Transcript Slide 1

NHS Yorkshire & the Humber
Monthly QIPP Resource Pack
April 2011
1
Introduction
This is the thirteenth QIPP resource pack. The pack has two components:
BETTER FOR LESS EXAMPLES: We have worked with you to develop practical examples of schemes which have been
developed locally and have potential to deliver better quality at lower cost. This month the ‘better for less’
example focuses on heart failure.
LONG TERM CONDITIONS ‘HOT TOPIC’: Each month we will produce one ‘hot topic’ briefing which provides more
detailed analysis on a subject relevant to QIPP. This month the hot topic is long term conditions. The analyses
presented here are designed to offer insight and raise questions about variation in performance. They need to be
interpreted in the local context.
The final resource pack in the current format will be published week commencing May 9th. The hot topic will be on
capital and estates. After this time we will be moving to analysis at cluster level. If you have any questions or
comments on the pack, please contact Ian Holmes. ([email protected])
Introduction
Note that we have decided to discontinue the QIPP metrics component of these packs. This is because we have
now developed a more detailed set of metrics which is used to underpin our Single Accountability and Assurance
Process. If you require further information on this please contact Andrew Tookey
([email protected])
2
1) Healthy Ambitions: Better for Less
3
Better for Less – BNP testing for heart failure
Early pathology input and the use of laboratory tests in clinical
pathways are essential to aid timely and cost effective
management of conditions such as hear failure. Tests for Brain
Natriuretic Peptide (BNP) can help identify patients who are at
the greatest risk of heart failure and act a cost effective prescreening ensuring only those patients deemed at higher risk
are referred on for specialist assessment with echocardiography
Why Heart Failure?
30-40% of patients diagnosed with heart
failure die in one year, thereafter mortality is
less than 10% per year.
The investigation most commonly used to
confirm diagnosis is echocardiogram and
access to the diagnostic test and consultant
outpatient is a limited and costly resource.
Better for Less
Heart failure occurs when the heart is unable
to pump blood at a sufficient rate for
metabolic requirements. The most common
causes are coronary artery disease and
hypertension.
Around 6,400 people each year in the region
are diagnosed with heart failure. The
prevalence is expected to rise as a result of
an ageing population and improved survival
rates of people with ischaemic heart disease.
4
Better for Less – BNP testing for heart failure
The difficulty in diagnosing heart failure in
primary care is that symptoms are often
non-specific and thus patients can be left
undiagnosed and untreated in the early
stages of the disease.
If BNP result is negative, and in the absence
of other clinical signs or symptoms, it is
possible to exclude heart failure as a
causative factor and rule out
echocardiogram.
Evidence suggests that patients with raised
BNPs and NT Pro-BNP concentration have
dramatically decreased survival rates
compared with patients with normal BNPs.
There is a clear relationship increasing BNP
and heart failure severity.
Benefits
How could we provide better for less?
Better for Less
A simple pathology test to determine the
levels of BNP hormones in the blood can be
used as a precursor to referral on to
specialist assessment. (including
echocardiogram).
The establishment of BNP testing could lead
to significant financial benefits and allow
earlier detection to reduce the severity of
heart failure. The benefits include:
• Improved use of outpatient services and
reduction in inappropriate referrals
• Improved decision making resulting in
better use of resources
• Reduced waiting times and cost of
echocardiogram
• Earlier detection leading to improved
outcomes for patients.
5
Better for Less – BNP testing for heart failure
Case Study: Wakefield District
NHS Wakefield District has had a BNP
service since 2005. During the financial
year 2009-10, a total of 680 patients had
their BNP tested. According to NICE
guidelines patients with a normal level of
BNP do not require onward referral for
specialist assessment or
echocardiography. Based on this criteria
415 patients (61%) would not have
required an echocardiogram in Wakefield
District.
Better for Less
For further information visit:
www.healthyambitions.co.uk
6
2) Hot topic: Long term conditions II
7
Contents
Asthma in adults
Neurological conditions
Annexes
Long term conditions II- Contents
Overview
8
Contents
Asthma in adults
Neurological conditions
Annexes
Long term conditions II- Contents
Overview
9
Overview
produced by the SHA to support organisations in developing their
understanding of some of the challenges and opportunities presented by
the QIPP agenda.
