European 4th Joint Task Force on CVD Prevention in Clinical Practice in the context of the National Cardiovascular Health Policy Hannah McGee, PhD, FEHPS, FESC Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

“Changing Cardiovascular Health” [10 year plan: ] CVH Policy Group Terms of Reference ‘…to develop a policy framework for the prevention, detection and treatment of cardiovascular disease including stroke and peripheral arterial disease, which will ensure an integrated and quality assured approach to their management’.

CVD Medication Use - GMS Scheme ( )

(N=1207, aged 45+) Normotensive (<140/90mmHg)(no meds) 40% Hypertensive –On medication (<140/90mmHg) 8% –On medication (>140/90mmHg) 18% –NOT on medication (>140/90mmHg) 34% SLÁN 2007: Hypertension management

Normotensive (<140/90mmHg)(no meds) 40% Hypertensive –On medication (<140/90mmHg) 8% –On medication (>140/90mmHg) 18% –NOT on medication (>140/90mmHg) 34% Not Treated: –Men/women: 40 / 27% –Age / / 33% –Social class (1-2/3-4/5-6): 35 / 33 /39% SLÁN 2007: Hypertension management

69 recommendations –Recommendation –Lead agency POLICY: Structure and Recommendations

69 recommendations –Recommendation –Lead agency SIX SECTIONS Prevention and Health Promotion Primary Care Hospital and Emergency Care Services Cardiac and Stroke Care and Rehabilititon Workforce Planning for the Policy A National Framework for Quality in Cardiovascular Health POLICY: Structure and Recommendations

10-year population targets: Smoking -annual 1% reduction prevalence -Annual 1% reduction in initiation rates Healthy body weight [Healthy eating /physical activity] - halt rise in 5 years - restore 1998 levels by 2019 Salt consumption EU 2012 Directive (16% reduction) Alcohol use Strategic Task Force on Alcohol targets (2007) POLICY: Prevention and Health Promotion

Patient/public awareness –blood pressure & cholesterol levels, family history, waist circumference, stroke signs/symptoms High risk approach - extend definition using ESC’s 4th Joint SocietiesTask Force (2007) approach –established disease, family members - premature atherosclerosis/multiple risk factors Risk identification & management –Single nationally agreed protocol –Opportunistic assessment (with systematic approach) –Phased evaluation of systematic assessment model POLICY: Primary Care I

SLÁN 2007: Attending GP in the previous year (gender, age and social class (%)) Population risk: systematic opportunistic assessment in general practice?

Stroke prevention –blood pressure - rigorous assessment, treatment, monitoring –atrial fibrillation - age 65+: pulse assessment in GP - anticoagulation services Heart failure management –Early detection: - education of primary care teams - liaison specialist HF nurses POLICY: Primary Care II

Commonalities - cardiac & stroke Secondary prevention for all –from TIA/mild strokes to complex cardiac cases - heart failure/PAD Step-down strategies from hospital to primary care services Staff training - chronic disease model: build on CR experience POLICY: Rehabilitation

Standards –Evidence-based guidelines/ performance indicators/ information & data requirements/updating guidelines –National Guidelines Coordination (liaise DoHC/HIQA) Surveillance –Information systems - registers, data standards, population surveys, audit –ICT - infrastructure, capacity & training Research and evaluation –Health Technology Assessment agenda POLICY: National Framework for Quality in Cardiovascular Health

Policy delivery 1. HSE Service Plan - Clinical Directorate priorities set Appointments: Stroke, Acute cardiac, Heart failure, Primary care 2. Cabinet Sub-Committee on Health: monitor population targets 3. Overall: CVH Policy Monitoring Group to be established Full formal review at 5 years (2015) –CVH Policy Monitoring Group POLICY: What happens next?

