stroke prevention services - quality & safety indicators
TRANSCRIPT
STROKE PREVENTION SERVICES QUALITY AND SAFETY INDICATORS IN A CHANGING CONTEXT
• David Pa;erson MD FRCP FRSPH • Professor of Cardiovascular Medicine • Consultant Cardiologist • Department of Cardiovascular Medicine, WhiMngton Health • CHIME, University College London • Helicon Health, Chief ExecuPve
HeartBeat/HeliconHeart - Seamless anticoagulation and stroke prevention services across north London building on 20 years of world-leading research on electronic health records
Good European ���Health Record 1992
1996
2000
1998 1996
2002 2004 2006 2006
2008
20 years of international research on the requirements, design, implementation, sharing and protection of electronic health records
Leading a global open source EHR Foundation Leading the development of
European and International EHR standards
implementation of an ISO EN 13606 conformant EHR server with a suite of cardiovascular web applications
Set up and seed funded by UCL in 2012 Key partners CHIME and Whittington Health
HeartBeat Anticoagulation���management and���advisory system 2006
1999
2011
2012
HeliconHeart is a unique package of clinical services comprising: -‐ Web soSware -‐ Clinically useful Electronic Health Record, standards-‐based -‐ Decision support – which drugs to use, how and when -‐ CollaboraPon tools -‐ EducaPon -‐ Governance & data analyPcs
NICE AF GUIDELINES 2014
Key prioriPes for implementaPon:
• Personalised package of care and informaPon
• Referral for specialised management • Assessment of stroke and bleeding risks
• IntervenPons to prevent stroke • Rate and rhythm control
2014 ATRIAL FIBRILLATION AWARE WEEK 24TH NOVEMBER -‐ 29TH NOVEMBER
The aims of the AF Aware week are simple: AF -‐ Detect, Protect, Correct:
! Detect: OpportunisPc Screening has been shown to increase detecPon of AF ! Protect: IdenPficaPon and treaPng paPents with AF at an early stage will
deliver significant health and cost benefits ! Correct: Early detecPon, diagnosis and appropriate medical management leads
to fewer appointments & admissions, saving individuals long-‐term ill health
The All-‐Party Parliament Group on AF (APGAF) has played a key role in helping to establish that AF should, in both policy and clinical domains, be considered a discrete enPty within “the family of cardiovascular disease”.
APGAF meets again tomorrow to explore the sPll exisPng barriers for paPents to gain access to the opPmal treatment.
WHAT ARE THE REASONS FOR OFFERING ANTICOAGULANT AND STROKE PREVENTION TREATMENT TO PATIENTS ?
“AnPcoagulaPon therapy is required for people with different condiPons, who are idenPfied in a range of seMngs and, in the case of deep venous thrombosis and pulmonary embolism, require urgent intervenPon.” NICE 2013 Based on epidemiological data and other informaPon, it is concluded that the number of adults aged 18 or over in England who require anPcoagulaPon therapy and may need access to an anPcoagulaPon therapy service include:
CondiEon AnEcoagulaEon therapy service
Atrial fibrillaEon (CHADS2 score=1) 226,000
Atrial fibrillaEon (CHADS2 score>1) 476,000
VTE including PE and DVT 125,000
Others 155,000
“Therefore, it is suggested that the indicaPve rate for people needing anEcoagulaEon therapy is up to 2.4% or 2400 per 100,000 of the populaPon aged 18 years or over” NICE 2013
ARE WE IDENTIFYING ALL THE PATIENTS WITH AF WHO SHOULD BE ANTICOAGULATED?
ATRIAL FIBRILLATION IS A MAJOR PREVENTABLE CAUSE OF STROKE NaPonal data obtained from GRASP-‐AF show
that only 66% of high risk paPents are managed using oral anPcoagulaPon
(May 2014 – 33% of all pracPces in England)
This is in spite NaPonal Guidelines from NaPonal InsPtute for Health and Care Excellence and the European Society of Cardiology promoPng their use
RAISING AWARENESS – IDENTIFYING PATIENTS WITH AF
The Atrial FibrillaEon AssociaEon (AFA) and the Stroke AssociaEon have undertaken awareness-‐raising events:
Know your pulse EducaEonal events
OpportunisEc is cost-‐effecEve
Flu vaccinaEon programme Surgery pre-‐assessment Eye appointments Pharmacy visit Supermarket visit Pub visits?