While recognising that it may raise more questions than answers, we hope
it will stimulate thought and debate within organisations and health
communities. Clearly the data presented need to be interpreted in the
local context.
We would be delighted to receive comments on the contents together with
any ideas for further long term conditions analysis.
Long term conditions II - Overview
This information pack is the thirteenth in a series ‘hot topics’ that will be
10
Foreword
Treatment and care of people with LTCs accounts for approximately 69% of the primary and acute
care budget in England. There are a wide range of LTCs that significantly impact the health and
wellbeing of the population of Yorkshire & the Humber.
This pack focuses on asthma and a group of neurological conditions. The key messages for these
areas is on a similar theme to other long term conditions - evidence suggests that there is the
potential for improved service quality, outcomes for patients and opportunities for efficiency
savings. Understanding the underlying drivers of this variation, and putting in place processes to
address it will be key to the delivery of QIPP.
Ivan Ellul
Director of Performance
NHS Yorkshire and the Humber
Long term conditions II – Overview
Last June we published a long term conditions QIPP resource pack covering chronic obstructive
pulmonary disease, diabetes and coronary heart disease. The overarching message was that
proactive and effective management in primary and community settings can significant improve
the lives of patients with these conditions, as well as reducing cost.
11
Overview of long term conditions
People in Yorkshire & the Humber can
currently expect to live between 15 years
(men) and 17 years (women) in poor
health or disability towards the end of
their lives as a result of LTCs. It is
estimated that the number of people
with at least one LTC will rise in YH to
nearly 1.5m people by 2020.
This resource pack focuses on asthma in adults and neurological conditions:
• Asthma affects over 200,000 adults in Yorkshire and the Humber. There is evidence that pro-active
management of the condition can improve health outcomes and reduce the need for secondary care
treatment.
• Around 8 million people in England have a neurological condition. There are a large number of conditions and
the precise cause of many is unknown. Accurate diagnosis and appropriate care pathways can significantly
improve quality and efficiency of services.
Long term conditions II – Overview
Long term conditions (LTCs) are those
which cannot currently be cured but can
be controlled with the use of medication
and/or other therapies.
12
Possible savings in Yorkshire & the Humber
People with LTC are far higher users of health and social care services than average, accounting for
approximately 55% of general practice consultations, 68% of A&E attendances and 77% of
inpatient bed days.
An estimated £570m was spent in YH in 2008/09 on unplanned admissions directly related to LTC
alone. The overall costs of LTC management will be far greater when prescribing and primary care
costs are also accounted fore. Better management of LCTs can help to prevent a large proportion
of health care contacts, these efficiency gains are supported by benefits to patients and their
families.
Systematic, coordinated, proactive and preventative care and management of long term
conditions across the health and social care system together with reducing associated avoidable
emergency admissions presents the largest of all quality and efficiency opportunities. The
challenge now is to make the necessary efficiency savings in a way in which this medium-term
radical agenda is accelerated and not set back1.
1
Nuffield Trust (2010). Making Progress on efficiency in the NHS in England: Options for System Reform .
Long term conditions II – Overview
The treatment and care of people with LTC accounts for approximately 69% of the primary and
acute care budget in England.
13
Contents
Asthma in adults
Neurological conditions
Annexes
Long term conditions II- Contents
Overview
14
Asthma is a chronic inflammatory
disease of the airways characterized by
variable and recurring symptoms,
reversible airflow obstruction, and
Bronchospasm.
Asthma can start at any age but most
commonly starts in childhood. At least 1
in 10 children have asthma however
almost half grow out of it by the time
they are adults. There are estimated to
be over 200,000 adults suffering with
asthma across the region.
The key risks for asthma include genetic
and environmental factors, and these
tend to be less well understood than
other long term conditions.
The aim of asthma care is to control
symptoms and enable people to lead a
normal life. Emergency admissions
indicates a loss of control of the
condition, and many of these could be
avoided through early identification and
effective and proactive management
the condition.
The prevalence of asthma has increased
significantly since the 1970s and it is
estimated that up to half a million
people in the region have the condition.
NHS Comparators, The NHS IC
Long term conditions II – Asthma in adults
Asthma in adults
15
The concept of measuring years of
life lost is to estimate the length of
time a person would have lived had
they not died prematurely. (This
measure covers all people under age
75.)
