AMPAMP((Angina Management Programme)Angina Management Programme)

Chesterfield Refractory Angina CentreChesterfield Refractory Angina Centre

Dr PJ Flann, Dr Clare HawleyDr PJ Flann, Dr Clare HawleyDr Kath Markus &Dr Kath Markus &

Cardiac Specialist Nurse Karen Dunn Cardiac Specialist Nurse Karen Dunn

Why am I here ?Why am I here ?

AMP – is something different AMP – is something different

We talk to patients We talk to patients

We inform and educate them We inform and educate them

We save money We save money

Todays’ RemitTodays’ Remit

Improve Quality Improve Quality

InnovativeInnovative

Saves money Saves money

Is Preventive Is Preventive

The Beginning The Beginning Training via NRAC & Prof Mike Chester Training via NRAC & Prof Mike Chester

Training 08Training 08

Chesterfield AMP Start 1/1/09Chesterfield AMP Start 1/1/09

Target of 50 patients for the first year. Target of 50 patients for the first year.

Why ?Why ?

Everyone wins Everyone wins

Why ?Why ?

Patient’s benefit Patient’s benefit

Cost savings Cost savings

Evidence Evidence

Government agendaGovernment agenda

Patient Benefits Patient Benefits

Quality of life Quality of life

DepressionDepressionNumber MI’sNumber MI’sAdmissionsAdmissionsNumber interventions Number interventions (( & complications )& complications )

Cost SavingsCost Savings(NRAC results )(NRAC results )

On Admissions On Admissions (15.5 bed days to 10.34)(15.5 bed days to 10.34)

MI’s + admissionsMI’s + admissions (14% to 2.3%) (14% to 2.3%)

ProceduresProcedures (86% would not choose (86% would not choose surgery) surgery)

Nice – cost per QALYNice – cost per QALY

ExerciseExercise £440£440

BypassBypass £19000£19000

AngioplastyAngioplasty £47000£47000

EvidenceEvidence

CourageCourage - no benefit of PCI in - no benefit of PCI in stable anginastable angina

CBTCBT - Reduces admissions- Reduces admissionsLifestlyeLifestlye - Reduces angina- Reduces anginaCost effectiveCost effective - Griffin et al - Griffin et al QOLQOLMisconceptions Misconceptions - reduces MI’s- reduces MI’sCollateralsCollaterals

Government AgendaGovernment Agenda““Improve healthcare by reducing Improve healthcare by reducing unnecessary waste” Hewitt /06unnecessary waste” Hewitt /06

NHS operating Framework - NHS operating Framework - supporting people with longterm supporting people with longterm conditionsconditions

““Our Health , Our say “ Our Health , Our say “ care closer to home care closer to home

What we DoWhat we Do

Listen & Educate patients Listen & Educate patients (rare nowadays)(rare nowadays)

What we do What we do

Angina is GoodAngina is Good

What we do What we do

Assess individual symptoms Assess individual symptoms

Establish their beliefs and misconceptionsEstablish their beliefs and misconceptions

Explain collateral development Explain collateral development

Explain pre-conditioningExplain pre-conditioning

Explain pain and nerve pathwaysExplain pain and nerve pathways

Help them control angina with relaxation Help them control angina with relaxation

Give lifestyle advice Give lifestyle advice

MisconceptionsMisconceptions

““angina damages the heart”angina damages the heart”

““angina is a kind of mini heart attack”angina is a kind of mini heart attack”

““angina is due to back pressure in the angina is due to back pressure in the heart” heart”

““the arteries are furring up and will the arteries are furring up and will eventually block and I’ll die “eventually block and I’ll die “

It is important to avoid anything that It is important to avoid anything that brings on angina”brings on angina”

What we do What we do

We empower the patient We empower the patient to take control of decisions to take control of decisions

How How

Time Time

2hrs individual time 2hrs individual time

4x2 hrs in group sessions4x2 hrs in group sessions

1 hr follow up1 hr follow up

1hr annual follow up 1hr annual follow up

Our Cost Our Cost

£2000 per patient £2000 per patient

Chesterfield ResultsChesterfield Results

25 patients -2 cohorts25 patients -2 cohorts

6 x PCI saved6 x PCI saved

3 x CABG saved 3 x CABG saved

1 Angiogram1 Angiogram

All improved with programmeAll improved with programme

SavingsSavings

£43,888 in procedures£43,888 in procedures( not including a transplant ) ( not including a transplant )

£40,221 on hospital activity£40,221 on hospital activity

Total £84,109Total £84,109

After Cost After Cost

25 Patients £52,25025 Patients £52,250

Overall saving = £31,859Overall saving = £31,859

£1,274 per patient £1,274 per patient

Our SatisfactionOur Satisfaction

Patients all have less anxietyPatients all have less anxiety

Patients all have less anginaPatients all have less angina

Fantastic patient satisfaction resultsFantastic patient satisfaction results

Number patients cry with relief Number patients cry with relief

ReferralsReferrals

CardiologyCardiology- new cardiac patients - new cardiac patients - longstanding difficult patients- longstanding difficult patients

GP’s GP’s - frequent flyers- frequent flyers- difficult patients - difficult patients

Problems Problems

Cost of training Cost of training

Time for training (8 days )Time for training (8 days )

GP enthusiasmGP enthusiasm

Pilot set up to train not save moneyPilot set up to train not save money

Convincing the PCT board Convincing the PCT board

Problems Problems

Consultants Consultants

GP referralsGP referrals

Correct patients Correct patients

Waiting list -DNA’sWaiting list -DNA’s

Present DayPresent Day

Running for 18 mthsRunning for 18 mths

Contract for 4 yrs from PCTContract for 4 yrs from PCT

Interest from Sheffield + Derby Interest from Sheffield + Derby

This is the futureThis is the future

DOH wants this rolled out DOH wants this rolled out

New NICE guidelines on the way New NICE guidelines on the way

Stents are now ethically challenged Stents are now ethically challenged

TestimonialsTestimonials““Looking back I shudder to think where I would be now Looking back I shudder to think where I would be now without these sessions. I expect more visits to my GP and without these sessions. I expect more visits to my GP and hospital coupled with yet more medication” - Patienthospital coupled with yet more medication” - Patient““Since you explained it, I have felt more reassured and Since you explained it, I have felt more reassured and confident that the underarm pain I experienced was not confident that the underarm pain I experienced was not related to Angina and don’t now feel I need to call the related to Angina and don’t now feel I need to call the emergency services.” - Patientemergency services.” - Patient““If, in the near future, I was offered stenting or re-grafting I If, in the near future, I was offered stenting or re-grafting I would be very reluctant to have any more invasive would be very reluctant to have any more invasive procedures carried out”. - Patientprocedures carried out”. - Patient““My wife benefited too by learning how to relax and knows My wife benefited too by learning how to relax and knows she doesn’t need to panic when I have an attack. She she doesn’t need to panic when I have an attack. She enjoys having my company on dog walks too” - Patientenjoys having my company on dog walks too” - Patient

He now understands the risk/benefits of further intervention He now understands the risk/benefits of further intervention when, previously, he was pushing for bypass and I don’t when, previously, he was pushing for bypass and I don’t need to see him again in my clinic - Consultantneed to see him again in my clinic - Consultant