OpportunisEc or screening programme?
NICE (2013) SUPPORT FOR COMMISSIONING: ANTICOAGULATION THERAPY NICE GUIDELINES FOR AF (2014)
• There is such an inPmate relaPonship between AF and other manifestaPons of CV Disease (The Family of Cardiovascular Disease) and to anPcoagulant and prevenPon services for strokes
• It is an essenPal step to idenPfy paPents with AF and direct appropriate paPents to anPcoagulant and stroke prevenPon therapy in order to reduce the incidence of stroke.
ATRIAL FIBRILLATION Hypertension
Raised lipids
Coronary artery disease
HEART FAILURE Hypertension
Coronary artery disease
Raised lipids
ANTICOAGULATION Monitoring
Frequent visits
PST & PSM opPons
WHY ARE WE HERE?
Cardiovascular disease (CVD) is the biggest killer in the UK
Costs of CVD are massive
Strokes are avoidable with preventive treatment
Wide variations in quality and safety
Strokes are very costly to the patient and society
Poor clinician and patient education
of UK population have CVD
ONS 2011
>11% £19b BHF 2014 Stroke Association 2014
153,000 Strokes/year UK
Not on effective therapy to reduce strokes
NICE UK
44% £23k Saving from each stroke prevented
NAO 2010
No. 1 risk “Not all staff have the required work competencies”
NPSA Risk of Anticoagulation, 2006
POPULATION ATTRIBUTABLE RISK
The contribuPon each risk factor makes to overall stroke prevalence can be calculated as a populaPon a;ributable risk (PAR). In England:
PAR of smoking 13.3% PAR of hypertension 34.8%
50% of the risk of stroke can be “preventable” by controlling these 2 risk factors.
There is logic in managing these risk factors at the same Pme as the risks a;ributable to atrial fibrillaPon (heart rhythm and rate control and oral anPcoagulaPon)
IMPACT OF HELICON AF & STROKE PACKAGE
Strokes/year
101
64 37 strokes saved
Before With Helicon’s AF& Stroke package
EsPmated cost saving: £592,000
Total populaPon: 320,000
>60y: 57,290
An Urban CCG
“The cost of stroke could be cut by 20% with beBer management of atrial fibrillaFon.” NICE 2006
UNIQUE ONLINE SOLUTION FOR SHARED CARE
Electronic Health Record An online care record shared across all venues of care
Clinical Decision Support Integrated tools for better diagnosis, risk assessment & treatment
Clinical Governance Analytics Robust analytics enables multi-site comparison
Clinician & Patient Education Patients are equipped for self-care and clinicians are kept up to date with accredited learning
EDUCATION
The patient The clinician It has features for the paEent, together with their carer or family member that include:
! Only comprehensive on-‐line resource to support the self-‐tesPng paPent
! Assessment tools to assess competencies ! More value on expansion to self-‐
management (inclusion of dosing support) ! Retain support of local pracPPoner for
skills-‐based training ! Resource that paPent can share with their
pracPPoner to facilitate consultaPons ! User can select different levels of
informaPon based on learning needs ! Produced and supported by experts in
field
Part of the course for the clinician is to study the course for the paEent.
! Offer both skills and knowledge based educaPon with assessments of both
! In addiPon to the clinical knowledge base we offer very pracPcal support in terms of service delivery, clinical governance and paPent-‐centred consultaPons
! User can select different levels of informaPon based on learning needs
! Supported by experts in field ! UCL branding ! Forum to allow interacPon with fellow
students and mentors / tutors ! Not a stand-‐alone product. ! Forum for alumni to help conPnue their
educaPon and to share experiences
THE INVOLVEMENT OF THE PATIENT AND CARER
CASE STUDY COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUST (CDDFT)
• In June 2013, 200 paPents taking warfarin were idenPfied and recruited for an INR self-‐tesPng study
• Within 6 months of the study starPng, 70% of paPents had increased their Pme in therapeuPc range (TTR) by over 20%. The average increase was 15%.