Years of life lost due to mortality from asthma, 2006-2008
4.00
3.50
3.00
2.50
2.00
1.50
In Yorkshire & the Humber on
average there are around 2.5 years
of life lost as a result of asthma
mortality. This is around 25% higher
than the national average.
There is also significant variation
across the region - Bradford and
Airedale has just over 1 year of life
lost, and Kirklees has over 3.5.
1.00
0.50
0.00
The NHS IC, Compendium of
health and clinical indicators
Long term conditions II – Asthma in adults
Asthma – Years of life lost
16
According GP Quality and Outcomes
Framework data 6% of the
population suffer from asthma in
Yorkshire and the Humber, over
330,000 people.
However QOF data is considered to
underestimate the true prevalence
of asthma. Relative to
epidemiological results, up to almost
40% of those with asthma are not
recognised on QOF registers. QOF
results for our region are closer to
expected levels than nationally.
In Yorkshire and the Humber the
ration of actual to expected rates of
asthma vary from 0.62 in Leeds to
0.73 in Doncaster.
Asthma prevalence, QOF 2008/09
7.0%
Y&H
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Quality & Outcomes Framework, The NHS IC
Ratio of actual to expected prevalence, 2008/09
0.74
0.72
0.7
0.68
0.66
0.64
0.62
0.6
0.58
0.56
Y&H
England
NHS Comparators, The NHS IC
Long term conditions II – Asthma in adults
Prevalence
17
There is a weak positive relationship
between asthma spend and recorded
prevalence across Yorkshire and the
Humber. PCTs with higher level of
spending may want to consider how
this expenditure is split across the
pathway and what actions could be
taken to improve quality and efficiency.
2,100
Asthma spend per 100,000 population and prevalence, 2008/09
Spend per 100,000 population
Annually, almost £95m is spent on
asthma in Yorkshire & the Humber, an
average of £1.8m per 100,000
population.
2,000
Barnsley
Doncaster
1,900
Bradford &
Airedale
1,800
North Yorks &
York
Rotherham
Hull Teaching
East Riding
North Lincs
Kirklees
North East Lincs
Sheffield
Wakefield District
1,700
Leeds
Calderdale
1,600
5.4%
5.6%
5.8%
6.0%
6.2%
Prevalence
6.4%
6.6%
6.8%
Long term conditions II – Asthma in adults
Asthma – spend and prevalence
18
Effective long-term management of
asthma requires appropriate monitoring
of the condition. Long term
management should minimise chronic
symptoms, prevent exacerbations and
enable patients to maintain near normal
activity levels and reduce secondary
health care contacts.
Asthma patients who have records of
the measures of the severity of the
disease are more likely to have an
accurate diagnosis of their condition
and be treated appropriately given the
level of their symptoms.
Proportion of asthma patients receiving reviews in the last 15
months, QOF 2009/10
84.0%
82.0%
80.0%
78.0%
76.0%
74.0%
72.0%
70.0%
Quality & Outcomes Framework, The NHS IC
Asthma prevalence with measures of variability and reversibility,
2008/09
Wakefield District
Kirklees
North Lincs
Doncaster
North Yorks & York
Leeds
East Riding
North East Lincs
Hull
Calderdale
Barnsley
Bradford & Airedale
Rotherham
Sheffield
Yorks & Humber
ENGLAND
76
78
80
82
84
86
88
90
92
Quality & Outcomes Framework, The NHS IC
Long term conditions II – Asthma in adults
Asthma – management in primary care
19
QOF exceptions for asthma, QOF 2009/10
QOF exceptions are patients who are
excluded from calculation of QOF
performance because of failure to
attend appointments or where
medicine cannot be prescribed due to
a contra-indication or side effect.
Up to 83% of patients on registers
across PCTs in the region have had a
review of their condition in the most
recently reported 15 month period. Of
the 50% of PCTs with the highest
proportion of patients receiving
reviews, 3 have QOF exception rates
for this indicator of more than 5%.
Proportion of asthma patients receiving reviews in the last 15
months and rate of QOF exceptions for indicator, QOF 2009/10
10.0%
QOF exceptions rate
High levels of exception reporting can
mean that practices are receiving QOF
payments but patients conditions are
not being effectively managed.
