Ten years of the CHD NSF

Professor Roger Boyle CBENational Director for Heart Disease and Stroke

Department of Health

Frustration

• Poor performance• Lack of teamwork• Inability to innovate –

new ideas stifled• Poor management

– Financial and general

• Poor results (outcomes)

• Increasing frustration

Modernising care

Networks

Improvement programme

CHD Partnership

CHD Collaborative

Heart Improvement Programme

NHS Improvement

Standards 1 & 2: Reducing heart disease in the population1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of

coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.

SMOKING PREVALENCE• All adult smoking rates have reduced over the period from 28% in 1998

to 21% in 2008.• Smoking in the routine & manual groups has reduced from 31% in 2001

to 29% in 2008.• In 10 years the number of smokers fell by one fifth (2 million fewer

smokers).

England – Smoking Rates & TargetsAll Adults & Routine & Manual Groups – 1998 - 2008

Standards 1 & 2: Reducing heart disease in the population1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of

coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.

England – Smoking Rates & TargetChildren Aged 11-15 years – 1996 - 2008

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000S

mo

kin

g C

es

sati

on

Se

rvic

e N

os.

Se

wtt

ing

Qu

it D

ate

& S

top

pin

g

Set Quit Date

Stopped Smoking

Set Quit Date 361,224 529,567 602,820 600,410 680,289 671,259

Stopped Smoking 204,876 298,124 329,681 319,720 350,800 337,054

2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

Record Annual Year/Q (All)

Financial Yr

Data

England – Smoking Cessation Services – 2003/04 - 2008/09People Setting a Quit Date & Stopped Smoking at 4 Weeks

Year % Stopped2003/04 57%2004/05 56%2005/06 55%2006/07 53%2007/08 52%2008/09 50%

SMOKING RATES IN CHILDREN

• Smoking rates in children aged 11-15 years have reduced from 13% to 6% in the period 1996 to 2006.

• These reductions are well ahead of target.

• This is encouraging news for the future.

IMPACT - SMOKING CESSATION SERVICES

• There has been an increase in the numbers of people attending Smoking Cessation services & setting a quit date from 361,000 in 2003/04 to 671,000 in 2008/09.

• Numbers of people successfully stopping have risen from 205,000 in 2003/04 to 337,000 tin 2008/09.

0

10

20

30

40

50

60

70

80

90

100

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

Men Women

% o

f th

e P

op

ula

tio

n

Underweight d

Normal e

Overweight f

Obese g

Data Years (All) HSE Table (All) HSE Topic BMI Age All Ages

Gender Data

Measure

Health Survey for England – % Obese, Overweight, Normal & Underweight – Males and Females – 1993 - 2008

Trend since 2000Trend since 2000

Standards 1 & 2: Reducing heart disease in the population1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of

coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1997 1998 2003 2004 2006 2008

% o

f th

e P

op

ula

tio

n

Low activity

Medium activity

High activity

Data Years (All) HSE Table (All) HSE Topic Physical Activity Gender Persons Age All Ages

Data

Measure

Discontinuous Years

High activity = Meeting recommended levels

Health Survey for England – Physical Activity –All Ages – 1993, 1998, 2003, 2004, 2006 & 2008

Less Physical Activity accounted for a 4.4% increase in CHD Mortality 1980-2000 (Capewell et al)

Trend since 2000

26 28 30 32 3335

26 28 29 30

36 36

29 28 30 3235 34

24 25

31 3034 32

19 1823

20

27 28

8 913 14 16 17

5 3 3 4 4 6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

1997

1998

2003

2004

2006

2008

1997

1998

2003

2004

2006

2008

1997

1998

2003

2004

2006

2008

1997

1998

2003

2004

2006

2008

1997

1998

2003

2004

2006

2008

1997

1998

2003

2004

2006

2008

1997

1998

2003

2004

2006

2008

16-24 25-34 35-44 45-54 55-64 65-74 75 Plus

% o

f th

e P

op

ula

tio

nLow activity

Medium activity

High activity

Data Years (All) HSE Table (All) HSE Topic Physical Activity Gender Women

Age Data

Measure

Health Survey for England – Physical Activity –All Ages – 1993, 1998, 2003, 2004, 2006 & 2008

Less Physical Activity accounted for a 4.4% increase in CHD Mortality 1980-2000 (Capewell et al)

PHYSICAL ACTIVITY – ALL AGE TREND

• Participation in physical activity which meets recommended levels has risen slowly since 2000.

• It still remain at around one third of people who meet the recommended levels.

PHYSICAL ACTIVITY – TREND BY AGE

• The increasing trend is most evident in the under 35s and those aged 65-74.

• There is, however, evidence in the latest Health Survey for England that people are over-optimistic about the duration of self-reported exercise compared with electronic monitoring.

