Dr Anne Scoular, Consultant in Public Health Medicine | December 2014
CHRONIC DISEASE IN NHS GREATER GLASGOW & CLYDE
Insights from Local Enhanced Services Programme 2012-2014
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Contents
I
II
III
IV
V
Index to figures & tables
Executive summary
Foreword
Introduction
Population need
2.1 Registered diagnoses
2.2 Disease prevalence
2.2 Premature disease
2.3 Multimorbidity
Clinical Service Delivery & Key Outcomes
3.1 Coronary Heart Disease
3.2 Type 2 Diabetes
3.3 Stroke/TIA
3.4 Chronic Obstructive Pulmonary Disease (COPD)
3.5 Left Ventricular Systolic Dysfunction (LVSD)
Conclusion
Appendix: CDM LES Review Final Report
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Index to figures and tables
Figure 1: Total chronic disease diagnoses in NHSGGC: 2012/13 vs 2013/14 (n) 11
Figure 2: Total number of chronic disease diagnoses in 2013/14, by partnership 11
Figure 3: Crude disease prevalence (per 1,000), by partnership, 2013/14 12
Figure 4: Crude disease prevalence (per 1,000), NHSGGC: 2012/13 vs 2013/14 12
Figure 5: % change in crude disease prevalence, by area: 2012/13 vs 2013/14 13
Figure 6: Age & sex standardised disease prevalence (per 1,000), by area, 2013/14 13
Figure 7: Premature male & female disease prevalence, by partnership, 2013/14 14
Figure 8: CDM LES patient cohort 2013/14: number of co-existent diagnoses 15
Table 1: CDM LES patient cohort 2013/14: details of co-existent diagnoses 15
Figure 9: CHD patients: age distribution 18
Figure 10: CHD patients: ethnicity recording & overview 18
Figure 11: CHD patients: detail of non-white ethnic groups, by partnership area 19
Figure 12: CHD patients: deprivation profile, by partnership area 19
Figure 13: CHD patients: exception coding, by partnership area 20
Figure 14: CHD patients: reason for exception coding, by partnership area 20
Figure 15: CHD patients: smoking status, by residential deprivation quintile 21
Figure 16: CHD patients: current smokers in each partnership area 21
Figure 17: CHD patients who smoke: smoking cessation referrals, by deprivation quintile 22
Figure 18: CHD patients who smoke: smoking cessation referrals, by partnership area 22
Figure 19: CHD patients: alcohol use 23
Figure 20: CHD patients: lipid control, by deprivation status 23
Figure 21: CHD patients: lipid control, by ethnic subgroup 24
Figure 22: CHD patients: lipid control, by age group 24
Figure 23: CHD patients: lipid control, by partnership area 25
Figure 24: CHD patients: % within target cholesterol range, by practice 25
Figure 25: CHD patients: % with AF, by age 26
Figure 26: CHD patients with AF: % receiving warfarin therapy, by age group 26
Figure 27: CHD patients with AF: therapy by partnership area 27
Figure 28: CHD patients with AF: % receiving warfarin therapy, by practice 27
Figure 29: Type 2 diabetes: age distribution 29
Figure 30: Type 2 diabetes: ethnicity recording & overview 29
Figure 31: Type 2 diabetes: detail of non-white ethnic groups, by partnership area 30
Figure 32: Type 2 diabetes: deprivation profile, by partnership area 30
Figure 33: Type 2 diabetes: exception coding, by deprivation quintile 31
Figure 34: Type 2 diabetes: exception coding, by partnership area 31
Figure 35: Type 2 diabetes: smoking status, by residential deprivation quintile 32
Figure 36: Type 2 diabetic patients who smoke: smoking cessation referrals, by deprivation quintile 32
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Figure 37: Type 2 diabetic patients who smoke: smoking cessation referrals, by partnership area 33
Figure 38: Type 2 diabetic patients: alcohol use 33
Figure 39: Type 2 diabetic patients: recorded levels of physical activity, by deprivation quintile 34
Figure 40: Type 2 diabetic patients: referrals to physical activity services, by partnership 34
Figure 41: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by deprivation quintile 35
Figure 42: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by partnership area 35
Figure 43: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by ethnic group 36
Figure 44: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by practice 36
Figure 45: Stroke/TIA patients: age distribution 38
Figure 46: Stroke/TIA patients: ethnicity 38
Figure 47: Stroke/TIA patients: deprivation profile, by partnership area 39
Figure 48: Stroke/TIA patients: exception coding, by deprivation quintile 40
Figure 49: Stroke/TIA patients: exception coding, by partnership area 40
Figure 50: Stroke/TIA patients: smoking status, by residential deprivation quintile 41