10.0%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Hull Teaching
8.0%
6.0%
Calderdale
4.0%
2.0%
Bradford &
&
Airedale North YorksLeeds
York
Rotherham
Barnsley
Sheffield
Doncaster
Kirklees
East Riding
Wakefield
District
North East
Lincs
North Lincs
0.0%
74.0% 75.0% 76.0% 77.0% 78.0% 79.0% 80.0% 81.0% 82.0% 83.0% 84.0%
Long term conditions II – Asthma in adults
Asthma – QOF exception reporting
Proportion of patients receiving a review
Quality & Outcomes Framework, The NHS IC
20
The standardised admissions ratio
compares the number of asthma
related admissions for the PCT to
the national average. Over half of
PCTs in the region have fewer
admissions than expected.
Bradford & Airedale has one of the
highest admissions ratios in the
region but the shortest median
length of stay; in contrast North
East Lincs has the lowest
admissions ratio but high length of
stay.
140.0
Standardised admissions ratio
120.0
100.0
80.0
60.0
40.0
20.0
0.0
Asthma UK, Y&H asthma dashboard
Median length of stay and bed days
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Bed days
Median LOS
3000
2500
2000
1500
1000
500
0
Long term conditions II – Asthma in adults
Asthma – hospital admissions
Asthma UK, Y&H asthma dashboard
21
Readmissions data indicates the extent
to which a patient’s health need is met
and managed prior to hospital
discharge. The median length of stay for
asthma complaints in NHS Bradford &
Airedale was the lowest in the region,
however the readmissions ratio is the
highest; NHS North Lincolnshire has the
lowest readmissions ratio in the region
but the longest length of stay.
Standardised readmissions ratio
140
120
100
80
60
40
20
0
Asthma UK, Y&H asthma dashboard
Commissioners should consider these
data together to understand the
outcomes for patients after their first
hospital admission, and whether more
pro-active action in primary and
community settings could be taken to
avoid re-admissions.
Comparison of standardised admissions and readmissions ratios
Wakefield
District
130
Standardised readmissions ratio
There also appears to be a weak
positive relationship between the
admissions and readmissions ratios
within PCTs.
120
Sheffield
110
North Yorks &
York
Leeds
Barnsley
Hull Teaching
Rotherham
Calderdale
Doncaster
100
90
Bradford &
Airedale
East Riding
Kirklees
80
North Lincs
70
60
70
80
90
100
110
120
130
140
150
Long term conditions II – Asthma in adults
Asthma – re-admissions
Standardised admissions ratio
Asthma UK, Y&H asthma dashboard
22
The rate of emergency bed days for
asthma across Yorkshire & the
Humber is greater than the national
average, and there is more than twofold variation across PCTs.
Emergency bed days for asthma per 1,000 population
(standardised rate)
6
5
Y&H
England
4
3
North East Lincolnshire has the
lowest emergency bed days rate in
the region and the lowest rate
compared to expected, they also
have the highest median length of
stay. PCTs should consider the
relationship between non-urgent and
emergency care to establish the
secondary care management of
asthma for patients in their region.
2
1
0
NHS Comparators, The NHS IC
Long term conditions II – Asthma in adults
Asthma – emergency bed days
23
The Care Quality Commission use two
asthma related indicators in assessing
ambulance trust performance. These
are the proportion of patients with
suspected asthma who have peak flow
recorded before treatment, and the
proportion of patients with suspected
asthma with spot oxygen saturation
recorded before treatment.
Yorkshire Ambulance Service performs
close to the national average on these
measures, achieving 50% on peak flow
measurement and 85% on the oxygen
saturation measurement.
Proportion of patients with suspected asthma with peak
expiratory flow recorded before treatment
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2008-2009
2009-2010
Proportion of patients with suspected asthma with spot oxygen
saturation (SP02) recorded before treatment
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2008-2009
2009-2010
Long term conditions II – Asthma in adults
Asthma – Ambulance trust performance
24
There is considerable variation in the
standardised emergency admission ratios (SAR)
for asthma across GP practices in Yorkshire and
the Humber. We have carried out practice level
regression analysis to understand the key
drivers of this variation.
