hypertension in berkshire - approachestvscn.nhs.uk/wp-content/uploads/2017/01/16-efforts... ·...
TRANSCRIPT
Hypertension in Berkshire - approaches
Dr Lise Llewellyn
Evidence and local plans
Discussion
Public Health Services for Berkshire Working together for health and wellbeing
Logic model - Impact
Risk factors : Non modifiable - age, ethnicity, family history Modifiable - not doing enough physical activity - 30% reduction being overweight or obese - x 3 - 4 having too much salt in your diet regularly drinking too much alcohol - binge cold
Consequences: mortality 20% men 24% women 50% of CHD in >30 years - BP Ischaemic and haemorrhagic stroke, myocardial infection, heart failure, chronic kidney disease, cognitive decline
Public Health Services for Berkshire Working together for health and wellbeing
Key risks attributable to DALYs
GBD (2013) indicates that the 5 main risks attributable to DALYs in South East England are:
Public Health Services for Berkshire Working together for health and wellbeing
Cardiovascular Diseases
Public Health Services for Berkshire Working together for health and wellbeing
Tobacco
Tobacco
Tobacco
Dietary
Dietary
Dietary
High BMI
High BMI
High BMI
High Systolic Blood Pressure
Low Phys. Activity
Low Phys. Activity
Low Phys. Activity
Air Pollution
Air Pollution
Air Pollution
Male Female Both
DA
LY
S p
er
10
0,0
00 p
op
ula
tion
• 48% of DALYs are attributable to dietary risks; 1,682 DALYs per 100,000 population
• High systolic BP accounts for 43% DALYs; 1,535 per 100,000
• High BMI is 29%; 1,024 DALYs per 100,000
• High Total Cholesterol is 23%; 828 DALYs per 100,000
High Systolic Blood Pressure
High Systolic Blood Pressure
High Total Cholesterol
High Total Cholesterol
High Total Cholesterol
High fasting plasma glucose
High fasting plasma glucose
High fasting plasma glucose
National profile • Prevalence
The Department of Health’s 2010 'Health Survey for England' report prevalence of hypertension in adults of 16 or older is 31.5% for men and 29% for women
Prevalence also increases with deprivation:
prevalence increased from 26% of men and 23% of women in the least deprived quintile
to 34% and 30% respectively in the most deprived quintile.
Public Health Services for Berkshire Working together for health and wellbeing
Berkshire / STP Approaches
• Primary prevention - NAO evidence • Part of treatment path • Link with digital programme – accessibility and
sustainability • NHS health checks • Local performance Appts (since 1/4/13) 41-71 % England 66% Received - 17-35% England 32% Capacity / worried well Reviewing delivery NHS health checks - targeting
Public Health Services for Berkshire Working together for health and wellbeing
Approaches continued …
• Secondary prevention
• Treatment
• Generally good – match CCG comparator performance / exceeds England average treatment measures
• Outlier stroke BP
• Improved Detection
• Ongoing
Public Health Services for Berkshire Working together for health and wellbeing
Local profiles Frimley STP prevalence:
Recorded - 12.0% in the 2014/15 QOF,
91,046 people recorded as having hypertension.
Estimated prevalence - 22.0%,
76,091 people “missing” from the GP registers in 2014/15.
England average of 13.8%.
West of Berkshire:
Recorded - 11.95% in the 2014/15 QOF
62,243 people recorded as having hypertension
Estimated prevalence - 22.2%,
53,197 people “missing” from the GP registers in 2014/15
12.69 13.2
10.62
12.39 13.01
0
2
4
6
8
10
12
14
Newbury &District CCG
North & WestReading CCG
South ReadingCCG
WokinghamCCG
England
%
Public Health Services for Berkshire Working together for health and wellbeing
STP savings • Based on PHE cost evidence • Conservative calculation of savings: best CCG performance
deliverable within 5 years not a reflection on ambition as target not estimated prevalence
East - £ 157k West - £ 84k • Change response to detection • Self care v treatment • Pharmacological – NICE guidelines Expectation on patients but with support
Public Health Services for Berkshire
Working together for health and wellbeing
Lifestyle interventions
• 10mm - 40% reduction mortality (30% - stroke)
• Weight 40%
• Exercise 30%
• Relaxation 25%
• Alcohol 30%
• Salt 25%
• Locally
Eat for Health
197 started programme with diagnosis of hypertension - 55 / 28% normal BP at end of programme - 12 weeks
Public Health Services for Berkshire Working together for health and wellbeing
Principles
• Capacity - primary care • Awareness • Self measurement equipment • Community - Slough • Pharmacies - new contract • Health settings - GP / hospitals / community • Support • Digital – patient portal • Pharmacist in practices - new and difficult
control Public Health Services for Berkshire
Working together for health and wellbeing
• All ideas welcome
Public Health Services for Berkshire Working together for health and wellbeing
End stage cardiovascular
disease –why we fail these
patients…
Dr Barbara Barrie, End of Life Lead, Thames Valley Strategic Clinical Network
Deaths from cardiovascular diseases in England -
implications for end of life care
February 2013
Annual number of cardiovascular disease deaths by disease category in England, 2004–11
Population dynamics will increase need
From pyramid to coffin
Anticipated 46% increase in HF prevalence by 2030 AHA Heart Disease and Stroke Statistics—2016 Update
CVD – mortality market share
Cardiovascular disease - leading cause of death in England, resulting in 158,500 deaths 34% of all deaths Cancer responsible For 23% of all deaths
34%
23%
Atlas of Risk (NHS 2009)
Service factors
• Poor end-of-life
planning
• Treatment focus
• Poor palliative /
supportive care
access
• Low coverage in
diverse settings
e.g. acute medicine /
nursing homes
• Cancer bias
Barriers to equitable and accessible heart failure
palliative care
Clinician Factors
• Palliative v.
