Untreated2003 & 2005-2008 (Health Survey for England)
26.3%
23.4% 23.5%
19.4%
Hypertensive untreated Hypertensive untreated
Hypertensive uncontrolledHypertensive uncontrolled
Standards 1 & 2: Reducing heart disease in the population1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of
coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.
PREVALENCE OF DIABETES• Increased diabetes prevalence accounted
for 4.8% of the increase in CHD mortality from 1980 to 2000.
• Since then prevalence has increased by 68% for women and 70% for men.
PREVALENCE OF CHD• All age prevalence reduced from 5.7% in
1998 to 5.2% in 2006.• There have been similar reductions in the
age groups 45-54 & 65-74. • with a more pronounced reduction in the
55-64 age group – from 9.6% in 1998 to 7% in 2006.
• Prevalence in the 75 plus age group has risen from 20.3% in 1998 to 22.8% in 2006.
• This is likely to be the result of delayed onset & increasing average age in the 75 plus age group.
1.9
2.5
3.4
4.2
2.9
3.3
4.3
5.6
2.4
2.8
3.9
4.9
0
1
2
3
4
5
6
1994 1998 2003 2006 1994 1998 2003 2006 1994 1998 2003 2006
Women Men Persons
Dia
be
tes P
reva
len
ce
(%
)
Data Years (All) HSE Table (All) Age All Ages HSE Topic DM Prevalence
Gender Data
Measure
Health Survey for England – Diabetes Prevalence –All Ages – 1994, 1998, 2003 & 2006
Increased Diabetes Prevalence accounted for a 4.8% increase in CHD Mortality 1980-2000 (Capewell et al)
Trend since 2000
Trend since 2000
Trend since 2000
2.6 3.0 2.7 2.4
8.19.6
8.47.0
15.1 16.1 15.3 15.1
18.220.3
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
va
len
ce
of
IHD
(%
)
Data Years (All) HSE Table (All) HSE Topic IHD Stroke Prevalence Measure IHD Prevalence (%) Gender Persons
Age Data
England – CHD PrevalencePersons – by Age – 1994,1998, 2003 & 2006 (Health Survey for
England)
FallSince 2000
FallSince 2000 Fall
Since 2000
FallSince 2000
-10.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Change % 16+
% Diagnosed 16+
Change % 16+ 0.0% -0.5% -1.0% -0.5% 0.1% -0.2% -1.1% -1.1% -1.0% -0.8%
% Diagnosed 16+ 87.2% 86.5% 83.8% 82.5% 78.2% 77.2% 76.7% 74.6% 70.5% 61.5%
North East
Yorkshire &
Humber
North West
East Midland
s
South Central
East Of England
South East
Coast
South West
West Midland
sLondon
Org Level SHA
SHA
Data
Coronary Heart Disease – QOF Prevalence Aged 16+ 2006/7 & 2007/8 & % of Estimated CHD Diagnosed (16+ 2006) – England by SHA
London QOF 16+ prevalenceIs 61.5% of expected(estimated) prevalence
There was little or no change in QOF prevalence between 2006/7 & 2007/8
% of CHD DiagnosedRanked QOF 2007/8 Prevalenceas a % of Estimated Prevalence
CHD Change in Prev Aged 16+ (%)Growth or reduction in 2007/8 Prevalence Compared with 2006/7 Prevalence
North EastQOF 16+ prevalenceIs 87% of expected(estimated) Prevalence
(1) Modelled estimates of prevalence of CHD for PCTs in England Version 1.0 (Eastern Region Public Health Observatory, September 2008) These estimates of the prevalence of CHD in people aged 16+ have been calculated using a model developed at the Dept of Primary Care and Social Medicine, Imperial College, London. The model was developed using data from the 2003-2004 Health Surveys for England. The model takes into account age, sex, ethnicity, smoking status and deprivation score.