In descending order, the following factors
explain 31.0% of the variation in the emergency
admission rates for asthma across the region:
* Deprivation as measured by the Indices of
Multiple Deprivation 2007
* The rating of doctor in asking patients about
their symptoms
* The percentage of patients with a LTC who
report that they definitely or to some extent
received enough support to manage their LTC
according to the GP Patient Survey
* Prevalence of smoking among patients with
a LTC
* Number of GPs per 1000 patients registered
at the practice
Long term conditions II – Asthma in adults
Emergency admissions – underlying drivers of variation
25
While the circumstances will inevitably vary locally, commissioners and GPs with high rates of
emergency admissions will want to consider which of these factors might apply to their patients,
and what mitigating actions could be taken to tackle emergency admissions.
Long term conditions II – Asthma in adults
Emergency admissions – underlying drivers of variation
26
There are a range of actions that could be taken locally to improve the way
care is managed, these include the following:
• Increasing the use of personalised asthma self management plans, and the
number of staff trained to support people in self management.
• Improving staff training, including increasing familiarisation with the British
Guideline on the Management of Asthma.
• Reviewing the percentage of patients who are on inhaled corticosteroids
when leaving hospital following an acute admission.
• Reviewing patients within seven days following discharge relating to an acute
admission for asthma.
Long term conditions II – Asthma in adults
Asthma – options for action
27
Contents
Asthma in adults
Neurological
Neurological conditions
conditions
Annexes
Long term conditions II- Contents
Overview
28
Around 8 million people in England have a neurological condition. There are a large number of
conditions and the precise cause of many is unknown.
It is estimated that 350,00 people in the UK need help with the activities of daily living because of a
neurological condition and 850,000 people care for someone with a neurological condition.
There are a wide range of neurological conditions (over 60)which can be both progressive and non
progressive. Whilst there are some synergies between these conditions, most tend to have specific
needs and specialist requirements across health and social care.
This section of the pack focuses on:
Spend on chronic neurological conditions per 1,000 population,
2007/08 and 2008/09
4,000
• Epilepsy,
• Multiple Sclerosis(MS),
• Motor Neurone Disease (MND)
3,500
2007/08
2008/09
3,000
2,500
2,000
1,500
1,000
500
-
Programme budgeting toolkit,
Department of Health
Long term conditions II – Neurological conditions
Overview – long term neurological conditions
29
Long term neurological conditions
consume a significant proportion of
NHS resources, in 200/09 PCTs in
Yorkshire & the Humber spent almost
£363m on neurological conditions,
representing 4% of total programme
budget expenditure.
Neurological conditions are the third
most common reason for seeing a GP
and account for 20% of acute hospital
admissions. There were over 136,000
elective and almost 168,000
emergency admissions for LTNCs in
Yorkshire & the Humber in 2009/10.
Elective and emergency admissions for long term neurological
conditions, standardised rate per 1,000 population, 2009/10
4.5
4
Elective
Emergency
3.5
3
2.5
2
1.5
1
0.5
0
The NHS IC, NHS Comparators
Commissioners with high emergency
admissions, should consider the
specialist community neuro-rehab
teams are available, and whether this
service could be used to improve
control of the condition .
The NHS IC, NHS Comparators
Long term conditions II – Neurological conditions
Overview – All conditions: service provision
30
The mean length of stay in hospital for an
individual with a long term neurological
condition is 10.9 days in Yorkshire & the
Humber, comparable to the national
average and more than twice as long as
those admitted with any other condition
(4.4 days).
Number of times longer a patient with an LTNC will stay in hospital
than those with all other admissions, 2009/10
3
2.5
2
1.5
1
0.5
In Doncaster, patients with an LTNC stay
on average almost 3 times longer than
other patients, Barnsley has the lowest
ratio with LTNC patients staying twice as
long as others.
0
The NHS IC, NHS Comparators
Long term conditions II – Neurological conditions
Overview – All conditions: service provision
31
Epilepsy is common: around 1 in 100
people have the condition. Epilepsy
is defined as the recurring tendency
to have seizures. Many more people
will have single or provoked seizures
but will not be diagnosed with
epilepsy.
Epilepsy prevalence by age group
16
Men
14
Women
12
10
8
6
4
2
Only 52% of people with epilepsy live
seizure-free, it is estimated that 70%
of people could be seizure free with
the right treatment.
