1 Commissioning services for the prevention of cardiovascular disease

1 Commissioning services for the prevention of cardiovascular disease

Cardiovascular diseases are diseases of the heart (cardio) or blood vessels (vascular). The underlying cause of most cardiovascular disease is the build-up of atheroma – fatty deposits lining the arteries – which can narrow the arteries or clause a blood clot (local thrombosis). Atheroma can contribute to a range of conditions including:

  • heart disease – including myocardial infarction (heart attack), angina and chronic heart failure

  • cerebrovascular disease – stroke and transient ischemic attack (TIA)

  • peripheral arterial disease[1],[2].

Commissioners should note that commissioning evidence-based interventions and services for the prevention of cardiovascular disease may also help prevent other non-communicable disease, including type II diabetes, chronic kidney disease, chronic obstructive pulmonary disease and some cancers.

Cardiovascular disease is the biggest public health burden in England (see box 1). Prevention should be a primary focus for local authority and clinical commissioners.

Box 1 Public health burden of cardiovascular disease

Cardiovascular disease is the country's biggest killer, causing more than 200,000 deaths per year – or around 1 in 3 deaths[a],[b].

Around 4.9 million people aged 16 or older in England have cardiovascular disease, or 11.73% of the population[c].

There were 1.4 million hospital admissions related to cardiovascular disease in 2010/11. Of these, around 60% were for people younger than 75 and more than 50% of admissions were as an emergency[d].

In more than 90% of cases, the risk of a first heart attack is related to nine modifiable risk factors[e]. These are:

  • high blood cholesterol (lipids)

  • smoking and tobacco use

  • overweight and obesity

  • high blood pressure (hypertension)

  • poor diet

  • insufficient physical activity

  • psychosocial stress

  • diabetes

  • excess alcohol consumption.

The prevalence of cardiovascular disease increases with deprivation and is more common among people from some black and minority ethnic groups, including people of South Asian, African and African-Caribbean descent[f].

The combined cost of cardiovascular disease to the NHS and UK economy is estimated at £30 billion[a],[b]. Preventing cardiovascular disease may also reduce the burden on social care, families and carers by preventing long-term illness and disability from heart attacks, strokes and other conditions caused by cardiovascular disease.

Obesity is a major cause of cardiovascular disease. Currently 1 in 3 adults and children are overweight or obese. By 2050 these figures are projected to rise to 9 in 10 adults and 2 in 3 children, at a cost of £50 billion per year[a],[b].

[a] Prevention of cardiovascular disease at the population level. NICE public health guidance 25 (2010).

[c] East of England Public Health Observatory modelled estimate of prevalence of cardiovascular disease in England. Applied to mid-2010 Office for National Statistics population estimates for England.

[d] Cardiovascular disease is here defined in terms of the following ICD-10 codes: All ICD-10 codes in Chapter IX - Diseases of the circulatory system (I00-I99) (2012/13 NHS outcomes framework, technical appendix).

[e] Yusuf S, Hawken S, Ounpuu S, et al (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Canada L8L 2X2. Lancet 364: 937–52.

Every person has some level of cardiovascular disease risk but the relative level of risk varies between individuals as a result of a range of modifiable and fixed risk factors. Figure 1 demonstrates a strong correlation between modifiable individual risk factors and the interventions to manage risk, both at population and individual level. Managing modifiable cardiovascular disease risk factors also helps to prevent other non-communicable disease, particularly diabetes and chronic kidney disease.

Figure 1 The prevention and management of cardiovascular disease

1.1 Commissioning for outcomes

Commissioners should refer to the NHS outcomes framework, the Public health outcomes framework for England, 2013–2016, Adult social care outcomes framework, Commissioning outcomes framework (COF) and Quality and outcomes framework (QOF) when commissioning cardiovascular disease prevention services.

It was the consensus of the Topic Advisory Group that commissioning services for the prevention of cardiovascular disease will contribute to achieving the national and local level outcomes set out in table 1.

Table 1 National and local outcomes of commissioning services for the prevention of cardiovascular disease

Reduction in under-75 mortality from cardiovascular disease – NHS outcomes framework improvement area 1.1

Increased healthy life expectancy – Public health outcomes framework outcome 1

Reduced differences in life expectancy and healthy life expectancy between communities – Public health outcomes framework outcome 2

Public health outcomes framework

Social care outcomes framework

Other local outcomes

Improvements against wider factors that affect health and wellbeing and health inequalities (domain 1)

Indicator: utilisation of green space for exercise/health reasons

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities (domain 2)

Indicator: alcohol-related admissions to hospital

Indicator: diet

Indicator: excess weight in adults

Indicator: proportion of physically active and inactive adults

Indicator: smoking prevalence – adult (over 18s)

Indicator: recorded diabetes

Indicator: take up of the NHS Health Check programme - by those eligible

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities (domain 4)

Indicator: mortality from all cardiovascular diseases (including heart disease and stroke)

Delaying and reducing the need for care and support (domain 2)

Indicator to be confirmed: effectiveness of prevention/preventative measures

Improved identification of people who are at risk of cardiovascular disease

QOF indicator PP1: In those patients with a new diagnosis of hypertension (excluding those with pre-existing coronary heart disease, diabetes, stroke and/or TIA) recorded between 1 April to 31 March: the percentage of patients aged 30 to 74 years who have had a face to face cardiovascular risk assessment at the outset of diagnosis (within 3 months of the initial diagnosis) using an agreed risk assessment tool.

Reduction in cardiovascular disease risk factors at an individual level

QOF indicator NM26: In those patients with a new diagnosis of hypertension aged 30-74 years, recorded between the preceding 1 April to 31 March (excluding those with pre-existing CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an agreed risk assessment tool) of > 20% in the preceding 15 months: the percentage who are currently treated with statins (unless there is a contraindication)

QOF indicator PP2: The percentage of people diagnosed with hypertension (diagnosed after 1 April 2009) who are given lifestyle advice in the preceding 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet.

Improved engagement of people who are under-represented in their access of primary healthcare services

  • NICE has accredited the process used by NICE to produce guides for commissioners. Accreditation is valid for 5 years from November 2011 and applies to guides produced since November 2008 using the processes described in 'Process manual for developing guides from NICE for commissioners: Information for internal NICE teams' (2011). More information on accreditation can be viewed at www.nice.org.uk/accreditation