A Primary Care Trust Perspective NHS North Lancashire

Dr Jim Gardner Medical Director & PEC Chair NHS North Lancashire

PCT Perspective Corporate Objectives Commission health care Improve health outcomes Reduce health inequalities Achieve financial balance ‘Patient Safety First’ Whole-systems thinking Not experts in VTE

VTE Improvement Cycle

Sources of data Primary Care –PRIMIS –QoF Secondary Care –Regional Data Warehouse (SUS) –CHKS –Hospitals’ own – pathology/haematology

Primary Care Prevalence from PRIMIS searches Total number of patients diagnosed with either DVT or PE as a % of a total GP population of 298,371 (5 practices data was not included due to discrepancies in the data collection)

Primary Care Patients on Warfarin from PRIMIS search Total number of patients prescribed Warfarin (in last 3/12) from the total GP population of 298,371 (5 practices data was not included due to discrepancies in the data collection)

Annual Hospital Incidence from SUS data. Data from Cumbria & Lancashire Commissioning Intelligence Support (CaLCIS) North Lancashire Residents (population 340,000).

Benchmarked Analysis of Venous Thromboembolism data

Venous Thromboembolism – primary or secondary position

Venous Thromboembolism – Length of Stay by type 2008 only NHS North Lancashire - Population 340,000.

Venous Thromboembolism – mortality rates 2008 only NHS North Lancashire – Population 340,000

VTE Improvement Cycle

Commissioning for Quality What is quality? –Safety, efficacy, personalisation, outcome ‘Advancing Quality’ – carrots v sticks Risk Assessment for all hospital admissions embedded in contracts Financial support to providers PCT Project Manger for VTE to monitor and support –Audits / Root Cause Analyses/ Trajectories

Refining DVT diagnosis in primary care >140,000 referrals for ?DVT/year in UK 80 – 90% do NOT have DVT Need to refine tests in primary care Clinical Decision Process including near- patient-testing ‘Safely Ruling out Deep Venous Thrombosis in Primary Care’. Buller et al. Ann intern Med. 2009; 150: One PBC consortium implementing.

VTE Mind Map from PCT Perspective

Project Plan Understand the data and the issues Raise awareness Set standards in contracts Support improvement initiatives Measure outcomes Link VTE to other initiatives Manage the project through a Lead Share learning

Questions In our PCT area, our two acute hospital trusts have different heparin regimes at discharge. This causes confusion for our community staff. In the interests of safety, should we (as a PCT) seek to standardise heparin protocols across our health economy? Should we, as an exemplar community, look to standardise heparin protocols across England?