Standards 1 & 2: Reducing heart disease in the population1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of

coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.

5.4

7.46.8

8.0 8.3

6.36.8

6.3 6.2 6.3

20.1

19.018.1

16.9 17.1

6.0

7.9 7.88.4

9.2

7.78.1

7.2 7.0 7.0

15.8

11.4

12.813.6

12.3

0

5

10

15

20

25

2003 2005 2006 2007 2008 2003 2005 2006 2007 2008 2003 2005 2006 2007 2008

Hypertensive controlled Hypertensive uncontrolled Hypertensive untreated

% o

f th

e P

op

ula

tio

n

Men

Women

Data Years (All) HSE Table (All) HSE Topic Blood Pressure Age (All)

Measure Data

Gender

Health Survey for England – Blood Pressure – % Population with Hypertension Controlled, Uncontrolled & Untreated – 2003, 2005, 2006, 2007 & 2008

Population BP fall accounted for a 9% reduction in CHD Mortality 1980-2000 (Capewell et al)

Steady reduction in the % of Males with untreated Hypertension

Steady but modest increase in the % of

Males & Females whoHave their Hypertension

Controlled

HYPERTENSION• There has been a steady but modest

increase in the % of males & females who have their hypertension controlled.

• There has been a steady reduction in the % of males who have their hypertension untreated.

HYPERTENSION UNTREATED & UNCONTROLLED

• People with hypertension untreated & hypertension treated but uncontrolled continue to be at risk.

• Between 2003 & 2008 – the % of men at risk due to

untreated & uncontrolled hypertension reduced from 26.3% to 23.4%

– The % of women at risk due to untreated & uncontrolled hypertension reduced from 23.5% to 19.4%.

• 23.4% of men & 19.4% of women continue to be at risk.

0.0

5.0

10.0

15.0

20.0

25.0

30.0

2003 2005 2006 2007 2008 2003 2005 2006 2007 2008

Men Women

% o

f th

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op

ula

tio

n

Hypertensive untreated

Hypertensive uncontrolled

Data Years (All) HSE Table (All) HSE Topic Blood Pressure Age (All)

Gender Data

Measure

England – Hypertension Uncontrolled & Untreated2003 & 2005-2008 (Health Survey for England)

26.3%

23.4% 23.5%

19.4%

Hypertensive untreated Hypertensive untreated

Hypertensive uncontrolledHypertensive uncontrolled

Standards 1 & 2: Reducing heart disease in the population1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of

coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.

PREVALENCE OF DIABETES• Increased diabetes prevalence accounted

for 4.8% of the increase in CHD mortality from 1980 to 2000.

• Since then prevalence has increased by 68% for women and 70% for men.

PREVALENCE OF CHD• All age prevalence reduced from 5.7% in

1998 to 5.2% in 2006.• There have been similar reductions in the

age groups 45-54 & 65-74. • with a more pronounced reduction in the

55-64 age group – from 9.6% in 1998 to 7% in 2006.

• Prevalence in the 75 plus age group has risen from 20.3% in 1998 to 22.8% in 2006.

• This is likely to be the result of delayed onset & increasing average age in the 75 plus age group.

1.9

2.5

3.4

4.2

2.9

3.3

4.3

5.6

2.4

2.8

3.9

4.9

0

1

2

3

4

5

6

1994 1998 2003 2006 1994 1998 2003 2006 1994 1998 2003 2006

Women Men Persons

Dia

be

tes P

reva

len

ce

(%

)

Data Years (All) HSE Table (All) Age All Ages HSE Topic DM Prevalence

Gender Data

Measure

Health Survey for England – Diabetes Prevalence –All Ages – 1994, 1998, 2003 & 2006

Increased Diabetes Prevalence accounted for a 4.8% increase in CHD Mortality 1980-2000 (Capewell et al)

Trend since 2000

Trend since 2000

Trend since 2000

2.6 3.0 2.7 2.4

8.19.6

8.47.0

15.1 16.1 15.3 15.1

18.220.3

21.422.8

5.0 5.7 5.2 5.2

0

5

10

15

20

25

1994 1998 2003 2006 1994 1998 2003 2006 1994 1998 2003 2006 1994 1998 2003 2006 1994 1998 2003 2006

45-54 55-64 65-74 75 Plus All Ages

Pre

va

len

ce

of

IHD

(%

)

Data Years (All) HSE Table (All) HSE Topic IHD Stroke Prevalence Measure IHD Prevalence (%) Gender Persons

Age Data

England – CHD PrevalencePersons – by Age – 1994,1998, 2003 & 2006 (Health Survey for

England)

