1. Improving outcomes for CVD
Dr Kathryn Griffith - CVD Clinical Lead, VOY CCG
Dr Maurice Pye - Consultant Cardiologist, YTHFT
Shane Hayward-Giles - NHS Right Care Delivery Partner
Fiona Ottewell - NHS Right Care Delivery Partner Carl Donbavand - Improvement Manager & Project lead, VOY CCG

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CVD

5. CVD Opportunities – CHD and Stroke
Primary care & Prevention
Unplanned Admissions
Hospital Length of Stay
Hospital Procedures
Acute MI,
Cerebral infarctions
Cholesterol,
Hypertension, AF

6. 8 19
4,964
339
1,149
952

7. Cholesterol management – CCG variation

8. Cholesterol management - Practice variation
QOF 14 - The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less

9. Cholesterol - What do we know?
Cholesterol Treatment Trialist’s (CTT) collaborators: meta-analyses of mortality and morbidity from all relevant large-scale randomised trials of statin therapy.
Per 1 mmol/l reduction in LDL-C
12% reduction in all-cause mortality
19% reduction in coronary mortality
24% reduction in the need for revascularisation
17% reduction in stroke
21% reduction in any major vascular
Importantly, a similar proportional benefit was observed in different age groups, across genders, at different levels of baseline lipids [including triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C)] and equally among those with prior CAD and cardiovascular (CV) risk factors as in those without.
Cholesterol Treatment Trialists’ (CTT) Collaborators. (2012). The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet, 380(9841), 581–590.

10. Case Study: Bradford Healthy Hearts
Highest premature mortality for CHD in England
Population-based mind-set approach.
Primary care led
System wide engagement primary & secondary care. Included: cardiology, diabetes, lipid clinic and vascular surgeons
Treatment to guidelines standards not to QOF
Over 6000 on simvastatin with total cholesterol >4 mmol/l or LDL >2 mmol/l were switched to atorvastatin 40/80mg
Completed switches within 3 months!

11. Case Study: Bradford Healthy Hearts
How they did it?
Clinical team from primary and secondary care developed protocols and clinical searches to identify patients not at target
Template letter sent to patients explaining reasons for change
Process supported by website and patient education programme
Coverage in local media and press
Bulk prescribing switches for all appropriate patients
Primary care workload?
Reported 1-2 mins per computer record review
Only a handful of patients that weren't happy about the switch and needed to speak to a GP or pharmacist – Patient communication and engagement was key
If done the traditional face to face way, statin switches & QRISK work would have taken up to an extra 24,000 appointments across CCG.

12. Case Study: Bradford Healthy Hearts
Outcomes:
Achieved 0.56% mmol/l reduction in LDL (and TC 0.9mmol/l) over 3 months (p<0.001)
Improved mortality – including 60 less deaths last year
Combined outcomes: Reduction in non-elective admissions estimated net savings £1.2M over 15 months
What can we do in the Vale of York?

13. ‘Yor-Healthy Hearts’?

14. Hypertension - What do we know?
High BP contributes to half of all heart attacks and strokes
Treatment is very effective at lowering blood pressure and at improving outcomes
Every 10 mmHg drop in BP was associated with a 20% reduction in cardiovascular events
BHF data for CCG

15. Hypertension detection – CCG variation

16. Hypertension Detection & Management
Detection of high BP
Management of high BP

17. What might help? Hypertension detection
Maximise uptake of NHS health check
Opportunistic testing / case finding in practices
Support access to BP equipment / empowering patients to do home testing / consider community pharmacy
Hypertension management
Develop hypertension protocols (e.g. Bradford Healthy Hearts)
Simple protocol following guidelines for all vascular patients used across primary and secondary care
Patient led protocols for management with home monitoring
Technology for diagnosis of BP with 24hr BP and home monitoring
Empowering patients to make behaviour changes
Education events for practitioners and patients
Pharmacist follow-up

18. 6
192 77 39

19. Stroke Pathway Summary: BP and AF
Quality
Opportunity
Patients with stroke/TIA whose BP > 150/90
192
Excess Mortality from stroke under 75 years 6
High-risk AF patients not on anticoagulation therapy 77
Stroke patients treated by early supported discharge team (qtrly opp) 39

20. AF produces big red clots!!
AF strokes are more severe strokes
25% AF strokes are fatal compared with 15% none AF strokes
Increased death persists for up to 8 years
Hospital admission times longer
Only 20% live independently after stroke

21. AF – What do we know?
Among those with a stroke, those with AF experienced a worse stroke with
70% increase in hospital mortality
40% reduction in relative change to discharge own home
20% increase in hospital LOS
The diagnosed prevalence in our CCG is 1.9% and the estimated prevalence is 2.6%.
There could be an additional 2,600 people with undiagnosed AF in the CCG.
Source: Health and Social Care Information Centre (HSCIC) Quality and Outcomes Framework (QOF), 2014/15; National Cardiovascular Intelligence Network (NCVIN), 2014/15

22. AF – Detection

23. AF patients on Anticoagulation therapy: QOF data CHADS2 >1

24. AF patients on Anticoagulation therapy
Warfarin INR reduces stroke risk by 64%
SSNAP (Sentinel Stroke National Audit Programme) data for period April – July 2016:
58 people in AF admitted to York Hospital with stroke.
26 had been prescribed anticoagulation prior to their stroke.
32 had a stroke without protection from an anticoagulant
With 64% reduction in events 21 strokes could have been avoided with appropriate anticoagulation
Over a year period there were 84 avoidable strokes from July 2015 – July 2016!

25. What are the barriers to detection and management of AF
What are the barriers to detection and management of AF? What support would you need to change?

26. Are you aware of these?

27. Our Priorities? Primary care & Prevention Unplanned Admissions
Hospital Length of Stay
Hospital Procedures
Acute MI,
Cerebral infarctions
Cholesterol,
Hypertension, AF

28. Be Actively involved Keep me informed
How can I get involved?
Keep me informed
Share ideas / input with solutions
Be Actively involved
E.g. Developing and testing out solutions, project group involvement, Training & development

29. Questions?

30. Thank you
Carl Donbavand – Innovation and improvement Manager & CVD Project lead, VOY CCG
Dr Kathryn Griffith – CVD clinical lead, VOY CCG
Dr Maurice Pye – Consultant Cardiologist, YTHFT
Shane Hayward-Giles NHS Right Care Delivery Partner
Fiona Ottewell - NHS Right Care Delivery Partner