1. Serum Natriuretic Peptide testing as part of the heart failure diagnostic pathway Candy Jeffries National Improvement Lead for Heart Failure

2. Heart Failure Diagnosis isn’t easy…. Heart failure out patient appointments cost the NHS £51m per year and £37m per year on diagnostic investigations alone 70% of patients referred for investigation for heart failure do not have heart failure 35% do not have a cardiac cause for their symptoms

3. NICE Chronic Heart Failure Guidelines August 2010 update Patients presenting with symptoms of heart failure and a history of previous MI should have an echo and be assessed by a specialist within 2 weeks. If no history of MI, measure Serum NP. If SNP levels raised(100-400 BNP, 400-2000 NTproBNP) should have an echo and be assessed by a specialist within 6 weeks If SNP levels high (>400 or >2000) should have an echo and be assessed by a specialist within 2 weeks Where echo shows no clear abnormality in a patient with previous MI, consider measuring SNP levels as they may indicate HF with preserved ejection fraction or other diagnosis SNP should also be considered for monitoring patients after admission or with problematic up-titration

4. The Evidence for Serum NP SNP levels are a clear indicator that the heart is being stretched and are 98% accurate as a negative predictor for heart failure. A large number of areas have audited services before and after introduction of Serum NP from Plymouth to E Yorks and Watford to Blackpool and shown improvement in clinical effectiveness, patient experience and cost savings.

5. Bedford General Hospital 2006-7 Referrals % Echos positive

6. Watford General Hospital 2006-7

7. WGH % Echo positive

8. Hemel Hempstead GH

9. Savings Average saving over WH PCT was £3000 per PBC group per 6 months after BNP introduced Bedford Town PBC (with direct access echo) saved £5000 in 6 months E&N Herts PCT showed a total saving of £9203.20 in three months

10. Other trials Blackpool and Fylde reduced referrals to the heart failure direct access echo clinic by 38% Plymouth reduced theirs by 30% E Yorks modelled savings of between £70,000 and £110,000 per year using Scenario Generator and actual results against predicted were within the expected range for the first 7 months of 2010.

11. Comparative cost of Serum NP tests Serum NP tests vary from £15 - £25 per test 1 DA echo = 4 - 6 BNP tests 1 OPA = 8 - 10 tests 1 admission = 100 - 200 tests

12. Lancs and Cumbria Computer simulation of the diagnostic pathway before and after the proposed introduction of Serum NP testing across the 6 PCTs Modelling showed annual cost savings of £100,000 per PCT where there was direct access echo, and £167,000 where the only option was referral into secondary care.

13. What is Scenario Generator? Computer simulation software designed specifically for use within the NHS by Simul8 and the Institute for Innovation and Improvement. Models how services of whole healthcare system could support care pathways Tests/compares responses to change in population, health, technology, practice and models of care Shows impact of throughput, cost and staffing Helps commissioners to find the most cost effective pathway

14. Limitations of Using Simulations Won’t tell you the answer, but help ask better questions Only as good as data put in, but help make sense of that data All models are wrong, but some are useful

15. As-Is Pathway

16. To-be Pathway

17. Data for modelling- yours or mine? Your pathway – open access echo? Out patient referral? Proportions? Population – or use national figures for your area- PCT or Consortia. Incidence – Usually use 0.13% but can alter if you know different. Referral rate, nationally around 0.4%- but can use your own figures. Costs: OPA £210, echo £90, SNP £20 are usual, but any or all can be changed. Usually model if SNP introduced exactly as now, if NICE guidelines are followed, and if SNP use is 25% higher than current referral rates

18. Heart Failure Model Year 1 Step Cost Year 2 Step Cost Year 3 Step Cost Year 4 Step Cost Year 5 Step Cost As Is Model£278,327£288,172£295,195£304,966£312,811 BNP Model - scenario 1 (stable/unstable ratio 90:10)£150,878£153,508£158,214£163,596£168,680 BNP Model - scenario 2 (stable/unstable ratio 80:20)£171,024£176,251£180,317£186,763£190,481 BNP Model - scenario 3 (stable/unstable ratio 70:30)£192,138£196,539£202,772£209,890£215,040 Savings Potential Scenario 1 - Full Year-£127,449-£134,664 - £136,981-£141,371-£144,131 Savings Potential Scenario 2 - Full Year-£107,302-£111,920 - £114,878-£118,204-£122,330 Savings Potential Scenario 3 - Full Year-£86,189-£91,633-£92,423-£95,076-£97,772

19. What is NHS Improvement offering Comprehensive cost modelling of the before and after SNP introduction pathways using Scenario Generator The chance for PCTs to see the effect of varying the pathway on costs by simulation a variety of pathways Worst and best case scenario simulations

20. In Conclusion Serum NP testing: Saves a small amount of money Improves clinical effectiveness Improves the patients experience NHS Improvement is offering computer simulation to help your business case. Can we help you?