Hospital discharges by CVD diagnosis ( ) discharges 1998 discharges 2008 Discharges: % Change CHD21,43522,0463 Heart Failure22,07320,872-5 PAD7,4137,7404 Stroke 6,8767,509 9 TIA 2,3772, All60,17460,8561

Hospital discharges by CVD diagnosis ( ) discharges 1998 discharges 2008 Discharges: % Change CHD21,43522,0463 Heart Failure22,07320,872-5 PAD7,4137,7404 Stroke 6,8767,509 9 TIA 2,3772, All60,17460,8561

Hospital discharges by CVD diagnosis ( ) discharges 1998 discharges 2008 Discharges: % Change CHD21,43522,0463 Heart Failure22,07320,872-5 PAD7,4137,7404 Stroke 6,8767,509 9 TIA 2,3772, All60,17460,8561

Hospital bed days by CVD diagnosis ( ) Bed days 1998 Bed days 2008 Discharge: % Change Bed Days: % Change CHD156,231119, Heart Failure261,499291, PAD98,323112, Stroke127,672145, TIA16,23616, BED DAYS659,961685,56414

Hospital bed days by CVD diagnosis ( ) Bed days 1998 Bed days 2008 Discharge: % Change Bed Days: % Change CHD156,231119, Heart Failure261,499291, PAD98,323112, Stroke127,672145, TIA16,23616, BED DAYS659,961685,56414

Hospital bed days by CVD diagnosis ( ) Bed days 1998 Bed days 2008 Discharge: % Change Bed Days: % Change CHD156,231119, Heart Failure261,499291, PAD98,323112, Stroke127,672145, TIA16,23616, BED DAYS659,961685,56414

Hospital bed days by CVD diagnosis ( ) Bed days 1998 Bed days 2008 Discharge: % Change Bed Days: % Change CHD156,231119, Heart Failure261,499291, PAD98,323112, Stroke127,672145, TIA16,23616, BED DAYS659,961685,56414

Medical Staffing Consultant workforce: –Cardiology: Joint Working Group (2004) – 10 per 500,000 needed –(preventive cardiology & heart failure expertise for network coverage) –Stroke: combination geriatric medicine/neurology with special interest in stroke/geriatric medicine/rehabilititon medicine –(5 acute stroke, 2-3 for other services, additional rehabilitiation physician expertise per 500,000) NCHD workforce: service need/capacity for next generation Multidisciplinary Team Staffing (+ICT) Primary Care Staffing (PCTs) POLICY: Workforce Planning

Regional networks Serving populations of c.500,000 Every hospital provides a complete range of services (cardiac or stroke) either on-site or in formal partnership with others in the network) Equitable - all can access same range of services Hospitals Two types: –GENERAL cardiac(stroke) centre (provides sub-acute and chronic care) –COMPREHENSIVE cardiac(stroke) centre (provides acute care) Some consultant and other staff with ‘network’ responsibilities POLICY: Structures - Networks

Clinical management - cardiac (ACS) STEMI & treatable within 180 mins: primary PCI –Centres with access, workforce expertise and adequate cover STEMI & not treatable within 180 mins: thrombolysis –Timely provision = priority Structures - cardiac –PCI: full range of imaging facilities/ 2 labs for timely access –CCU reconfigured - Critical Cardiac Care focus –Thrombolysis: pre-hospital/advanced paramedic and hospital combination POLICY: Hospital Care I

Services –Emergency services: advanced paramedics/ICT essential –Rapid Access Chest Pain Services –Heart failure - ambulatory services: shared care model –PAD services: vascular service access –Cardiac surgery: workforce adequate - Protected ICU beds (single room) the priority –Congenital heart disease /GUCH: needs separate focus POLICY: Hospital Care II

Clinical management - stroke –Thrombolysis: ‘consultant stroke physician’ administered 24/7 cover needed Structures - stroke –Stroke units: capacity, MD Teams, care protocols, early start to rehabilitation; discharge plan –TIA/Stroke Prevention Clinics: same day assessment; timely access to vascular surgery where needed –Neuroradiology/Vascular Surgery: services access POLICY: Hospital Care III

Philosophy - REDUCING THE INCIDENCE OF CVD: The European Heart Health Charter “Every child born in the new millenium has the right to live until the age of at least 65 without suffering from avoidable cardiovascular disease” (June 2007)