KSS AHSN / Eastbourne Hailsham and Seaford CCG
Eastbourne, Hailsham and Seaford CCG Quality & Productivity (QP) indicators will be used to improve diagnosis and treatment of heart failure. The process is aligned directly with NICE guideline CG108 and the Chronic Heart Failure Quality Standard (QS9). The data from this programme will be used to assess key stages in the pathway and also aligns with the work in the Enhancing Quality Programme.
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Aims and objectives
To improve the pathway from suspecting chronic heart failure through to treatment in primary care. To compliment and enhance audit indicators in the Quality & Outcomes Framework for Primary Care. The process focuses on three specific points of the pathway.
1) To optimise the urgency of diagnosis of those at highest risk of heart failure by measuring the time from suspecting heart failure to referral in patients with very high natriuretic peptide levels. (from 1st April 2013).
2) To audit current doses of ACE inhibitors or Angiotensin Receptor Blockers and Beta-blockers in all patients on the GP Left Ventricular Systolic Dysfunction registers and report what percentage are on at least 50% of the maximum dose. This is based on the reporting of the national heart failure audit, that to gain significant clinical benefit, patients with LVSD need to be on at least 50% of the maximum dose of each of ACE/ARB and Beta-blockers.
3) To audit the proportion of all newly diagnosed heart failure patients from 1st April 2013, have evidence of a personalised care plan in their notes. The results will be used as a baseline to assess current diagnosis and management and to produce a gap analysis for each indicator. This will then be used to guide commissioners for the future management of heart failure patients.
Reasons for implementing your project
The local diagnosis and management of heart failure has already improved significantly with the full implementation of Natriuretic Peptide Testing, increased commissioning of heart failure nurses and ongoing commitment from the local trust.
However there are still significant opportunities to improve, including the timely referral of patients at highest risk of heart failure, particularly those with very high natriuretic peptide levels. A baseline audit was undertaken of 48 patients referred with very high natriuretic peptide levels to the community cardiology service. Although 75% had an echo and specialist assessment within 2 weeks of receipt of referral, only 29% were seen within 2 weeks of the NP result. Review of all very high NP levels revealed a handful of patients who were admitted before referral had taken place and in three cases, had died before referral. This supported the assumption that timely action was important at all stages of the pathway and that there was, at baseline, no detailed data about time from receipt of the result to a referral being made. The Biochemistry department at Eastbourne DGH has a same day turnaround for analysis of NTproBNP on weekdays.
Achievement of adequate doses of heart failure medication is seen in the registers of heart failure nurses recorded in the Enhancing Quality and Recovery (EQR) Programme now affiliated to the Kent Sussex & Surrey Academic Health Science Network. However there has been little record of doses of these drugs in primary care as it is not required in QOF or QIPP. Thirteen practices volunteered information about heart failure registers for the EQR programme and this demonstrated a significant difference in achievement between primary care and specialist nurses.
Personalised care planning is an indicator in the community pathway of EQR and a care plan at discharge is one of the heart failure quality standards, but again there is no requirement for primary care to confirm and record that such a plan exists for all new heart failure patients. QP provided an opportunity for GPs to record the percentage of their new heart failure patients with written documentation of a heart failure plan in the form of a copy of written advice sent to the patients.
How did you implement the project
We were able to use the existing evidence from the EQR programme to guide changes most likely to make the necessary pathway changes. Discussions were held with managers from the CCG using the NICE heart failure Quality Standard to establish signposts for the QP plan. An outline plan and then full implementation document were written by the CCG managers with clinical input. This was then put forward as a proposal to the board of the CCG. After approval a summary of the plan was presented by the Chief Clinical Officer of the CCG at a CCG wide educational event. This was supported by a brief powerpoint presentation circulated to all GPs via practice managers. An email address of the lead clinician was provided and regular dialogue has taken place with a QP lead from several of the practices. Costs incurred were simply for the managers time and about 6 hours of clinician input. We are still at the initial phase of implementation but it has already been shown to increase awareness of the issues raised and feedback suggests management of these patients is changing.
There has been combined work including NP testing, rapid access to echocardiography and specialist opinion, access for new LVSD patients to a heart failure specialist nurse for optimisation of medication, personalised care planning as well as a dedicated heart failure consultant and well functioning MDT. This led to a heart failure admission saving in 2012/13 of £330,000 (approximately 35%). QP will be used to sustain those savings and hopefully further reduce costs by ensuring access of the whole target population.
This is at an early evaluation stage and it is too soon to assess specific outcomes but it is expected to show ongoing improvements in time to access echo and specialist opinion and to improve treatment of patients in both disease modifying medication and lifestyle changes. The first quarter of heart failure admissions appears to show not only sustained low levels of admission but potentially further savings with the usual caveats about first quarter data. Admission numbers for the CCG population of 180,000, between April and June, have reduced from 62 to 58, costs reducing from £202,949 to £160957.
The increased awareness of heart failure and the sub-optimal management of LVSD has led to questions about access to heart failure nurses and concerns that it may lead to a dramatic increase in referrals. It has been made clear to GPs that this is an analytical phase of the work and that GPs should try to up-titrate medication first and we will use the data collected to inform commissioners of the need and the best way to meet that need. This may involve commissioning more nurses or enhancing local services through primary care and their staff. Education will be a central part of the plan, possibly up-skilling GPs and nurses.
Key learning points
I would advise other organisations to look at the successes achieved through the work of the EQR programme and the implementation through the efforts of the heart failure specialist nurses. The implementation of natriuretic peptide testing in East Sussex has shown it is safe in triaging suspected heart failure patients, misses very few cases of significant heart failure and, when used appropriately saves referrals and money. Increased awareness leads to increased referrals so this needs to be managed. However using NP testing finds more heart failure patients and treating them with disease modifying medication in LVSD and personalised care planning, leads to reduced morbidity, admissions and overall costs.
This plan needs to be linked to commissioning intentions and requires forward thinking to invest in appropriate services. Using QP or QIPP engages primary care to enhance services above and beyond QOF to make sure this work really improves outcomes for patients.
GPSI Cardiology / Heart Failure Lead
KSS AHSN / Eastbourne Hailsham and Seaford CCG
Is the example industry-sponsored in any way?