Figure 51: Stroke/TIA patients who smoke: smoking cessation referrals, by deprivation quintile 41
Figure 52: Stroke/TIA patients who smoke: smoking cessation referrals, by partnership area 42
Figure 53: Stroke/TIA patients: alcohol use 42
Figure 54: Stroke/TIA patients: functional problems, by age group 43
Figure 55: Stroke/TIA patients: recorded use of services relative to scale of functional problems 43
Figure 56: COPD patients: age distribution 45
Figure 57: COPD patients: ethnicity recording & overview 45
Figure 58: COPD patients: deprivation profile, by partnership area 46
Figure 59: COPD patients: exception coding, by deprivation quintile 47
Figure 60: COPD patients: exception coding, by partnership area 47
Figure 61: COPD patients: smoking status, by residential deprivation quintile 48
Figure 62: COPD patients who smoke: smoking cessation referrals, by deprivation quintile 49
Figure 63: COPD patients who smoke: smoking cessation referrals, by partnership area 49
Figure 64: COPD patients: alcohol use 50
Figure 65: COPD patients: MRC grade, by age group 50
Figure 66: COPD patients: referral to pulmonary rehabilitation, by partnership area 51
Figure 67: COPD patients: referral to pulmonary rehabilitation, by practice 51
Figure 68: LVSD patients: age distribution 53
Figure 69: LVSD patients: aetiology 53
Figure 70: LVSD patients: ethnicity 54
Figure 71: LVSD patients: deprivation profile, by partnership area 54
Figure 72: LVSD patients: exception coding, by deprivation quintile 55
Figure 73: LVSD patients: exception coding, by partnership area 55
Figure 74: LVSD patients: smoking status, by residential deprivation quintile 56
Figure 75: LVSD patients who smoke: smoking cessation referrals, by deprivation quintile 56
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Figure 76: LVSD patients who smoke: smoking cessation referrals, by partnership area 57
Figure 77: LVSD patients: alcohol use 57
Figure 78: LVSD patients: NYHA class, by partnership area 58
Figure 79: LVSD patients: cardiac therapy prescribed within last 12 months, by NYHA Class 59
Table 2: Detail of cardiac drug therapy in preceding 3 months, by NYHA Class 60
Figure 80: LVSD patients: overview of drug therapy over preceding year, by number of agents 61
Figure 81: Percentage of practice LVSD cohort receiving one or more therapies 61
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Executive summary
As at 31 March 2014, 146,461 patients were registered on one or more LES CDM disease registers, an increase of
2.4% compared with the 2012/13 cohort of 143,077 patients. A total of 194,714 chronic disease diagnoses was
recorded, representing an average of 1.3 conditions per patient.
Of the five disease areas, CHD was the most prevalent, closely followed by Type 2 diabetes. COPD prevalence
which showed a threefold variation across the NHSGGC partnerships. Crude prevalence of premature disease
showed marked spatial variation and was generally highest in partnership areas with more intense
socioeconomic deprivation. The gradient in premature disease prevalence was steepest for COPD and least
marked for CHD. For all conditions apart from COPD, the prevalence of premature disease was substantially
higher in men than in women. ‘Multimorbidity’ (generally defined as two or more co-existent chronic
conditions) was present in 38,411 (26%) of the current cohort.
CHD patients represent the largest single disease register in the CDM programme, closely followed by Type 2
diabetes. The proportion of patients who belonged to non-white ethnic subgroups was highest for Type 2
diabetes and CHD, however there was considerable variability at local partnership level. In South Glasgow, for
example, approximately 1 in 4 Type 2 diabetic patients belonged to an ethnic minority subgroups. The
deprivation distribution of patients with all disease areas differed strikingly across partnerships, but was most
polarised towards SIMD quintile 1 areas in COPD and CHD.
Exception coding provides some insights into the proportion of patients who were not sought for review. For
all disease areas, exception coding rates were higher in residents of more socio-economically deprived
neighbourhoods, although there was considerable variability between different partnerships. Overall, the
magnitude and distributional patterns of exception coding are likely to be contributing to inequalities in health
status within NHSGGC and require further attention in consultation with practices. The proportion of patients
exception coded was lowest for patients with LVSD (11%) and highest for COPD patients (19%).