0
0-4
05-15
16-24
25-34
35-44
45-54
55-64
65-74
75-84
85+
Source: The Joint Epilepsy Council
Reported vs expected prevalence of epilepsy (over age 18),
2008/09
1.2
Misdiagnosis rates in the UK, where a
diagnosis of epilepsy is incorrectly
made, are between 20 and 31%. As a
result, there are estimated to be over
100,000 people with a diagnosis and
receiving anti epileptic drugs who do
not have the condition (Joint Epilepsy
Council)
1
0.8
0.6
0.4
0.2
0
The NHS IC, NHS Comparators
Long term conditions II – Neurological conditions
Epilepsy - overview
32
Epilepsy has implications for the
potential for people to live a full
life – people with epilepsy are less
likely to be employed or be able to
drive. 1 in 5 people with epilepsy
will also have learning disabilities.
Years of life lost due to mortality from epilepsy: directly
standardised rate per 10,000 population under 75
years, 2006-2008
Across Yorkshire and the Humber
there is significant variation in the
years of life lost associated with
epilepsy. North and North East
Lincolnshire, Doncaster and
Rotherham have the highest
estimated rates of years of life lost.
A key challenge facing epilepsy services nationally is the high rate of misdiagnosis. Estimates
suggest that misdiagnosis in is the region of 20-31% in England. The Joint Epilepsy Council
estimate the costs of misdiagnosis to be in the region of £145m nationally.
The NHS IC, NHS Comparators
Long term conditions II – Neurological conditions
Epilepsy - overview
33
Organisations across Yorkshire and
the Humber spends close to £40m
per annum on epileptic drugs. The
increase over the last financial year
was around 10%.
Fig 11a. Yorkshire & The Humber SHA - prescribing frequency:
antiepileptics April - September 2010
Doncaster (0.8%)
Wakefield District (0.7%)
Barnsley (0.7%)
North Yorkshire & York (0.6%)
North of England (0.7%)
East Riding of Yorkshire (0.7%)
Bradford & Airedale (0.6%)
Yorkshire & The Humber (0.7%)
Kirklees (0.6%)
England (0.6%)
Rotherham (0.7%)
There is significant variation in the
rates and costs of prescribing varies
significantly across organisations in
the region.
Leeds (0.6%)
Sheffield (0.7%)
Hull Teaching (0.8%)
Calderdale (0.7%)
North Lincolnshire (0.8%)
North East Lincolnshire Care Trust Plus (0.8%)
0
100
150
200
250
300
350
400
450
500
DDD/epilepsy patient
Gabapentin
Note: Gabapentin and pregabilin
which together account for around
30% of prescribing frequency are also
used for neuropathic pain as well as
epilepsy.
50
Pregabalin
Sodium Valproate
Carbamazepine
Lamotrigine
Phenytoin Sodium
Others
Fig 11b. Yorkshire & The Humber SHA - prescribing costs:
antiepileptics April - September 2010
Wakefield District (0.7%)
North Yorkshire & York (0.6%)
Kirklees (0.6%)
Bradford & Airedale (0.6%)
Doncaster (0.8%)
Leeds (0.6%)
Yorkshire & The Humber (0.7%)
North of England (0.7%)
Barnsley (0.7%)
England (0.6%)
East Riding of Yorkshire (0.7%)
Rotherham (0.7%)
Calderdale (0.7%)
Hull Teaching (0.8%)
North Lincolnshire (0.8%)
North East Lincolnshire Care Trust Plus (0.8%)
Sheffield (0.7%)
0
100
200
300
400
500
600
NIC(£)/epilepsy patient
Pregabalin
Levetiracetam
Sodium Valproate
Gabapentin
Carbamazepine
Lamotrigine
Others
700
Long term conditions II – Neurological conditions
Epilepsy – prescribing costs
34
Across Yorkshire and the Humber
there appears to be a weak but
positive association between the
proportion of people receiving a
review of their medication and the
proportion on a practice list that
have suffered a seizure in the last 12
months.
Commissioners and GPs with epilepsy
patients with high rates of seizure
should consider whether medicines
reviews should be carried out more
routinely to improve seizure control.