FallSince 2000

FallSince 2000 Fall

Since 2000

FallSince 2000

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Change % 16+

% Diagnosed 16+

Change % 16+ 0.0% -0.5% -1.0% -0.5% 0.1% -0.2% -1.1% -1.1% -1.0% -0.8%

% Diagnosed 16+ 87.2% 86.5% 83.8% 82.5% 78.2% 77.2% 76.7% 74.6% 70.5% 61.5%

North East

Yorkshire &

Humber

North West

East Midland

s

South Central

East Of England

South East

Coast

South West

West Midland

sLondon

Org Level SHA

SHA

Data

Coronary Heart Disease – QOF Prevalence Aged 16+ 2006/7 & 2007/8 & % of Estimated CHD Diagnosed (16+ 2006) – England by SHA

London QOF 16+ prevalenceIs 61.5% of expected(estimated) prevalence

There was little or no change in QOF prevalence between 2006/7 & 2007/8

% of CHD DiagnosedRanked QOF 2007/8 Prevalenceas a % of Estimated Prevalence

CHD Change in Prev Aged 16+ (%)Growth or reduction in 2007/8 Prevalence Compared with 2006/7 Prevalence

North EastQOF 16+ prevalenceIs 87% of expected(estimated) Prevalence

(1) Modelled estimates of prevalence of CHD for PCTs in England Version 1.0 (Eastern Region Public Health Observatory, September 2008) These estimates of the prevalence of CHD in people aged 16+ have been calculated using a model developed at the Dept of Primary Care and Social Medicine, Imperial College, London. The model was developed using data from the 2003-2004 Health Surveys for England. The model takes into account age, sex, ethnicity, smoking status and deprivation score.

79% 79% 78%81% 80% 79%

76% 75% 74%

79% 79% 77%

66% 66% 65%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2006/7 2007/8 2008/9 2006/7 2007/8 2008/9 2006/7 2007/8 2008/9 2006/7 2007/8 2008/9 2006/7 2007/8 2008/9

1 2 3 4 5

Avera

ge Q

OF

Pre

vale

nc

e a

s %

of

Esti

mate

d P

revale

nce -

16 y

rs p

lusSHA (All) SHA Code (All) Org Level PCT Old SHA (All) PCT (All) Spearhead (All) PCT Short (All)

Average of CHD Prev QOF as % of Est

Quintile Ave IMD Year

Vascular Programme – CHD - QOF Prevalence aged 16 years plus as a % of Estimated Prevalence- Average for PCTs by IMD Quintile – 2006/7 – 2008/9 – England

Quintile 1Least

Deprived

Quintile 5Most

Deprived

Standards 3 & 4: Preventing CHD in high risk patients3. General practitioners and primary care teams should identify all people with established cardiovascular disease and

offer them comprehensive advice and appropriate treatment to reduce their risks.4. General practitioners and primary health care teams should identify all people at significant risk of cardiovascular

disease but who have not developed symptoms and offer them appropriate advice and treatment to reduce their risks.

BLOOD PRESSURE – PEOPLE WITH CHD• QOF reporting started in 2004/05.• QResearch has published earlier trends in

BP control for their population of 3.4 million people.

• The trend for the QResearch sample (01/02-06/7) & the QOF results (04/05-08/09) shows a steady increase in the % of people on CHD registers with BP<150/90.

• By 2008/09 QOF reported 89.7% of people with CHD had BP<150/90.

CHOLESTEROL – PEOPLE WITH CHD• The trend for the QResearch sample

(01/02-06/7) & the QOF results (04/05-08/09) shows a steady increase in the % of people on CHD registers with Cholesterol of 5 mmol/l or less.

• By 2008/09 QOF reported 82.1% of people with CHD had cholesterol of 5 mmol/l or less.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

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Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

% o

f P

eo

ple

wit

h C

HD

QR BP <150/90

QOF BP<150/90

REG BP<150/90

Year Quarter

Data

QResearch BP<150/90Pre-introduction of QOF

QOF Reported BP<150/90

QOF Reported BP<150/90

as % ofCHD Register

England – QOF % of People with CHD with BP <150/90 – 2001/02 – 2008/09QResearch Population & National QOF Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

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Q3

Q4

Q1

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Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

% o

f P

eo

ple

wit

h C

HD

QR Chol <5 mmol/l

QOF Chol <5 mmol/l

Reg Chol <5 mmol/l

Year Quarter

Data

QResearch Chol <5mmol/lPre-introduction of QOF

QOF Reported Chol <5mmol/l

QOF Reported Chol <5 mmol/l

as % ofCHD Register

England – QOF % of People with CHD with Cholesterol 5mmol/l or less –2001/02 – 2008/09 - QResearch Population & National QOF Results