79% 79% 78%81% 80% 79%
76% 75% 74%
79% 79% 77%
66% 66% 65%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2006/7 2007/8 2008/9 2006/7 2007/8 2008/9 2006/7 2007/8 2008/9 2006/7 2007/8 2008/9 2006/7 2007/8 2008/9
1 2 3 4 5
Avera
ge Q
OF
Pre
vale
nc
e a
s %
of
Esti
mate
d P
revale
nce -
16 y
rs p
lusSHA (All) SHA Code (All) Org Level PCT Old SHA (All) PCT (All) Spearhead (All) PCT Short (All)
Average of CHD Prev QOF as % of Est
Quintile Ave IMD Year
Vascular Programme – CHD - QOF Prevalence aged 16 years plus as a % of Estimated Prevalence- Average for PCTs by IMD Quintile – 2006/7 – 2008/9 – England
Quintile 1Least
Deprived
Quintile 5Most
Deprived
Standards 3 & 4: Preventing CHD in high risk patients3. General practitioners and primary care teams should identify all people with established cardiovascular disease and
offer them comprehensive advice and appropriate treatment to reduce their risks.4. General practitioners and primary health care teams should identify all people at significant risk of cardiovascular
disease but who have not developed symptoms and offer them appropriate advice and treatment to reduce their risks.
BLOOD PRESSURE – PEOPLE WITH CHD• QOF reporting started in 2004/05.• QResearch has published earlier trends in
BP control for their population of 3.4 million people.
• The trend for the QResearch sample (01/02-06/7) & the QOF results (04/05-08/09) shows a steady increase in the % of people on CHD registers with BP<150/90.
• By 2008/09 QOF reported 89.7% of people with CHD had BP<150/90.
CHOLESTEROL – PEOPLE WITH CHD• The trend for the QResearch sample
(01/02-06/7) & the QOF results (04/05-08/09) shows a steady increase in the % of people on CHD registers with Cholesterol of 5 mmol/l or less.
• By 2008/09 QOF reported 82.1% of people with CHD had cholesterol of 5 mmol/l or less.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
% o
f P
eo
ple
wit
h C
HD
QR BP <150/90
QOF BP<150/90
REG BP<150/90
Year Quarter
Data
QResearch BP<150/90Pre-introduction of QOF
QOF Reported BP<150/90
QOF Reported BP<150/90
as % ofCHD Register
England – QOF % of People with CHD with BP <150/90 – 2001/02 – 2008/09QResearch Population & National QOF Results
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
% o
f P
eo
ple
wit
h C
HD
QR Chol <5 mmol/l
QOF Chol <5 mmol/l
Reg Chol <5 mmol/l
Year Quarter
Data
QResearch Chol <5mmol/lPre-introduction of QOF
QOF Reported Chol <5mmol/l
QOF Reported Chol <5 mmol/l
as % ofCHD Register
England – QOF % of People with CHD with Cholesterol 5mmol/l or less –2001/02 – 2008/09 - QResearch Population & National QOF Results
70%
75%
80%
85%
90%
95%
100%
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/9
1 2 3 4 5
% o
f P
eo
ple
with
CH
D
Org Level PCT PCT Code (All) Practice Code (All) SHA (All) Spearhead (All) SHA Name (All)
CHD06 QOF %
IMD Quintile Year
PCT Short
England – QOF % of People with CHD with BP <150/90 – 2004/05 – 2008/09Results for PCTs by IMD Quintile
Quintile 1Least
Deprived
Quintile 5Most
Deprived
QOF % 2004/5 2008/9Max 87% 91%Ave 85% 90%Min 81% 88%
IMD QUINTILE 1QOF % 2004/5 2008/9Max 87% 92%Ave 82% 89%Min 78% 87%
IMD QUINTILE 5
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/9
1 2 3 4 5
Org Level PCT PCT Code (All) Practice Code (All) Spearhead (All) SHA (All)
CHD08 QOF %
IMD Quintile Year
PCT Short
England – QOF % of People with CHD with Cholesterol 5mmol/l or less –2004/05 – 2008/09 – BY PCT & IMD Quintile
Quintile 1Least
Deprived
Quintile 5Most
Deprived
QOF % 2004/5 2008/9Max 79% 85%Ave 73% 82%Min 67% 77%
IMD QUINTILE 1QOF % 2004/5 2008/9Max 80% 86%Ave 69% 81%Min 54% 77%
IMD QUINTILE 5
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
91
/92
92
/93
93
/94
94
/95
95
/96
96
/97
97
/98
98
/99
99
