CVD affects the lives of millions of people and is one of the largest causes of death and disability in this country. Huge improvements have been made in the prevention and treatment of CVD over the last decade, with a 40% reduction in under 75 mortality rates between 2001 and 2010. Over the same period, the difference in under 75 mortality rates between the most and least deprived areas in England has narrowed.
Despite these improvements, comparisons with other countries show that England could still do better in improving CVD mortality rates – as demonstrated by the recent Lancet article on the Global Burden of Disease Study. With an ageing population and the current levels of obesity and diabetes, unless there are improvements in prevention, past gains will not be sustained.
The starting point for development of this section was to assess the costs and benefits of the CVD Outcomes Strategy published in March 2013. However, we have identified additional high impact interventions.
- 3.1 NHS Health Check
- 3.2 Increased training in cardio-pulmonary resuscitation (CPR)
- 3.3 Improved management of people with diagnosed Atrial Fibrillation (AF)
- 3.4 Early diagnosis of people with Familial Hypercholesterolaemia (FH)
- 3.5 Increase proportion of patients with Transient Ischaemic Attack (TIA) treated within 24 hours
- 3.6 Establishment of hyper-acute stroke services
- 3.7 Encourage use of Intermittent Pneumatic Compression sleeves in stroke patients
- 3.8 Improved management of patients with ST-elevated Myocardial Infarction (STEMI)
- 3.9 Improved management of nSTEMI patients
- 3.10 Increase proportion of patients offered cardiac rehabilitation
- 3.11 Increase availability of Early Supported Discharge (ESD) for stroke patients
Risk awareness, risk assessment and management
Issue: The NHS Health Check programme has considerable potential to prevent or delay CVD through earlier identification and management of behavioural and physiological risk factors. The programme also has a huge potential to support CCGs in their priority role for earlier detection of disease. However, implementation and take up rates are not consistent across England and follow-up management, whether through medical interventions, or interventions to improve people’s lifestyles, needs to improve in many areas.
Suggested Action: Local authority commissioners should localise products released from the national marketing team to increase awareness and engagement of the target population. Local practices to support improved take-up by adapting invitation methodology to their population and thereafter, clinical follow-up by ensuring that people who are identified as having, or being at risk of CVD, are appropriately engaged in general practice and receive appropriate lifestyle and/or pharmacological interventions, or onward referral. Longer term tracking and support (i.e. ≥12 months) should be utilised through enhanced data flow between commission and provider.
Issue: Currently CPR is attempted in only 20 percent to 30 percent of cases following an out of hospital heart attack. However, evidence suggests that where CPR is attempted, survival rates are doubled.
Suggested Action: Through contract specifications, NHS provider staff who work with patients are taught CPR, including healthcare assistants, physiotherapy assistants etc.
Issue: There are relatively high rates of undiagnosed cases of AF and treatment varies across the country. People with AF have a 5-6 fold increased risk of stroke and AF is estimated to be directly responsible for 12,500 strokes per annum.
Suggested Action: CCGs could work with local practices to target people at risk of AF and ensure appropriate pharmacological interventions in line with NICE guidelines. CCGs may wish to consider promoting use of the GRASP risk assessment tool in local practices.
Issue: Estimates suggest that around 120,000 individuals in Britain are affected by FH, a hereditary condition which increases risk of coronary heart disease. However, only 15-17 percent of cases are diagnosed.
Suggested Action: CCGs could consider introducing cascade testing of people with a hereditary risk of FH, in line with the NICE clinical guideline for the Identification and Management of FH (CG71).
Issue: In 2012 around 1 in 20 TIAs led to a stroke within a week, but there is significant regional variation in availability and capacity of TIA services, despite evidence that improved management of TIAs could be cost saving.
Suggested Action: Through joint strategic needs assessment and subsequent contracting arrangements ensure adequate capacity of TIA services.
Issue: The London model of hyper-acute stroke services reconfiguration has reduced mortality from stroke by 28 percent, by concentrating specialist care into a small number of hyper-acute stroke units, whilst also delivering significant reductions in disability and the cost of services provision.
Suggested Action: Commissioners to consider work across local health communities through with health and wellbeing boards and area teams to explore potential scope for delivery of hyper-acute stroke services
Issue: Approximately 60,000- 80,000 patients each year are admitted to UK hospitals with an acute stroke and are immobile. It is estimated that 10-25 percent will develop a Deep Vein Thrombosis (DVT).
Suggested Action: Commissioners to consider use of contracting levers to promote use of IPC sleeves by providers of stroke services.
Issue: There is considerable variation in care processes for patients following a heart attack. Implementation of the NICE guideline on STEMI in all cardiac centres would speed up the process between “door to balloon time” and reduce mortality and muscle damage.
Suggested Action: Ensure service specifications in contracts require services to be delivered in line with the standards set out in the NICE guideline ‘Myocardial infarction with ST-segment-elevation (STEMI)’.
Issue: For STEMI patients ambulance protocols dictate that the ambulance team should take the patient directly to a cardiac centre, but there is no automatic requirement to do so for nSTEMI. As a result, inter-hospital transfers to specialist centres can be delayed and some patients die awaiting a transfer.
Suggested Action: Through contract specifications with local ambulance providers, encourage ambulance crews to take patients directly to a cardiac centre.
Issue: Currently, many people who might benefit do not receive adequate cardiac rehabilitation, particularly following a diagnosis of heart failure. There are also marked inequalities in the way people access the available services. Women, minority ethnic groups, the elderly and people with more severe chronic heart disease are all under-represented among users of rehabilitation services.
Suggested Action: Commission increased capacity in cardiac rehabilitation units and use contracting levers to encourage providers to increase access to rehabilitation for currently under-represented groups including women and people from certain ethnic groups.
Discharge from hospital
Issue: Currently, only 66 percent of hospitals have an early supported discharge team, despite evidence that ESD teams can provide better (and potentially more cost-effective) outcomes than exclusively hospital-based rehabilitation for stroke patients with moderate disabilities.
Suggested Action: Consider use of contracting levers to encourage providers to establish ESD units for stroke patients at relevant hospitals.