• Financially, INR self-‐tesPng was cost neutral when all CCG costs were included such as the reducPon in adverse events. Self-‐tesPng also freed up clinic capacity.
• PaPents loved the service -‐ every paPent in the study said they would recommend it
Average TTR across all 200 paFents, before & aMer study
6 months before study 59.7%
3 months before study 59.0%
3 months ader study 71.9%
6 months ader study 74.7%
PATIENT SELF-‐TESTING AND/OR SELF-‐MANAGING
THE CONTROL OF THE INR
! FINGER PRICK TESTING WITH COAGUCHEK ! COMMUNICATION WITH HCP:
Grace concludes: • “I get comfort from knowing that, thanks to
HeliconHeart, all my clinicians have access to a single electronic health record for me. I also like playing an acFve role in my treatment and I find I worry less about my AF.”
ADDRESSING THE CO-‐MORBIDITIES OF AF
! BLOOD PRESSURE & PULSE/HEART RATE ! SMOKING ! ACTIVITY/EXERCISE/DANCE ! WEIGHT MEASUREMENT (PARTICULARLY FOR
HEART FAILURE MANAGEMENT)
SUPPORTED BY
! ON-‐LINE EDUCATION ! LOCAL HEALTH CARE PROFESSIONAL WITH
ACCESS TO EHR AND ADVISORY SYSTEMS ! STRONG CLINICAL GOVERNANCE
IVR
Web
App
STROKE PREVENTION SERVICES WARFARIN CLINIC VISIT
COMMUNITY BASED STROKE PREVENTION SERVICES IN ROMIRE STROKE PREVENTION IN PATIENTS WITH ATRIAL FIBRILLATION PERIOD 01.01.2014 – 31.12.2014
TOTAL NUMBER OF PATIENTS SUSTAINING A STROKE IN ROMIRE : 236 Data from NaEonal SenEnel Stroke Audit
THOSE THAT HAD AF
THOSE THAT NOW HAVE AF
AF PREVIOUSLY DIAGNOSED PROPORTION ON AN OAC AT TIME OF STROKE
PROPORTION NOW ON AN ORAL ANTICOAGULANT
100 80%
100%
40%
QUALITY OF SERVICE VKA CONTROL TTR > 70 TTR > 60
65% 81%
NUMBER TAKING A NOAC 5
THOSE THAT HAD AF AND SMOKED PROPORTION WHO HAD A SMOKING
INTERVENTION
20 15%
THOSE THAT HAD RECOGNISED HYPERTENSION
PROPORTION TAKING HYPOTENSIVE AGENTS 40% PROPORTION WHOSE BP WAS WELL CONTROLLED
30 %
EXERCISE/ACTIVITY PROPORTION TAKING EXERCISE > 5 TIMES PER WEEK
20% PROPORTION WHO ARE SEDENTERY 45%
PREVENTION OF STROKE NEW OPPORTUNITIES
The expanded HeliconHeart package that results from our new strategic partnership with InHealthCare, is an integrated, web-‐based soluPon for stroke prevenPon, which makes it easier for busy healthcare professionals to plan and manage AF, oral anPcoagulaPon and stroke prevenPon services. It is also designed for paPents who wish to play a more acPve role in managing their condiPon.
THE PACKAGE FEATURES:
! Real-‐Pme electronic health record (EHR) shared with clinical colleagues and paPent
! AnPcoagulant & AF advisory systems
! Interoperability with exisPng GP systems and other clinical systems
! Affordable paPent self-‐monitoring, using BP monitor and Roche’s Coaguchek
! Hosted on NHS spine via N3 ! EducaPon for clinicians
! EducaPon for paPents
KEEP IN TOUCH
To discuss today’s presentaPon or any ma;ers arising please email me at d.pa;[email protected]
I will be on the Roche stand between 3 and 4 this aSernoon
To find out more about Helicon Health’s unique package of stroke prevenPon services, go to www.heliconhealth.co.uk