/00
00
/01
01
/02
02
/03
03
/04
04
/05
05
/06
06
/07
07
/08
08
/09
Ne
t In
gre
die
nt
Co
st (
00
0s)
0
10,000
20,000
30,000
40,000
50,000
60,000
Pre
scrib
ed
Ite
ms
(00
0s)
Statin Type (All)
Year
Data
England – Statin Prescribing – Total Statins (Proprietary & Generic)Prescribed Items (000s) & Net Ingredient Costs (£000s)
Statins – Prescribed Items (000s)
Statins – Net Ingredient Cost (£000s)
NSFCHD
Total StatinsBetween 2000/01 & 2008/09-Net Ingredient Cost - up 38%-Prescribed Items - up 388%
0% 0% 0%
40%
54%
62%
69%72%
0% 0% 0%
38% 38%
15%19% 18%
14%
100% 100% 100%
60%
46%
38%
31%28%
100% 100% 100%
62% 62%
85%81% 82%
86%
49%
51%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09
Items(000s) NIC(£000s)
% o
f T
ota
l S
tati
ns
- N
IC &
Pre
sc
rib
ed
Ite
ms
Generic
Proprietory
Sum of % of Total
Data2 Year
Statin Type
England – Statin Prescribing – Proprietary & Generic Statins – 2000/01 – 2008/09% Share of Prescribed Items (000s) & Net Ingredient Costs (£000s)
Prescribed Items Net Ingredient Cost
Generic Statins72% of ItemsIn 2008/09
Generic Statins14% of NICIn 2008/09
Standards 5,6 & 7: Heart attack and other acute coronary syndromes5. People with symptoms of a possible heart attack should receive help from an individual equipped
with and appropriately trained in the use of a defibrillator within 8 minutes of calling for help, to maximise the benefits of resuscitation should it be necessary.
PHASE 1 - SAVING LIVES – OUR HEALTHIER NATION
• The White Paper ‘Saving Lives: Our Healthier Nation’ was launched in 1999
• £2m invested in installing 681 automated external defibrillators (AEDs) in busy public places (airports, stations, shopping centres)
• From February 2005 all 681 AEDs were handed over to 21 Ambulance Services & financial allocations made to each Trust to ensure programme continuity.
• All AEDs managed as core NHS activity.
PHASE 2 - THE NHS PLAN• The NHS Plan (July 2000) 3,000
automated external defibrillators (AEDs) in public places.
• £6m was awarded to the BHF• Community Defibrillation Officers
appointed• A further 2,300 AEDs were funded
– based on bids received from Ambulance Trusts
Over 100 survivors to hospital discharge
Over 100 survivors to hospital discharge
Standards 5,6 & 7: Heart attack and other acute coronary syndromes6. People thought to be suffering from a heart attack should be assessed professionally
and, if indicated, receive aspirin. Thrombolysis should be given within 60 minutes of calling for professional help.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2001/0
2 Q
4
2002/0
3 Q
1
2002/0
3 Q
2
2002/0
3 Q
3
2002/0
3 Q
4
2003/0
4 Q
1
2003/0
4 Q
2
2003/0
4 Q
3
2003/0
4 Q
4
2004/0
5 Q
1
2004/0
5 Q
2
2004/0
5 Q
3
2004/0
5 Q
4
2005/0
6 Q
1
2005/0
6 Q
2
2005/0
6 Q
3
2005/0
6 Q
4
2006/0
7 Q
1
2006/0
7 Q
2
2006/0
7 Q
3
2006/0
7 Q
4
2007/0
8 Q
1
2007/0
8 Q
2
2007/0
8 Q
3
2007/0
8 Q
4
2008/0
9 Q
1
2008/0
9 Q
2
2008/0
9 Q
3
2008/0
9 Q
4
2009/1
0 Q
1
2009/1
0 Q
2
DTN30 %
CTN60 %
CY Quarter (All) New SHA (All) Level England SHA Short (All)
Fin Yr Q
Data
Acute Myocardial Infarction - STEMI -Thrombolysis% Door to Needle in 30 minutes & % Call to Needle in 60 minutes – 2002 - 2009
% Door to Needle in 30 minutes
% Call to Needle in 60 minutes
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005 2006 2007 2008 2009
lytictherapypPCI
% Thrombolysis
% Primary PCI
100%
40%
0%
60%
Acute Myocardial Infarction - STEMI -ThrombolysisShift from Thrombolysis to Primary PCI
THROMBOLYSIS FOR STEMI• Thrombolysis for STEMI was implemented
soon after the publication of the NSF.• The % of patients with Call to Needle within
60 minutes reached 70% in Q4 2007/08.• The % of patients with Door to Needle within
30 minutes reached 80% plus from Q2 2003/04.