70%

75%

80%

85%

90%

95%

100%

20

04

/5

20

05

/6

20

06

/7

20

07

/8

20

08

/9

20

04

/5

20

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/6

20

06

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/8

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20

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06

/7

20

07

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20

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06

/7

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07

/8

20

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/9

20

04

/5

20

05

/6

20

06

/7

20

07

/8

20

08

/9

1 2 3 4 5

% o

f P

eo

ple

with

CH

D

Org Level PCT PCT Code (All) Practice Code (All) SHA (All) Spearhead (All) SHA Name (All)

CHD06 QOF %

IMD Quintile Year

PCT Short

England – QOF % of People with CHD with BP <150/90 – 2004/05 – 2008/09Results for PCTs by IMD Quintile

Quintile 1Least

Deprived

Quintile 5Most

Deprived

QOF % 2004/5 2008/9Max 87% 91%Ave 85% 90%Min 81% 88%

IMD QUINTILE 1QOF % 2004/5 2008/9Max 87% 92%Ave 82% 89%Min 78% 87%

IMD QUINTILE 5

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

20

04

/5

20

05

/6

20

06

/7

20

07

/8

20

08

/9

20

04

/5

20

05

/6

20

06

/7

20

07

/8

20

08

/9

20

04

/5

20

05

/6

20

06

/7

20

07

/8

20

08

/9

20

04

/5

20

05

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20

06

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20

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20

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/5

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20

06

/7

20

07

/8

20

08

/9

1 2 3 4 5

Org Level PCT PCT Code (All) Practice Code (All) Spearhead (All) SHA (All)

CHD08 QOF %

IMD Quintile Year

PCT Short

England – QOF % of People with CHD with Cholesterol 5mmol/l or less –2004/05 – 2008/09 – BY PCT & IMD Quintile

Quintile 1Least

Deprived

Quintile 5Most

Deprived

QOF % 2004/5 2008/9Max 79% 85%Ave 73% 82%Min 67% 77%

IMD QUINTILE 1QOF % 2004/5 2008/9Max 80% 86%Ave 69% 81%Min 54% 77%

IMD QUINTILE 5

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

91

/92

92

/93

93

/94

94

/95

95

/96

96

/97

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/98

98

/99

99

/00

00

/01

01

/02

02

/03

03

/04

04

/05

05

/06

06

/07

07

/08

08

/09

Ne

t In

gre

die

nt

Co

st (

00

0s)

0

10,000

20,000

30,000

40,000

50,000

60,000

Pre

scrib

ed

Ite

ms

(00

0s)

Statin Type (All)

Year

Data

England – Statin Prescribing – Total Statins (Proprietary & Generic)Prescribed Items (000s) & Net Ingredient Costs (£000s)

Statins – Prescribed Items (000s)

Statins – Net Ingredient Cost (£000s)

NSFCHD

Total StatinsBetween 2000/01 & 2008/09-Net Ingredient Cost - up 38%-Prescribed Items - up 388%

0% 0% 0%

40%

54%

62%

69%72%

0% 0% 0%

38% 38%

15%19% 18%

14%

100% 100% 100%

60%

46%

38%

31%28%

100% 100% 100%

62% 62%

85%81% 82%

86%

49%

51%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09

Items(000s) NIC(£000s)

% o

f T

ota

l S

tati

ns

- N

IC &

Pre

sc

rib

ed

Ite

ms

Generic

Proprietory

Sum of % of Total

Data2 Year

Statin Type

England – Statin Prescribing – Proprietary & Generic Statins – 2000/01 – 2008/09% Share of Prescribed Items (000s) & Net Ingredient Costs (£000s)

Prescribed Items Net Ingredient Cost

Generic Statins72% of ItemsIn 2008/09

Generic Statins14% of NICIn 2008/09

Standards 5,6 & 7: Heart attack and other acute coronary syndromes5. People with symptoms of a possible heart attack should receive help from an individual equipped

with and appropriately trained in the use of a defibrillator within 8 minutes of calling for help, to maximise the benefits of resuscitation should it be necessary.

PHASE 1 - SAVING LIVES – OUR HEALTHIER NATION

• The White Paper ‘Saving Lives: Our Healthier Nation’ was launched in 1999

• £2m invested in installing 681 automated external defibrillators (AEDs) in busy public places (airports, stations, shopping centres)

• From February 2005 all 681 AEDs were handed over to 21 Ambulance Services & financial allocations made to each Trust to ensure programme continuity.

• All AEDs managed as core NHS activity.

PHASE 2 - THE NHS PLAN• The NHS Plan (July 2000) 3,000

automated external defibrillators (AEDs) in public places.

