Transcript Document

Keeping CR on the agenda
Bob Lewin
Professor of Rehabilitation [email protected]
CARE AND EDUCATION RESEARCH GROUP
Some terms
Minimum dataset (MDS) – the information – that is collected by
everyone in the audit – can be built into any database system – eg.
Tomcat.
CCAD – Central Cardiac Audit Datasets – the collection of UK audits for
CARDIAC specialties - MI, Surgery, Stents, ICDs, Arrhythmia nursing
(coming soon) and Cardiac Rehabilitation The NACR Database – Lotus notes database that is used to send the
data up to CCAD who store the information
Benchmarking – comparing your results with other programmes
Process Benchmarking – comparing how the outcomes of CR are
effected by the different processes the patient has experienced
Audit – reporting what is achieved by each programme, where needs are
not being met (locality, gender, ethnicity, social class etc)
Principles of the NACR
• no unfair ‘league tables’ – improvement scores not raw outcomes
• record resources (staff) available to each programme to make fair
comparisons as show how results depend on resources
• include local indices of deprivation and other health indices to
ensure fair comparisons
• benchmarking confidential to each programme
• developed by CR for CR – it’s going to be as good as YOU make it
Minimum Dataset
Literature search, international consultation, possible questionnaires
tried out by a panel of 100 patients and clinician from 10 CR
programmes focus groups to select best measures, dissemination to
experts, professional bodies and the clinical community for comment.
Download papers, dataset, definitions and the questionnaires
from www.cardiacrehabilitation.org.uk/datasets
BHF/BACR/CCAD Lotus Database
Built in ‘buttons’ for commonly requested reports
All your data can be exported to Excel at any time for your own
purposes
Many users can unite secondary and community care
Template letters or design your own
Lots of free text ‘comments boxes’ for you to record notes –
add as much information as you want.
30 ‘spare fields’ for you to enter any other data you want or
need to collect – e.g. repeat exercise tests, dietary
assessment, etc.
Lists anxious and depressed patients automatically etc etc etc
And it is free courtesy of the BHF
Annual Audit Reports to
DH, HCC, BHF, Public, Patients
BHF York
CCAD
CR programme staff enter data
Cardiac Rehab Patients fill in questionnaires 3 times,
before, after CR and at 12 months
We need every CR programme to join
Planed to recruit 45 per quarter so that recruitment is complete end 2007
projected figure by end of 2nd quarter 2006 was 130 actual no. with software
committed to take part is 210
Number linked electronically 101
April - Dec
2005
Q2
Year 2. 2006
Year 3. 2007
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Newly
enrolled
15
25
45
45
45
45
45
40
40
35
Target
15
40
85
130
210
100
175 220 265 305 345 380
Actual
Linked
Year 4
2008
Total
380
Annual / online / paper survey with Alton
Annual National Audit Reports to
HCC, BHF, Public, Patients.
BHF York
Not connected, Or, less than 12 months (April-March) data
AND ANNUAL staffing questionnaire for everyone
Annual / online / paper survey
HCC – will use this data to assess trusts IF you
complete the paper survey and join the NACR
You’re never alone with the NACR!
BHF York
CCAD
HELPLINE
BHF
REGIONAL CRCs
CARDIAC NETWORK
Lee, Margaret
Smart group - [email protected]
You
Other Users
People
BHF York (all part-time)
Project Manager – Corinna Petre
Data Manager / analysis - Simon Coulton
Data Quality officer – Jo Orchard
Secretarial / Admin – Roz Thompson
Statistician – to be appointed
BHF regional Cardiac Rehabilitation Coordinators
Shirley Hall, Dianne Card, Steph Dilnot, Step Lillie, Elaine Tanner
Cardiac Network
Lee Panter, Margaret Leid
CCAD
Help Desk at CCAD for your IT people
Organisations involved
BHF - champion, financial sponsor
BACR – part of core requirement for a CR programme?