• In many parts of the country pre-hospital thrombolysis was implemented & by 2007 17% of thrombolysis was being given before arrival at the hospital.
THROMBOLYSIS & PRIMARY PCI• From 2003 Primary PCI started to be
adopted as a more effective alternative.• The National Infarct Angioplasty Project
(NIAP) evaluated implementation at pilot sites.
• DH guidance (2008) recommended the roll-out of PPCI to areas where 120 call to balloon times could be delivered.
• Thrombolysis now accounts for 40% of post STEMI treatment & PPCI accounts for 60%.
How are heart attacks being managed?
0
10
20
30
40
50
60
70
80
90
100
2003
-4
2004
-5
2005
-6
2006
-7
2007
-8
2008
-9
2009
-10
Primary angioplasty
Pre-hospitalthrombolytic treatmentIn-hospitalthrombolytic treatment
%
Standards 5,6 & 7: Heart attack and other acute coronary syndromes7. NHS Trusts should put in place agreed protocols/systems of care so that people admitted to hospital with proven heart attack are appropriately assessed and offered treatments of proven clinical and cost
effectiveness to reduce their risk of disability and death.
PRIMARY PCI – RESPONSE TIMESDoor to Balloon (DTB)• The national mean time reduced from 61.7
minutes in 2007 to 53.8 minutes in 2008• In 2008 – 81.3% were less than 90 minutesCall to Balloon• The national mean time Call to Balloon was
116.6 minutes in 2008• In 2008 - 78.8% were less than 150 minutes.
OUTCOMES FOR PATIENTS WITH ACS• While 30 day mortality after nSTEMI has
been falling, outcomes for patients with ACS (nSTEMI) remain of concern.
• The immediate diagnosis & treatment of nSTEMI has lagged behind that for STEMI.
NICE GUIDANCE – MARCH 2010• NICE is preparing clinical guidance on
– The management of ACS - published March 2010
• Future improvements in management & treatment to be based on guidance issued.
Unadjusted 30-day mortality after nSTEMI is falling
Unpublished data - John Birkhead
Some 1200-1500 fewer deaths each year
61.7
53.8
116.6
0
20
40
60
80
100
120
140
2007 2008 2008
Door to Balloon Call to Balloon
Min
ute
s
Sum of Minutes
Measure Year
Acute Myocardial Infarction - STEMI – Primary PCICTB 2008 & DTB 2008 & 2009 (National Mean of Unit Median Times)
Source: BCIS Audit – P.Ludman
DTB - 81.3% < 90 mins
CTB – 78.8% < 150 mins
Falling mortality rates – MINAP data
STEMIs30 days
Falling mortality rates – MINAP data
Non STEMIs30 days
Standard 8: Stable angina8. People with symptoms of angina or suspected angina should
receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2003-
2004-05 2005-06 2006-07 2007-08 2008-09 2009-
% o
f R
AC
P C
lin
ica
l R
efe
rra
ls
% Refs within 24 hrs
% All Refs Seen in 14 days
% Outcome Cardiac
Level National Area (All) SHA Name (All)
Year Quarter
Data
England – Rapid Access Chest Pain Clinics – 2002/03 – 2009/10% Referred within 24 hours, Seen with 14 days & % Cardiac in Origin
Rapid increase in Specificity of referral
43% of referralsCardiac in origin
90% of referrals made within 24 hrs
97% of referrals Seen within 14 days
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2003-
2004-05 2005-06 2006-07 2007-08 2008-09 2009-
RA
CP
C R
efe
rra
ls
Total
Linear (Total)
Area Name (All) SHA (All) Area (All) SHA Name (All) Level SHA Area Code (All)
Sum of Patients
Year Quarter
Trend
England – Rapid Access Chest Pain Clinics – 2002/03 – 2009/10National Trend in the Number of ReferralsRAPID ACCESS CHEST PAIN CLINICS
• Central funding enabled Rapid Access Chest Pain Clinics to be developed across the country
• Since 2002/03 referrals have been running at over 25,000 in each quarter
• Over the period since their introduction there has been an upward trend in referrals nationally – so no let up in symptomatic presentation.
• In each of the last 5 quarters to June 2009 there have been over 30,000 referrals.