• £6m was awarded to the BHF• Community Defibrillation Officers

appointed• A further 2,300 AEDs were funded

– based on bids received from Ambulance Trusts

Over 100 survivors to hospital discharge

Over 100 survivors to hospital discharge

Standards 5,6 & 7: Heart attack and other acute coronary syndromes6. People thought to be suffering from a heart attack should be assessed professionally

and, if indicated, receive aspirin. Thrombolysis should be given within 60 minutes of calling for professional help.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2001/0

2 Q

4

2002/0

3 Q

1

2002/0

3 Q

2

2002/0

3 Q

3

2002/0

3 Q

4

2003/0

4 Q

1

2003/0

4 Q

2

2003/0

4 Q

3

2003/0

4 Q

4

2004/0

5 Q

1

2004/0

5 Q

2

2004/0

5 Q

3

2004/0

5 Q

4

2005/0

6 Q

1

2005/0

6 Q

2

2005/0

6 Q

3

2005/0

6 Q

4

2006/0

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1

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2

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3

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4

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1

2007/0

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2

2007/0

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3

2007/0

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4

2008/0

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1

2008/0

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2

2008/0

9 Q

3

2008/0

9 Q

4

2009/1

0 Q

1

2009/1

0 Q

2

DTN30 %

CTN60 %

CY Quarter (All) New SHA (All) Level England SHA Short (All)

Fin Yr Q

Data

Acute Myocardial Infarction - STEMI -Thrombolysis% Door to Needle in 30 minutes & % Call to Needle in 60 minutes – 2002 - 2009

% Door to Needle in 30 minutes

% Call to Needle in 60 minutes

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005 2006 2007 2008 2009

lytictherapypPCI

% Thrombolysis

% Primary PCI

100%

40%

0%

60%

Acute Myocardial Infarction - STEMI -ThrombolysisShift from Thrombolysis to Primary PCI

THROMBOLYSIS FOR STEMI• Thrombolysis for STEMI was implemented

soon after the publication of the NSF.• The % of patients with Call to Needle within

60 minutes reached 70% in Q4 2007/08.• The % of patients with Door to Needle within

30 minutes reached 80% plus from Q2 2003/04.

• In many parts of the country pre-hospital thrombolysis was implemented & by 2007 17% of thrombolysis was being given before arrival at the hospital.

THROMBOLYSIS & PRIMARY PCI• From 2003 Primary PCI started to be

adopted as a more effective alternative.• The National Infarct Angioplasty Project

(NIAP) evaluated implementation at pilot sites.

• DH guidance (2008) recommended the roll-out of PPCI to areas where 120 call to balloon times could be delivered.

• Thrombolysis now accounts for 40% of post STEMI treatment & PPCI accounts for 60%.

How are heart attacks being managed?

0

10

20

30

40

50

60

70

80

90

100

2003

-4

2004

-5

2005

-6

2006

-7

2007

-8

2008

-9

2009

-10

Primary angioplasty

Pre-hospitalthrombolytic treatmentIn-hospitalthrombolytic treatment

%

Standards 5,6 & 7: Heart attack and other acute coronary syndromes7. NHS Trusts should put in place agreed protocols/systems of care so that people admitted to hospital with proven heart attack are appropriately assessed and offered treatments of proven clinical and cost

effectiveness to reduce their risk of disability and death.

PRIMARY PCI – RESPONSE TIMESDoor to Balloon (DTB)• The national mean time reduced from 61.7

minutes in 2007 to 53.8 minutes in 2008• In 2008 – 81.3% were less than 90 minutesCall to Balloon• The national mean time Call to Balloon was

116.6 minutes in 2008• In 2008 - 78.8% were less than 150 minutes.

OUTCOMES FOR PATIENTS WITH ACS• While 30 day mortality after nSTEMI has

been falling, outcomes for patients with ACS (nSTEMI) remain of concern.

• The immediate diagnosis & treatment of nSTEMI has lagged behind that for STEMI.

NICE GUIDANCE – MARCH 2010• NICE is preparing clinical guidance on

– The management of ACS - published March 2010

• Future improvements in management & treatment to be based on guidance issued.

Unadjusted 30-day mortality after nSTEMI is falling

Unpublished data - John Birkhead

Some 1200-1500 fewer deaths each year

61.7

53.8

116.6

0

20

40

60

80

100

120

140

2007 2008 2008

Door to Balloon Call to Balloon

Min

ute

s

Sum of Minutes

Measure Year

Acute Myocardial Infarction - STEMI – Primary PCICTB 2008 & DTB 2008 & 2009 (National Mean of Unit Median Times)

Source: BCIS Audit – P.Ludman

DTB - 81.3% < 90 mins

CTB – 78.8% < 150 mins

Falling mortality rates – MINAP data

STEMIs30 days

Falling mortality rates – MINAP data

Non STEMIs30 days

Standard 8: Stable angina8. People with symptoms of angina or suspected angina should

receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

2003-

2004-05 2005-06 2006-07 2007-08 2008-09 2009-

% o

f R

AC

P C

lin

ica

l R

efe

rra

ls

% Refs within 24 hrs

% All Refs Seen in 14 days

% Outcome Cardiac

Level National Area (All) SHA Name (All)