Smoking is a major risk factor for all five disease areas within the current CDM programme. High smoking
prevalence remains a challenge, particularly in residents of the most deprived neighbourhoods. Smoking
cessation support is a powerful clinical intervention in its own right, however relatively low proportions of
patients were reported as ‘ready to stop’ and this subgroup had variable recorded rates of referral to smokefree
services. However, more encouragingly, there was considerable variability in these proportions at local level
and referral rates of patients at the ‘right’ stage of change were consistently higher in residents of the most
deprived areas. Overall, however, tobacco continues to generate substantial additional morbidity and mortality
within a population already bearing a heavy burden of chronic disease. This situation can be improved by
tackling overall rates of smoking in areas of deprivation and further upskilling clinicians with behavioural brief
interventions suitable for busy primary care professionals, building on the many novel ideas for improving the
health promoting opportunities within the CDM programme identified by general practice staff themselves
involved in the last year of the Keep Well programme (see separate report).
Specific clinical indicators are presented for each disease area:
In CHD care, achieving target total cholesterol values of ≤5 mmol/l was a NICE/European Cariguideline-
informed recommendation in the 2013/14 contract year, however this was achieved in only two thirds
of patients overall and an even lower proportion (60%) among CHD patients who lived in the most
deprived neighbourhoods compared with residents of more affluent areas (67%). Although ‘treating to
target’ has subsequently been the subject of considerable debate, there remain very strong trial data
that more aggressive lipid lowering is associated with a continued reduction in mortality and adverse
cardiovascular events.
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For Type 2 diabetes, recommended levels of physical activity (which has a major independent beneficial
effect on glycaemic control) were reached by only 38% of the cohort in the most deprived SIMD quintile
and 50% in the least deprived and referral rates to physical activity services were uniformly low (2%)
across all deprivation quintiles. Overall, a minority (18,760; 36%) of Type 2 diabetic patients had HbA1c
values compatible with good glycaemic control, with poorer glycaemic control was poorer in black
ethnic minority subgroup and among those with no recorded ethnicity, which may may reflect gaps in
structured, systematic care.
In stroke/TIA patients, a high proportion had functional problems which are highly amenable to
therapy, however recorded use of services appeared relatively low, although this may be partly
explained by incomplete Read code capture of the full range of relevant services.
In COPD, pulmonary rehabilitation should be offered to all people with COPD at MRC Grade 3 and
above who consider themselves functionally disabled by their condition. However, only around half of
patients in this category are referred, with considerable variation between partnerships and between
individual practices.
Clinical indicators for the LVSD programme suggest that a number of areas require attention. Firstly,
there are issues concerning the diagnostic precision of Read coding. A separate, detailed audit
undertaken within the local CDM programme in 2013 identified considerable variability in Read coding
for heart failure. This highlighted two broad types of issues: firstly, the extent to which patients with
heart failure were captured on any heart failure register; and secondly, the validity and precision of
documented subtypes of heart failure diagnoses. There is a need to clean practice heart failure registers,
standardise secondary care discharge letters and enhance support to improve and maintain accurate
coding across the whole system in the future.
Functional capacity assessment is a central component of clinical care for patients with heart failure. In
NHSGGC, however, over one third of LVSD patients within the primary care CDM programme had no
recorded NYHA class, although this proportion varied from 20 to 49% across different partnerships.
Therapeutic management of LVSD patients also requires more detailed audit. 4,600 (41%) patients
appeared not to have been recently (ie in the previous three months) prescribed a beta blocker and
3,426 (31%) appeared not to have been prescribed an ACE-I or ARB in the same period. Over a longer
retrospective time period (12 months), 3,083 (28%) of patients appeared not to have been prescribed a
beta blocker and 2,185 (20%) had not record of having received either an ACE-I or ARB. It is quite
conceivable that these apparent prescribing anomalies may be artefactual (as a result of extraction
problems) or a result of the inaccurate disease coding previously discussed, however it is a matter of
concern that the two main groups of drugs recommended in LVSD may not be prescribed in a sizeable
number of LVSD patients and needs more detailed analysis as a matter of urgency.