SPEED OF ACCESS & % CARDIAC IN ORIGIN• Since 2006 90% of referrals have been made
within 24 hrs of GP decision to refer.• Over 95% of referrals have been seen within
14 days (97% in the quarter to June 2009)• Over the first year of their introduction
specificity of referral increased & over 40% of referrals have been cardiac in origin (43% in the quarter to June 2009)
Standards 9 & 10: Revascularisation9. People with angina that is increasing in frequency or severity should
be referred to a cardiologist urgently or, for those at greatest risk, as an emergency.10. NHS Trusts should put in place hospital-wide systems of care so that patients with suspected or
confirmed coronary heart disease receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent coronary events.
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
An
gio
gra
ms
Angiography
Angio Plus PCI
Angiography 98,949 106,329 114,658 126,434 130,339 139,377 147,757 166,125
Angio Plus PCI 8,272 8,738 10,621 13,956 14,791 15,553 14,170 11,461
2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007 2007-2008
HA/Board England
Data
Intervention
England – Angiography Activity –Angiography Alone & Angiography with PCI - 2000-2001 to 2007-2008
Increase of 66%2000/1-2007/8
ANGIOGRAPHY – GROWTH IN ACCESS
• Access to angiography has improved substantially
• The number of angiograms increased by 66% between 2000/01 & 2007/08.
ANGIOGRAPHY – SPEED OF ACCESS
• Speed of response has improved markedly.
• Since April 2004• Total waiters have reduced by
over 15,000 - down 66%• In April 2004 - 26% of people
waited a month or less• By December 2009 – 82% of
people waited a month or less.0
5,000
10,000
15,000
20,000
25,000
Ap
r-0
4M
ay-
Ju
n-0
4Ju
l-0
4A
ug
-04
Se
p-0
4O
ct-
04
No
v-0
4D
ec-0
4Ja
n-0
5F
eb
-05
Ma
r-0
5A
pr-
05
Ma
y-
Ju
n-0
5Ju
l-0
5A
ug
-05
Se
p-0
5O
ct-
05
No
v-0
5D
ec-0
5Ja
n-0
6F
eb
-06
Ma
r-0
6A
pr-
06
Ma
y-
Ju
n-0
6Ju
l-0
6A
ug
-06
Se
p-0
6O
ct-
06
No
v-0
6D
ec-0
6Ja
n-0
7F
eb
-07
Ma
r-0
7A
pr-
07
Ma
y-
Ju
n-0
7Ju
l-0
7A
ug
-07
Se
p-0
7O
ct-
07
No
v-0
7D
ec-0
7Ja
n-0
8F
eb
-08
Ma
r-0
8A
pr-
08
Ma
y-
Ju
n-0
8Ju
l-0
8A
ug
-08
Se
p-0
8O
ct-
08
No
v-0
8D
ec-0
8Ja
n-0
9F
eb
-09
Ma
r-0
9A
pr-
09
Ma
y-
Ju
n-0
9Ju
l-0
9A
ug
-09
Se
p-0
9O
ct-
09
No
v-0
9D
ec-0
9
Nu
mb
ers
Wa
itin
g
9+ mths
8-9 mths
7-8 mths
6-7 mths
5-6 mths
4-5 mths
3-4 mths
2-3 mths
1-2 mths
0-1 mths
Year (All) Quarter (All) First Last (All) Intervention Angiography Old SHA (All) New SHA (All) Trust Short (All)
Period
Data
England – Total Waiters by Time Band – AngiographyApril 2004 – December 2009
Total WaitersDown 66%
Waiting 0-1Months = 26%
Waiting 0-1Months = 82%
Standard 11: Heart failure11. Doctors should arrange for people with suspected heart failure to be offered appropriate
investigations (e.g electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely to
both relieve their symptoms and reduce their risk of death should be offered.
ECHOCARDIOGRAPHY – SPEED OF ACCESS
• Diagnostic waiting times have reduced as part of achieving 18 weeks
• For echocardiography – in March 2009
– 88% of people waited less than 4 weeks
– 99% of people waited less than 6 weeks.