Year Quarter

Data

England – Rapid Access Chest Pain Clinics – 2002/03 – 2009/10% Referred within 24 hours, Seen with 14 days & % Cardiac in Origin

Rapid increase in Specificity of referral

43% of referralsCardiac in origin

90% of referrals made within 24 hrs

97% of referrals Seen within 14 days

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

2003-

2004-05 2005-06 2006-07 2007-08 2008-09 2009-

RA

CP

C R

efe

rra

ls

Total

Linear (Total)

Area Name (All) SHA (All) Area (All) SHA Name (All) Level SHA Area Code (All)

Sum of Patients

Year Quarter

Trend

England – Rapid Access Chest Pain Clinics – 2002/03 – 2009/10National Trend in the Number of ReferralsRAPID ACCESS CHEST PAIN CLINICS

• Central funding enabled Rapid Access Chest Pain Clinics to be developed across the country

• Since 2002/03 referrals have been running at over 25,000 in each quarter

• Over the period since their introduction there has been an upward trend in referrals nationally – so no let up in symptomatic presentation.

• In each of the last 5 quarters to June 2009 there have been over 30,000 referrals.

SPEED OF ACCESS & % CARDIAC IN ORIGIN• Since 2006 90% of referrals have been made

within 24 hrs of GP decision to refer.• Over 95% of referrals have been seen within

14 days (97% in the quarter to June 2009)• Over the first year of their introduction

specificity of referral increased & over 40% of referrals have been cardiac in origin (43% in the quarter to June 2009)

Standards 9 & 10: Revascularisation9. People with angina that is increasing in frequency or severity should

be referred to a cardiologist urgently or, for those at greatest risk, as an emergency.10. NHS Trusts should put in place hospital-wide systems of care so that patients with suspected or

confirmed coronary heart disease receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent coronary events.

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

An

gio

gra

ms

Angiography

Angio Plus PCI

Angiography 98,949 106,329 114,658 126,434 130,339 139,377 147,757 166,125

Angio Plus PCI 8,272 8,738 10,621 13,956 14,791 15,553 14,170 11,461

2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007 2007-2008

HA/Board England

Data

Intervention

England – Angiography Activity –Angiography Alone & Angiography with PCI - 2000-2001 to 2007-2008

Increase of 66%2000/1-2007/8

ANGIOGRAPHY – GROWTH IN ACCESS

• Access to angiography has improved substantially

• The number of angiograms increased by 66% between 2000/01 & 2007/08.

ANGIOGRAPHY – SPEED OF ACCESS

• Speed of response has improved markedly.

• Since April 2004• Total waiters have reduced by

over 15,000 - down 66%• In April 2004 - 26% of people

waited a month or less• By December 2009 – 82% of

people waited a month or less.0

5,000

10,000

15,000

20,000

25,000

Ap

r-0

4M

ay-

Ju

n-0

4Ju

l-0

4A

ug

-04

Se

p-0

4O

ct-

04

No

v-0

4D

ec-0

4Ja

n-0

5F

eb

-05

Ma

r-0

5A

pr-

05

Ma

y-

Ju

n-0

5Ju

l-0

5A

ug

-05

Se

p-0

5O

ct-

05

No

v-0

5D

ec-0

5Ja

n-0

6F

eb

-06

Ma

r-0

6A

pr-

06

Ma

y-

Ju

n-0

6Ju

l-0

6A

ug

-06

Se

p-0

6O

ct-

06

No

v-0

6D

ec-0

6Ja

n-0

7F

eb

-07

Ma

r-0

7A

pr-

07

Ma

y-

Ju

n-0

7Ju

l-0

7A

ug

-07

Se

p-0

7O

ct-

07

No

v-0

7D

ec-0

7Ja

n-0

8F

eb

-08

Ma

r-0

8A

pr-

08

Ma

y-

Ju

n-0

8Ju

l-0

8A

ug

-08

Se

p-0

8O

ct-

08

No

v-0

8D

ec-0

8Ja

n-0

9F

eb

-09

Ma

r-0

9A

pr-

09

Ma

y-

Ju

n-0

9Ju

l-0

9A

ug

-09

Se

p-0

9O

ct-

09

No

v-0

9D

ec-0

9

Nu

mb

ers

Wa

itin

g

9+ mths

8-9 mths

7-8 mths

6-7 mths

5-6 mths

4-5 mths

3-4 mths

2-3 mths

1-2 mths

0-1 mths

Year (All) Quarter (All) First Last (All) Intervention Angiography Old SHA (All) New SHA (All) Trust Short (All)

Period

Data

England – Total Waiters by Time Band – AngiographyApril 2004 – December 2009

Total WaitersDown 66%

Waiting 0-1Months = 26%

Waiting 0-1Months = 82%

Standard 11: Heart failure11. Doctors should arrange for people with suspected heart failure to be offered appropriate

investigations (e.g electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely to

both relieve their symptoms and reduce their risk of death should be offered.