Percentage of patients on drug treatment who have been
seizure free in the last 12 months
NORTH YORKS &
YORK
78.0%
Proportion seizure free in last 12 months
Reviewing epilepsy patients
medication can be important to
ensure that the effective and
appropriate treatment is being
provided.
EAST RIDING
76.0%
LEEDS
BRADFORD &
AIREDALE
74.0%
WAKEFIELD
DISTRICT
72.0%
KIRKLEES
SHEFFIELD
70.0%
68.0%
DONCASTER NORTH LINCS
CALDERDALE HULL
BARNSLEY
ROTHERHAM
NORTH EAST
LINCS
66.0%
64.0%
92.5%
93.0%
93.5%
94.0%
94.5%
95.0%
95.5%
96.0%
Proportion receiving medication review in last 15 months
Source: The NHS IC, Quality &
Outcomes Framework, 2009/10
Long term conditions II – Neurological conditions
Epilepsy – medicines review
35
Comparison of epilepsy prevalence (%) and Emergency
admissions for epilepsy per 1000 population 2009/10
The rate of emergency admissions
related to epilepsy per 1,000
population is slightly higher in
Yorkshire & the Humber (0.8) than
the national average (0.7).
The regional mean length of stay
following emergency admission for
epilepsy is close to the national
average. There is a 60% variation in
the average length of stay across
the region.
Emergency admits per 1,000
population
There appears to be a relationship
between epilepsy prevalence rates
and emergency admissions across
PCTs. Doncaster seems to be an
outlier with relatively high
prevalence but a lower than
average emergency admissions
rate.
1.5
Hull
1.4
1.3
1.2
1.1
1
Bradford &
Kirklees Leeds Airedale
0.7
0.75
North Yorks &
York
0.8
East Riding
0.9
0.8
0.85
0.7
Barnsley
0.6
0.5
North Lincs
Calderdale
Wakefield
North East
District
Lincs
0.9Rotherham
0.95
Doncaster
Sheffield
Prevalence (%)
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
1
Mean length of stay (emergency admissions) 2009/10
England
Y&H
Long term conditions II – Neurological conditions
Epilepsy – emergency admissions
36
There is significant variation in the rates of seizures and emergency admissions for epilepsy. Some
of this is due to underlying prevalence – epilepsy is more prevalent in lower income groups, older
age groups, vascular disease and older age groups, however unwarranted variation can be caused
by appropriateness of clinical management and differences in the control of the condition.
Possible options for action include:
• Review patients’ prescriptions once a year
• Identifying approaches to improving patient concordance with prescriptions
• Establish local epilepsy services to enable not only the identification of people who have epilepsy
but also the differentiation of people who have serious brain disorder.
Long term conditions II – Neurological conditions
Epilepsy – potential actions
37
Proportion of all MS cases by age and sex
Around 100,000 people in
the UK have multiple
sclerosis (MS); it is the most
common disabling
neurological condition
affecting young adults. The
condition is most
commonly diagnosed in
people aged 20 – 40 and
women are almost twice as
likely to develop it as men
(Multiple Sclerosis Society).
Source: Health Technology Assessment
2002, vol.6, No 10, Richards et al
There is little data determining the baseline prevalence of MS in England. A study in Leeds in 1996
reported prevalence of 75 cases per 100,000 population. However, relative to other areas this is
unusually low. Based on the General Practice Research Database national prevalence was
estimated to be 102 cases per 100,000 population in 1991. the proportion of missed cases is
estimated to be between 10% and 20% (Source: Health Technology Assessment 2002, vol.6, No 10,
Richards et al). Incidence of MS is estimated to be 3.5 per 100,000.
http://www.hta.ac.uk/fullmono/mon610.pdf
Long term conditions II – Neurological conditions
Multiple sclerosis - overview
38
There are fewer elective admissions for
MS in Yorkshire & the Humber per 1,000
population than the England average.
However, there is 6-fold variation across
the region, with 0.2 admissions per 1,000
in Kirklees compared to 1.2 in East Riding.
The tariff price for elective MS admissions
is £1,293.
There is also wide variation in the mean
length of stay across PCTs in the region;
the average is 2.5 days less than the
England average. The long stay trim point
is 10 days, the mean length of stay in
Sheffield is greater yielding additional
bed day payments for the average
patient.