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
Wa
itin
g L
ist
Nu
mb
ers
Apr-08
Mar-09
Apr-08 7630 7321 5327 3448 1756 668 327 149 130 101 90 58 22 45
Mar-09 7901 7562 5697 3605 2360 915 91 57 16 12 6 3 1 13
0 <01 weeks
01 <02 weeks
02 <03 weeks
03 <04 weeks
04 <05 weeks
05 <06 weeks
06 <07 weeks
07 <08 weeks
08 <09 weeks
09 <10 weeks
10 <11 weeks
11 <12 weeks
12 <13 weeks
13+ weeks
Diagnostic Echocardiography SHA Name (All)
Data
Month
England – Waiting Time in Weeks –April 2008 & March 2009 - Echocardiography
In March 200988% waited less than 4 weeks99% waited lss than 6 weeks
Standard 11: Heart failure11. Doctors should arrange for people with suspected heart failure to be offered appropriate
investigations (e.g electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely to
both relieve their symptoms and reduce their risk of death should be offered.
HEART FAILURE - MORTALITY• There is some evidence that mortality among newly diagnosed cases of heart failure has
decreased (South East England Hillingdon/Bromley 1995/97 & Hillingdon/ Hastings 2004/05).
Heart Failure – Improval in survival of incident cases of Heart FailureCohort Study – 1995/97 & 2004/05 (Mehta et al, Heart 2009 95:1851-1856)
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,00019
98/9
1999
/0
2000
/1
2001
/2
2002
/3
2003
/4
2004
/5
2005
/6
2006
/7
2007
/8
2008
/9
1998
/9
1999
/0
2000
/1
2001
/2
2002
/3
2003
/4
2004
/5
2005
/6
2006
/7
2007
/8
2008
/9
1998
/9
1999
/0
2000
/1
2001
/2
2002
/3
2003
/4
2004
/5
2005
/6
2006
/7
2007
/8
2008
/9
Congestive heart failure Left ventricular failure Heart failure, unspecified
Hea
rt F
ailu
re -
Ad
mis
sio
ns
& F
CE
s
FCEs
Admissions
Data
England – Heart Failure – Hospital Finished Consultant Episodes & Admissions –
By Specific Diagnosis - 1998/9-2008/9
Left Ventricular Failure - Admissions & FCEs have reduced FCEs by 35% since 1998/99 & by 30% since 2000/01
Admissions by 49% since 1998/99 & by 43% since 2000/01
Receipt of cardiac rehabilitation
0
10
20
30
40
50
60
70
80
%
Acute MI CABG PCI All cases
2005/6
2006/7
2007/8
2008/9
% of patients with MI, CABG and PCI receiving cardiac rehabilitation
0
10
20
30
40
50
60
70
%
NE NW SEC E of E Y & H WM SW EM SC Lond
2005/6
2006/7
2007/8
2008/9
EnglandMI CABG PCI
WalesMI CABG PCI
Reasons for rejection
Uptake by ethnicity
Quality requirement two: Diagnosis and TreatmentPeople presenting with arrhythmias, in both emergency and elective settings,
receive timely assessment by an appropriate clinician to ensure accurate diagnosisand effective treatment and rehabilitation. .
Heart Rhythm Devices – UK National Surveys
• Annual surveys & reports• Tracking progress –
nationally & by Network & PCT
• Compare observed with expected
• 2009 Report due July 2010
• Overall mapping shows improved access rates between 2006 & 2008 for
– Pacemakers– ICD– CRT
Source: Cunningham et al, Heart Rhythm DevicesUK National Survey, 2008
Outcomes – CHD MortalityCHD MORTALITY UNDER 75• Between 1995/97 & 2005/07 average
annual deaths from all causes reduced from 202,061 to 159,921
• Deaths from CHD reduced from 46,615 to 24,495
• Deaths from Other Circulatory Diseases reduced from 27,610 to 18,557.