general medicine /
cardiology tension
• Technophobia
• Reluctance to
address end of
life issues
• Inadequate
assessment skills
• Fear of defeat
Patient factors
•Disempowered
• Unexplored /
unrealistic goals
•Stoicism
• Reluctance to
accept impending
death
• Social isolation /
poverty
Disease factors
• Need for dual
treatment /
palliative
approaches
• Comorbidities:
cognitive impairment
• Lack of
predictability
Modified from Goodlin SJ JACC, 2009, 54:386-96
The heart failure disease trajectory
Every HF patient’s trajectory is unique
Gott M et al. Palliat Med 2007; 21: 95-9
Fifty shades of dying
End of life symptomatic spectrum in heart failure
Prevalence of refractory symptoms
Dyspnoea 60-88%
Fatigue 69-82%
Pain 63-80%
Nausea 17-48%
Anxiety 49%
Depression 9-36%
Confusion 18-32%
Solano JP et al. J Pain Symp Manag, 31: 58, 2006
HF care – a protocol driven paradigm
Challenges to initiating PC
• The culture of HF care favours a medical
model and is treatment focussed.
• Evidence based intervention is often
the default position.
• Patients’ preferences may be unexplored
or they may be disempowered by technicalities or lack capacity.
• A structure of sub-speciality silo working.
• There is a reluctance to discuss prognosis in the face of uncertainty.
Spencer Tunick
Implantable cardioverter defibrillators
(ICDs): unintended consequences?
ICDs are implanted for the primary or secondary prevention of SCD in patients who have had a life-threatening ventricular arrhythmia or at risk of developing such arrhythmias,
but – patients about to die with end-stage HF or an unrelated terminal illness often exhibit metabolic and biochemical derangement and complex agonal arrhythmias that could trigger multiple ICD discharges.
Rates of implantation of defibrillators
High Energy Implant Rate trend per million population in England: ICD vs CRT‐D
Thames Valley
‘Ironic technology’
“I have an ICD and a pacemaker. It’s prolonged my life a little bit. But the longer it prolongs my life, the more things happen to me that it can’t correct. So the question is, do you want to have those effects, or do you want to end it all?” —86 year old man.
.
Elements of palliative care for heart failure
Patient
End of life care
Family/ informal carer
Heart failure professional
Spiritual care
Rehabilitation
Symptom control
Psychological support
Information
Family / bereavement care
Advance care planning Primary care
Secondary / emergency care
General palliative care
Specialist palliative care
Social support
ESC HFA workshop, Copenhagen, Nov 2007
Optimising device therapy
Who should co-ordinate end of life care?
• GP
• Community matrons / case managers
• District / heart failure nurses
• Community specialist palliative care
• Hospital specialists
– Palliative care
– Cardiology
– Other specialties
About 90% of the last year of life is spent at home 59% of deaths take place in hospital
MDT working and good patient navigation essential
HF: Early integration of palliative care
Courtesy of Deborah Meyers MD, Texas Heart Institute
Meyers DE, Goodlin SJ. Can J Cardiol 32:1148-56, 2016
Amber Care Bundle
• Gap between health and
dying with uncertain outcome
• May recover or deteriorate
• DNACPR
• Devices
• Ceiling of Care
• Communication
– Situation
– Choices – PPC / PPD
– Advance care planning
May 2014
Driving the provision of
palliative care for heart failure
• Raise awareness – make it mainstream
• Develop better approaches to prognostication
but undertake needs assessment early
• Improve disease specific symptom management
• Build a robust evidence base
• Form effective multidisciplinary models of collaborative practice across provider systems
Caring Together Task Force
52