Elective admissions, MS and demyelinating diseases 2009/10
1.2
1
0.8
0.6
0.4
0.2
0
14
Mean length of stay for inpatients, MS and demyelinating
diseases 2009/10
12
England
10
8
6
4
2
0
Y&H
Long term conditions II – Neurological conditions
Multiple Sclerosis – elective admissions
39
Across PCTs in Yorkshire & the Humber
there are 0.1 emergency admissions per
1,000 population. There is however wide
variation in the rate of emergency
admissions compared to the expected
level based on national activity. In East
Riding there were almost twice as many
emergency admissions as expected, there
were nearly 40% fewer in Doncaster. The
tariff price for non-elective Multiple
Sclerosis is £3,039.
Ratio of actual to expected count of elective admissions, 2009/10
100
80
60
40
20
0
-20
-40
25
There is almost 5 fold variation in the
non-elective mean length of stay for MS
across PCTs.
20
15
10
5
0
Mean length of stay emergency admissions, MS and
demyelinating diseases 2009/10
Long term conditions II – Neurological conditions
Multiple Sclerosis – emergency admissions
40
MND is a rapidly progressive, fatal disease, the cause is unknown and there is no known cure. The
highest incidence is amongst people aged 50 – 70; most people diagnosed are over 40. In
contrast to MND, men are more commonly affected by MND than women, the ratio of men:
women affected is 3:2.
Based on estimates of national incidence and prevalence rates derived in 2003; there are
estimated to be over 3,600 people living with MND in Yorkshire & the Humber in 2010
(prevalence rate of 7 per 100,000). The number of cases per PCT varies from 10 to 60 dependent
on the size of the population.
There are estimated to be over 100 new diagnoses of MND in the region each year, the incidence
rate has been estimated at 2 per 100,000.
Long term conditions II – Neurological conditions
Motor Neurone Disease - overview
41
In 2009/10 there were just over 2.3
admissions per 100,000 population in
Yorkshire & the Humber, compared to
2.8 nationally.
14
12
10
8
6
Given the low volume of patients and
nature of the condition there is wide
variation in mean length of stay
across PCTs in the region.
4
2
0
Mean length of stay elective admissions, MND & spinal
muscular atrophy 2009/10
Long term conditions II – Neurological conditions
Motor Neurone Disease – elective admissions
42
Nationally there were less than
1,000 emergency admissions relating
to MND in 2009/10. There were a
total of 15,301 bed days for MND in
England however there were 16.5%
more bed days in Yorkshire & the
Humber than expected based on
national data.
Mean length of stay emergency admissions, MND & spinal
muscular atrophy 2009/10
45
40
35
30
25
20
15
10
5
Compared to other neurological
diseases, MND is the third highest
cause of death, accounting for 1 in
almost 500 deaths in 1996.
0
Long term conditions II – Neurological conditions
Motor Neurone Disease – emergency admissions
43
In 1995 the MND association established the Care Centre Programme, there are 17
centres, including 1 in Leeds.
Best practice care for MND patients requires a co-ordinated multi-disciplinary and
holistic approach to care management. MND is not a common condition, General
Practitioners may only see 1 or 2 cases in their entire career. However, people with
MND have high health care service requirements, Care Centre teams provide specialist
support for local more generalist services. (NHS Evidence).
NICE GUIDELINES
Respiratory muscled weakness resulting in respiratory impairment is a major feature
of MND and is a strong predictor of quality of life and survival. Non-invasive
ventilation can improve symptoms and signs related to respiratory impairment and
hence survival. The latest NICE guideline contains recommendations for the use of
non-invasive ventilation for MND patients
(http://www.nice.org.uk/nicemedia/live/13057/49885/49885.pdf).
Long term conditions II – Neurological conditions
MND – providing effective services
44
Contents
Asthma in adults
Neurological conditions
Annexes
Long term conditions II- Contents
Overview
45
Contacts
Ian Holmes – Associate Director, Economics and System Management, NHS Y&H
[email protected]
Jake Abbas – Deputy Director, YHPHO
[email protected]
Long term conditions II – Annexes
Colin McIlwain – Associate Director, Care Partnerships, NHS Y&H
[email protected]
46