• Between 1995/97 & 2005/07 - mortality rates from All Causes reduced from 397 per 100,000 to 302 per 100,000 – down 24%
• Mortality rates from CHD reduced from 89 to 45 per 100,000 – down 50%
• Mortality rates from Other Circulatory Disease reduced from 52 to 34 per 100,000 – down 35%
46,61524,495
27,610
18,557
71,363
62,007
56,472
54,862
0
50,000
100,000
150,000
200,000
250,000
P Ave 95-97 P Ave 05-07
ENGLAND
NU
mb
er
of
de
ath
s
Other Causes
Cancer
Other Circulatory
CHD
Level National Measure OBS
SHA Year
Data
England – All Cause Mortality – Aged Under 75 years –Number of Deaths by Cause – 3 Year Average 1995-97 & 2005-07
202,061
159,921
1995-97 2005-07
8945
52
34
141
115
115
107
0
50
100
150
200
250
300
350
400
450
P Ave 95-97 P Ave 05-07
ENGLAND
Mo
rta
lity -
DS
R p
er
10
0,0
00
- A
ll C
au
se
s
Other Causes
Cancer
Other Circulatory
CHD
Level National Measure DSR
SHA Year
Data
England – All Cause Mortality – Aged Under 75 years –Directly Standardised Rate (per 100,000) by Cause – 1995-97 & 2005-07
397
302
1995-97 2005-07
Outcomes – CVD MortalityCVD MORTALITY UNDER 75• As a result of these reductions there
has been a reduction of 47% in death rates from circulatory disease.
• The Public Service Agreement target was to achieve a 40% reduction by 2010.
• The target has been achieved 5 years ahead of schedule.
INEQUALITIES• In addition, the aim is to reduce the
absolute gap between the worst fifth of areas in the country for health & deprivation (the spearhead PCTs) & the national average by 40% by 2010.
• The absolute gap has reduced by 38.4% between 1996 and 2007 – well on the way to achieving that target.
Outcomes – CHD MortalityCHD MORTALITY UNDER 75• However, comparison of the
changing rates between Local Authorities – grouped into deprivation quintiles (using the Index of Multiple Deprivation) shows a different picture.
• In 1995-97, there was a large overlap in the mortality rates between the local authorities in the 1st (least deprived) and 5th (most deprived) quintiles.
• By 2005-07, the gap had widened & the overlap had almost disappeared.
• However, the variation in mortality rates within the 1st & 5th deprivation quintiles has narrowed
• AND• In both the 1st & 5th quintiles the
highest (worst) mortality rates in 2005-07 are lower (better) than the lowest (best) mortality rates in 1995-97.
0
20
40
60
80
100
120
140
160
1 5 1 5
DSR 95-97 DSR 05-07
DS
R p
er
10
0,0
00
Level LA Measure DSR SHA (All)
Ave CHD DSR
Year IMD Quintile
Area Short
England – CHD Mortality – Aged Under 75 yrs – Directly Standardised Rates (DSR) – Local Authorities 1st & 5th IMD Quintiles – 1995-97 & 2005-07
CHDUnder 75s
OverlapThe gap
has widened
1995-97 2005-07
Range ofDSRs forLAs in the5th Quintile
In 95/97
0
20
40
60
80
100
120
140
160
1 5 1 5
DSR 95-97 DSR 05-07
DS
R p
er
10
0,0
00
Level LA Measure DSR SHA (All)
Ave CHD DSR
Year IMD Quintile
Area Short
England – CHD Mortality – Aged Under 75 yrs – Directly Standardised Rates (DSR) – Local Authorities 1st & 5th IMD Quintiles – 1995-97 & 2005-07
CHDUnder 75s
The variation has narrowed
The variation has narrowed
BUT
1995-97 2005-07
ANDIn both cases the
worst in 05/07 is betterthan the best in 95/97
Next ten years!
8945 23
52
3416
141
115
89
115
107
99
0
50
100
150
200
250
300
350
400
1995-97 2005-7 2015-17
DS
R d
eath
s p
er 1
00,0
00
Other causes
Cancer
Other CVD
CHD
?
How it looked 10 years ago
1995-97
22%
13%
36%
29%
CHD
Other CVD
Cancer
Other
How it looks now
2005-7
15%
11%
38%
36%CHD
Other CVD
Cancer
Other
How it might look 10 years from now- the next 50%
2015-17
10%7%
39%
44% CHD
Other CVD
Cancer
Other
34,000 fewer deaths each year cf. 1995-97
Challenges for hospital care
• Maintaining quality during current economic climate
• Driving up efficiency– Reducing LOS– Reducing admissions/readmissions– Reducing follow-ups
• Working primary care to improve CV care and referral patterns
What is left for primary care to do?
• Further optimise secondary prevention
• Get upstream – Health Checks– Prevent CVD and diabetes
• Identify and manage people with AF– Prevent about 5,000 strokes
• Identify people with FH– Entirely treatable condition once diagnosed
• Run the NHS!