In summary, this report provides local intelligence on the scale and clinical performance of the CDM
programme in each of the five disease areas. Specific topics are highlighted for a possible future improvement
focus and it is proposed that these are clinically led by the CDM Review and Implementation Group as part of
the ongoing programme redesign process established in 2013, following the CDM LES programme review (Final
report embedded as Appendix 1). Greater emphasis is required on optimising coverage and delivery of clearly
defined, evidence based interventions that hold the greatest potential to change clinical outcomes, together
with investment of dedicated clinician time in person-centred consultations, workforce development to ensure
that the most effective use is made of that time, further improvements on the recent electronic template
changes and ‘whole system’ supportive infrastructure to ensure that a well organised, structured approach to
improving outcomes and health status for the increasing numbers of patients who will in the future need
effective community based care for chronic disease.
Foreword
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This paper provides insights into the clinical performance of NHS Greater Glasgow & Clyde’s Chronic Disease Management (CDM) programme, which delivers practice based CDM care for patients with five major chronic diseases:
Coronary Heart Disease (CHD)
Type 2 Diabetes
Stroke/TIA
Chronic Obstructive Pulmonary Disease (COPD)
Left Ventricular Systolic Dysfunction (LVSD).
The NHS Greater Glasgow & Clyde (NHSGGC) CDM programme is delivered in primary care, but strongly
underpinned by a whole population perspective across all aspects of service planning, coordinated by a
multidisciplinary planning group, with input from a Consultant in Public Health Medicine, a GP Medical
Editor, the Primary Care Support Team, four Managed Clinical Networks (Heart, Diabetes, Respiratory &
Stroke) and specialists in Information Management & Technology and in Health Improvement.
The programme is delivered via a General Medical Services (GMS) Local Enhanced Services (LES) contractual
arrangement, which evolved from a pilot programme initiated in 1999: ‘Glasgow’s Responsive Angina Secondary
Prevention Programme’ (GRASPP), targeting patients with coronary heart disease (CHD). With the advent of
the new GMS contract in 2004, the GRASPP programme became a CHD LES, along with analogous contracts
for Type 2 Diabetes and Stroke/Transient Ischaemic Attack (TIA). These service models were incrementally
extended to Chronic Obstructive Pulmonary Disease (COPD) and Left Ventricular Systolic Dysfunction (LVSD)
from November 2010.
Data extracted primarily for the purposes of LES contracting also generate valuable understanding of the needs
and characteristics of patients with chronic disease. Unfortunately, problems with data extraction led to a gap
in production of ‘Insights’ reports between 2010 and 2012, however these problems are now resolved and I am
pleased to provide, in the report that follows, an overview of these aspects of the CDM programme for the
contract year 2013/14.
This will be my last report as Public Health lead for the CDM programme, so I would like to take this
opportunity to wholeheartedly thank Frances Paton and her excellent team in Information Services for their
enormous support with data production for the ‘Insights’ reports over the past seven years. A huge thank you
is also due to everyone involved in delivering and supporting the entire CDM programme; every practice nurse,
our Primary Care Support team, our Medical Editor and our MCNs have all played a vital role in the
programme’s success and this continuing dedication to patient-centred care will ensure that it continues to
develop and go from strength to strength in the future.
Dr Anne Scoular, Consultant in Public Health Medicine
Keep Well/Enhanced Services Data Group Chair December 2014
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I Introduction
Chronic disease management (CDM) is a generic term for systematic delivery of coordinated healthcare for
populations with established LTCs. Its overall aim is to transform care for patients with chronic illnesses from
acute and reactive to proactive, planned and population-based. CDM has the following key features (Box 1):
The original evidence underpinning CDM came from a review of interventions to improve care for various chronically ill populations. A subsequent Cochrane Collaboration review concluded that several elements work synergistically together to strengthen provider/patient relationships and improve health outcomes. This Cochrane Review concluded that four elements had the most direct relationship to health outcomes: i) increasing provider expertise and skill ii) educating and supporting patients iii) making care delivery more team-based and planned iv) making better use of registry-based information systems.
These components now form the basis of the CDM model which has been delivered in NHSGGC for over 15
years. Accumulated evidence continues to support this model as an integrated framework for improving both
the processes and outcomes of healthcare for patients with chronic disease. However it is vital that structured
approaches (building on those employed in the recently discontinued Keep Well programme; see below) are
designed into the CDM system to ‘inequalities-proof’ the basic CDM model, as there is abundant evidence that
interventions reliant on individual patients’ motivation to seek and maintain CDM care generally worsen
existing inequalities, unless systematic ‘inequalities proofing’ is used. CDM is underused in women and older
people with CHD, and those in lower socioeconomic strata are more likely to have angina but less likely to
consult their doctor.