DH Heart Team – Roger Boyle has put resource in
Cardiac Networks – Lee, Margaret
Health & Social Care Information Systems - mother organisation
for CCAD, HES and other NHS and social datasets
HCC – will use our data to assess trusts IF you complete the paper
survey and join the NACR
The audit will provide you with
•
automatic reporting of NSF targets & many other reports about
your programme
•
evidence about what you achieve as a health gain for your local
population
•
evidence to inform local planners as to the adequacy of CR
provision in your patch
•
an understanding of how well funded you are compared to the
national norms
•
the ability to compare what your programme achieves with the
national averages on a range of outcomes – national benchmarking
Descriptive overview of patients on the database
Number of patients on the database
25,557
% Male
70
Mean age at initiating event
65 yrs
% White
91%
Mean time from initiating event to referral
14.2 days
Mean time from initiating event to invitation
36.4 days
Mean time from initiating event to start
47.9 days
Life
9.4
er
12.4
Oth
1.8
visi t
s
me
an
ry
17.2
Hom
e
pr og
r am
a pl
cove
0
Ang
in
to r e
ual
0.5
Hom
e
Roa
d
m an
1.1
Hea
rt
s
ses
al a
s
0.6
tion
al
3.2
Voc
a
In d i
vidu
up
ysio
Gr o
l ph
OT
In d i
vidu
a
olog
i cal
10
OT
n
al
olog
ic
l ps
ych
sych
atio
Rela
x
ual
oup
divid
Diet
ary
gr
lks/v
ideo
28.7
In d i
vidu
a
e
on-w
ritte
n
on-t
a
cati
rcis
22.9
Diet
aryin
cati
edu
exe
30
Gr o
up p
edu
style
style
Life
Hom
e
20
xerc
ise
ise
xerc
In d i
vidu
al e
Gr o
up e
%
Rehab Processes across 4 ‘stages’
100
90
80
70
60
53.1
50
43.1
40
31.9
25.1
28.7
19.5
16.3
10.6
0
1
NSF targets measured at 12 weeks…
NSF Target
Week
0
Week
12
50% will be non-smokers
81%
90%
50% will have BMI <30kg/m2
73%
77%
50% will be exercising 30 minutes 5 times
per week
22%
50%
those who attend – Quality of life indicators…
5
4
Dartmouth COOP score
3.61
3.13
3
2.97
2.71
2.48
2.33
2.32
2.29
2.36
2.26
2.16
2.11
1.97
2
1.87
1.86
1.66
1
Fitness
Feelings
Daily activities
Social activities
Pain
Change in health
Overall health
Overall quality of
life
Of those who do attend – anxiety and depression…
10
9
8
7
5.98
HADS
6
5.08
5
4.41
4
3.69
3
2
1
0
Anxiety
Depression
Analysis
CR-MDS
HES
ONS
Descriptives of CR programme - logistic regression
modelling assessing factors associated with
success. – (inc. disability, age, programme
staffing level etc.
Weighted comparison of uptake for cardiac events
(acute MI, PTCA, CABG) stratified by Acute Trust, PCT,
SHA, age, gender, ethnicity. Additional PCT, Acute Trust
& SHA factors - regression modelling assessing
external factors associated with uptake
Quality &
Service
Additional demographic
factors, social
Delivery
deprivation and health indices factors added
to regression model to explore factors
associated with success.
By 2002 85% of MI and
revasc patients will be
offered cardiac
rehabilitation
After that all except
unstable angina patients
should receive CR.
Best guestimate 25-30%
of patients getting CR in
2005-6.
Problems
under treatment
inequalities – women, poor, ethnic minorities, depressed, smokers,
elderly, all believed to be under-represented, postcode lottery
failure to invite all indicated in NSF – angina, heart failure, ICD,
arrhythmia
dropout – varies widely from programme to programme
staffing – from single-handed, part-time, coordinator for 600 patients to
a full multi-disciplinary team. Only 50% of programmes have an
identifiable budget.
poor outcomes?- pragmatic’ RCT by Robert West
Can Cardiac rehabilitation survive?
Evidence based
Healthcare
2000/2001 £31m for revascularisation
2002/2003 £161m. 400% increase
Probably 2-5% reduction in mortality from
CABG vs. medical treatment
No increase in funding of CR apart
from BHF Lottery £4m
not costed in ‘payment per treatment’
Been rejected by GPs as a QOF target.
In the new age of ‘self-management’ and
‘Chronic Disease Management’ why have
we not seen a single mention of CR in
Government literature?
Using NSF criteria for those expected to
benefit, guesstimated shortfall of
330,000 patients a year
How do others get funding?
Central
Cardiac
Audit
Database
National
Pacemaker &
ICD Database
Regional variations in ICD
implantation rate.
Only health authorities shown in orange
reach the new implant rate required by
N.I.C.E. guidelines.
NACRed or wot? The good news is…
The technology works and is helping programmes all over the
country organise and communicate better
information sharing between trusts and across primary/secondary
care may be about to become very simple making the project even
more effective
around 50% of UK programmes have already committed
there is solid support from major stakeholders, BHF, DH, HCC
NICE guidance on MI and secondary prevention strongly supports
CR, indeed treats it as obvious that all patients including heart
failure patients should take part
Amanda Hutchinson – Healthcare Commission
“I was involved in a large project about the National Service
Framework and I became increasingly passionate about the
importance of cardiac rehabilitation.
We identified that it was one of the standards where less progress
had been made despite the enormous commitment of staff and the
effort that was being made to try and make it work given the
historic lack of priority that cardiac rehabilitation services have
been given.
… patients were extremely positive about this as a service and it
was something that was valued by everyone we spoke to and
surveyed.
A key finding was that only 16% of Trusts were able to provide the
data we required ... This is why the audit database is so important,
because without the data, it is extremely difficult to make a case for
service improvement and why the audit is such an exciting
prospect.”
Change the future
COULD be the beginning of the best period yet for CR – BUT it
could also be the beginning of the end - replaced by leaflet bearing
lay health trainers in primary care.
We have powerful friends but NO active champions – we are going
to have to DO IT OURSELVES working with charities (BHF),
patients, the media and politicians.
Proposal - we should join together in a sustained 5 year campaign
using NACRed to draw attention to the unmet need.
We should show what we can achieve and how much more we
could achieve if we were all adequately funded.
And we must all do it all together – have a moan, whinge all you
want complain about the extra work - but do it – join NACR today
and change the future.
WE WILL WIN!