ECHOCARDIOGRAPHY – SPEED OF ACCESS

• Diagnostic waiting times have reduced as part of achieving 18 weeks

• For echocardiography – in March 2009

– 88% of people waited less than 4 weeks

– 99% of people waited less than 6 weeks.

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

Wa

itin

g L

ist

Nu

mb

ers

Apr-08

Mar-09

Apr-08 7630 7321 5327 3448 1756 668 327 149 130 101 90 58 22 45

Mar-09 7901 7562 5697 3605 2360 915 91 57 16 12 6 3 1 13

0 <01 weeks

01 <02 weeks

02 <03 weeks

03 <04 weeks

04 <05 weeks

05 <06 weeks

06 <07 weeks

07 <08 weeks

08 <09 weeks

09 <10 weeks

10 <11 weeks

11 <12 weeks

12 <13 weeks

13+ weeks

Diagnostic Echocardiography SHA Name (All)

Data

Month

England – Waiting Time in Weeks –April 2008 & March 2009 - Echocardiography

In March 200988% waited less than 4 weeks99% waited lss than 6 weeks

Standard 11: Heart failure11. Doctors should arrange for people with suspected heart failure to be offered appropriate

investigations (e.g electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely to

both relieve their symptoms and reduce their risk of death should be offered.

HEART FAILURE - MORTALITY• There is some evidence that mortality among newly diagnosed cases of heart failure has

decreased (South East England Hillingdon/Bromley 1995/97 & Hillingdon/ Hastings 2004/05).

Heart Failure – Improval in survival of incident cases of Heart FailureCohort Study – 1995/97 & 2004/05 (Mehta et al, Heart 2009 95:1851-1856)

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,00019

98/9

1999

/0

2000

/1

2001

/2

2002

/3

2003

/4

2004

/5

2005

/6

2006

/7

2007

/8

2008

/9

1998

/9

1999

/0

2000

/1

2001

/2

2002

/3

2003

/4

2004

/5

2005

/6

2006

/7

2007

/8

2008

/9

1998

/9

1999

/0

2000

/1

2001

/2

2002

/3

2003

/4

2004

/5

2005

/6

2006

/7

2007

/8

2008

/9

Congestive heart failure Left ventricular failure Heart failure, unspecified

Hea

rt F

ailu

re -

Ad

mis

sio

ns

& F

CE

s

FCEs

Admissions

Data

England – Heart Failure – Hospital Finished Consultant Episodes & Admissions –

By Specific Diagnosis - 1998/9-2008/9

Left Ventricular Failure - Admissions & FCEs have reduced FCEs by 35% since 1998/99 & by 30% since 2000/01

Admissions by 49% since 1998/99 & by 43% since 2000/01

Receipt of cardiac rehabilitation

0

10

20

30

40

50

60

70

80

%

Acute MI CABG PCI All cases

2005/6

2006/7

2007/8

2008/9

% of patients with MI, CABG and PCI receiving cardiac rehabilitation

0

10

20

30

40

50

60

70

%

NE NW SEC E of E Y & H WM SW EM SC Lond

2005/6

2006/7

2007/8

2008/9

EnglandMI CABG PCI

WalesMI CABG PCI

Reasons for rejection

Uptake by ethnicity

Quality requirement two: Diagnosis and TreatmentPeople presenting with arrhythmias, in both emergency and elective settings,

receive timely assessment by an appropriate clinician to ensure accurate diagnosisand effective treatment and rehabilitation. .

Heart Rhythm Devices – UK National Surveys

• Annual surveys & reports• Tracking progress –

nationally & by Network & PCT

• Compare observed with expected

• 2009 Report due July 2010

• Overall mapping shows improved access rates between 2006 & 2008 for

– Pacemakers– ICD– CRT

Source: Cunningham et al, Heart Rhythm DevicesUK National Survey, 2008

Outcomes – CHD MortalityCHD MORTALITY UNDER 75• Between 1995/97 & 2005/07 average

annual deaths from all causes reduced from 202,061 to 159,921

• Deaths from CHD reduced from 46,615 to 24,495

• Deaths from Other Circulatory Diseases reduced from 27,610 to 18,557.