Keep Well was launched in October 2006, part of the Scottish Government’s 2005 policy ‘Delivering for Health’.
Its initial focus was on health inequalities in cardiovascular disease (CVD). Its core element, the Keep Well
consultation (or ‘health check’), targeted individual residents in Scotland’s most disadvantaged areas, to whom
it offered appropriate interventions to address modifiable CVD risk factors and health behaviours (eg high
blood pressure, high cholesterol, smoking, overweight etc). In NHSGGC, the Keep Well health check also
sought to address the impact of wider social issues including poverty, employability, literacy and mental health
& wellbeing. In March 2010, in advance of publication of its final national evaluation report, the Scottish
Government announced its intention to mainstream the programme across NHS Scotland from April 2012.
However this decision was overturned a few years later, in December 2013, when the Scottish Government
announced its decision to end funding for Keep Well from March 2017. NHSGGC had evaluated Keep Well
extensively, which indicated that variation at three critical points largely explained practice-to-practice
variations that were likely to curtail the programme’s overall effectiveness:
Box 1: Key features of Chronic Disease Management (CDM) model
Population orientation (ie defined by a condition, not a service)
Comprehensive, multidisciplinary care
Integrated care continuum across entire disease cycle
Effective systems for coordination
Active client–patient management tools (health education, empowerment, self-care)
Structured, evidence-based approach
Use of guidelines, protocols and care pathways
Deployment of information technology and system solutions
Continuous audit and quality improvement
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Before engagement (effectiveness of engaging subgroups with greatest need)
At the consultation (effectiveness of initiating changes in health literacy, risk factors, health
associated behaviours and use of wider practice systems)
After the consultation (sustained change following the consultation, both at individual patient level
and in the overall responsiveness of local health improvement services)
An anticipatory care toolkit was developed during 2013 to translate these evaluation findings into practical
actions for practices; the toolkit has transferable value in wider aspects of chronic disease management in
primary care. In the last year of Keep Well (2014/15), NHSGGC commissioned practices to self-assess their
existing CDM programmes against the toolkit and were encouraged to further develop the toolkit in ways that
best fitted their own local context and systems. Flexibility, innovation and practical approaches to service
delivery was actively encouraged and practices were supported to share details of these activities, both with
other practices and with NHSGGC, using simple and clearly structured electronic methods and a highly
successful webinar series. This has generated a rich collection of ideas, evidence and actions developed by
practices in the context of their own CDM programme, with enormous transferability of organisational learning
to other practices that will further strengthen and enrich the CDM programme across the entire NHSGGC area
if supported and sustained. A brief summary of the full report from the Keep Well final (2014/15) contract year
will be available in early 2015 and this will bring useful transferable learning for all involved in the CDM
programme.
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II Population need
2.1 Registered diagnoses
As at 31 March 2014, 146,461 patients were registered on one or more LES CDM disease registers, an increase of
2.4% compared with the 2012/13 cohort of 143,077 patients (Figure 1).
Figure 1: Total chronic disease diagnoses in NHSGGC: 2012/13 vs 2013/14 (n)
Among the 146,461 patients in the 2013/14 contract year, a total of 194,714 chronic disease diagnoses was
recorded, representing an average of 1.3 conditions per patient. The distribution of these diagnoses across
partnership areas is shown in Figure 2 below.
Figure 2: Total number of chronic disease diagnoses in 2013/14, by partnership
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2.2 Disease prevalence
Of the five disease areas, CHD was the most prevalent, closely followed by Type 2 diabetes. COPD prevalence
which showed a threefold variation across the NHSGGC partnerships (Figure 3).
Figure 3: Crude disease prevalence (per 1,000), by partnership, 2013/14
Absolute numbers and crude rates of disease reflect ‘real world’ population prevalence of disease, which is obviously vital information for planning purposes. Crude prevalence of all diseases apart from CHD increased in NHSGGC between 2012/13 and 2013/4, however, there were major spatial variations in these trends across the Health Board area, reflecting underlying differences in population characteristics (Figures 4 & 5).
Figure 4: Crude disease prevalence (per 1,000), NHSGGC: 2012/13 vs 2013/14
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As shown in Figure 4, an 1.8% rise in crude Type 2 Diabetes prevalence occurred between 2012/13 and 2013/14,
with more modest rises in COPD and stroke/TIA prevalence of 1.1% and 0.8% respectively and little change in
LVSD (+0.2%) or CHD (-0.2%), however as highlighted in Figure 5, not all areas showed similar trends, for
example crude CHD prevalence showed markedly divergent patterns, even within Glasgow City.