• Between 1995/97 & 2005/07 - mortality rates from All Causes reduced from 397 per 100,000 to 302 per 100,000 – down 24%

• Mortality rates from CHD reduced from 89 to 45 per 100,000 – down 50%

• Mortality rates from Other Circulatory Disease reduced from 52 to 34 per 100,000 – down 35%

46,61524,495

27,610

18,557

71,363

62,007

56,472

54,862

0

50,000

100,000

150,000

200,000

250,000

P Ave 95-97 P Ave 05-07

ENGLAND

NU

mb

er

of

de

ath

s

Other Causes

Cancer

Other Circulatory

CHD

Level National Measure OBS

SHA Year

Data

England – All Cause Mortality – Aged Under 75 years –Number of Deaths by Cause – 3 Year Average 1995-97 & 2005-07

202,061

159,921

1995-97 2005-07

8945

52

34

141

115

115

107

0

50

100

150

200

250

300

350

400

450

P Ave 95-97 P Ave 05-07

ENGLAND

Mo

rta

lity -

DS

R p

er

10

0,0

00

- A

ll C

au

se

s

Other Causes

Cancer

Other Circulatory

CHD

Level National Measure DSR

SHA Year

Data

England – All Cause Mortality – Aged Under 75 years –Directly Standardised Rate (per 100,000) by Cause – 1995-97 & 2005-07

397

302

1995-97 2005-07

Outcomes – CVD MortalityCVD MORTALITY UNDER 75• As a result of these reductions there

has been a reduction of 47% in death rates from circulatory disease.

• The Public Service Agreement target was to achieve a 40% reduction by 2010.

• The target has been achieved 5 years ahead of schedule.

INEQUALITIES• In addition, the aim is to reduce the

absolute gap between the worst fifth of areas in the country for health & deprivation (the spearhead PCTs) & the national average by 40% by 2010.

• The absolute gap has reduced by 38.4% between 1996 and 2007 – well on the way to achieving that target.

Outcomes – CHD MortalityCHD MORTALITY UNDER 75• However, comparison of the

changing rates between Local Authorities – grouped into deprivation quintiles (using the Index of Multiple Deprivation) shows a different picture.

• In 1995-97, there was a large overlap in the mortality rates between the local authorities in the 1st (least deprived) and 5th (most deprived) quintiles.

• By 2005-07, the gap had widened & the overlap had almost disappeared.

• However, the variation in mortality rates within the 1st & 5th deprivation quintiles has narrowed

• AND• In both the 1st & 5th quintiles the

highest (worst) mortality rates in 2005-07 are lower (better) than the lowest (best) mortality rates in 1995-97.

0

20

40

60

80

100

120

140

160

1 5 1 5

DSR 95-97 DSR 05-07

DS

R p

er

10

0,0

00

Level LA Measure DSR SHA (All)

Ave CHD DSR

Year IMD Quintile

Area Short

England – CHD Mortality – Aged Under 75 yrs – Directly Standardised Rates (DSR) – Local Authorities 1st & 5th IMD Quintiles – 1995-97 & 2005-07

CHDUnder 75s

OverlapThe gap

has widened

1995-97 2005-07

Range ofDSRs forLAs in the5th Quintile

In 95/97

0

20

40

60

80

100

120

140

160

1 5 1 5

DSR 95-97 DSR 05-07

DS

R p

er

10

0,0

00

Level LA Measure DSR SHA (All)

Ave CHD DSR

Year IMD Quintile

Area Short

England – CHD Mortality – Aged Under 75 yrs – Directly Standardised Rates (DSR) – Local Authorities 1st & 5th IMD Quintiles – 1995-97 & 2005-07

CHDUnder 75s

The variation has narrowed

The variation has narrowed

BUT

1995-97 2005-07

ANDIn both cases the

worst in 05/07 is betterthan the best in 95/97

Next ten years!

8945 23

52

3416

141

115

89

115

107

99

0

50

100

150

200

250

300

350

400

1995-97 2005-7 2015-17

DS

R d

eath

s p

er 1

00,0

00

Other causes

Cancer

Other CVD

CHD

?

How it looked 10 years ago

1995-97

22%

13%

36%

29%

CHD

Other CVD

Cancer

Other

How it looks now

2005-7

15%

11%

38%

36%CHD

Other CVD

Cancer

Other

How it might look 10 years from now- the next 50%

2015-17

10%7%

39%

44% CHD

Other CVD

Cancer

Other

34,000 fewer deaths each year cf. 1995-97

Challenges for hospital care

• Maintaining quality during current economic climate

• Driving up efficiency– Reducing LOS– Reducing admissions/readmissions– Reducing follow-ups

• Working primary care to improve CV care and referral patterns

What is left for primary care to do?

• Further optimise secondary prevention

• Get upstream – Health Checks– Prevent CVD and diabetes

• Identify and manage people with AF– Prevent about 5,000 strokes

• Identify people with FH– Entirely treatable condition once diagnosed

• Run the NHS!