Figure 5: % change in crude disease prevalence, by area: 2012/13 vs 2013/14
Some of this variation is likely to be due to differential changes in population structures; CHD, stroke and, to
a lesser extent, Type 2 diabetes are all commoner among older people and South Asian populations have an
approximately fourfold increased risk of Type 2 Diabetes. However, after standardisation for age and sex,
Glasgow City is clearly at the extreme end of a steep gradient in disease prevalence within GG&C (Figure 6).
Figure 6: Age & sex standardised disease prevalence (per 1,000), by area, 2013/14
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2.2 Premature disease
The prevalence of premature disease showed marked spatial variation and was generally highest in partnership
areas with more intense socioeconomic deprivation (Figure 7). For all conditions, the NE Glasgow partnership
area had the highest premature disease prevalence and East Renfrewshire or East Dunbartonshire shared the
lowest. The gradient in premature disease prevalence was steepest for COPD and least marked for CHD. For
all conditions apart from COPD, the prevalence of premature disease was substantially higher in men than in
women.
Figure 7: Premature male & female disease prevalence, by partnership, 2013/14
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2.3 Multimorbidity
‘Multimorbidity’ is generally defined as two or more co-existent chronic conditions. In the context of the five
conditions covered by the current NHSGGC LES programme, 38,411 (26%) of the current cohort of 146,461
unique patients have two or more of the five LES eligible conditions (Figure 8).
Figure 8: CDM LES patient cohort 2013/14: number of co-existent diagnoses
The specific combinations of comorbidity in the 2013/14 patient cohort are detailed in Table 1 below.
Table 1: CDM LES patient cohort 2013/14: details of co-existent diagnoses
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3. Clinical Service Delivery & Key Outcomes
The data presented in the sections that follow are based on clinical measurements recorded during the financial
year 2013/14. However, until April 2014 there has been no reliable coding mechanism for explicitly
differentiating patients who had these measurements recorded during a formal annual CDM review or in the
course of routine clinical care; in the past, various proxies, such as financial achievement and/or various
combinations of Read codes entered within a short time window, were used as a substitute for this, however
closer scrutiny of these proxies in 2013 has shown them to be unreliable. New Read codes for ‘completed annual
review’ were sought in late 2013 and these were implemented in April 2014, with the new clinical template
release. This will, in future, allow reporting of robust data on the proportion of each CDM cohort who received
a structured annual review during the relevant contract year.
In the meantime, exception coding is used as a way of providing some insights into the proportion of patients
in each disease area who were not sought for review. The concept of ‘exception reporting’ is a feature of the
GMS contract intended to ensure that practices are not penalised where it may not be clinically appropriate or
possible to undertake a specific activity due to particular circumstances, for example, patients persistently do
not attend for review or where a medication cannot be prescribed due to a contraindication or side-effect.
For each clinical area, data are provided on the size and characteristics of each of the five chronic diseases
currently within the disease programme, followed by selected indicators of clinical care.
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3.1 Coronary Heart Disease
Key points
CHD remains the biggest single contributor to deaths and disability in NHSGGC and, at 59,352 patients,
is the largest disease register in the CDM programme. In some areas of NHSGGC (notably South
Glasgow), approximately 1 in 5 CHD patients belong to ethnic minority subgroups.
25,638 (43%) CHD patients live in neighbourhoods classified by the Scottish Index of Multiple
Deprivation (SIMD) as the most intensely deprived in Scotland (SIMD Quintile 1). This proportion was
highest in NE Glasgow.
Exception coding provides some insights into the proportion of patients who were not sought for
review. Overall, 8,005 (13.5%) CHD patients were exception coded; this proportion was highest among
residents of SIMD quintile 1.
Smoking cessation in patients with existing CHD reduces the likelihood of a recurrent event, need for
further interventions and cardiovascular death by a factor of around half. Unfortunately, however, 9,780
patients with CHD in NHSGGC continue to smoke, with a particularly high smoking prevalence (23.3%)
in the most deprived neighbourhoods, dropping steeply to 5.9% in the least deprived
However, a very small proportion (around 6%) of current smokers were assessed as ready to stop. Of
these, fewer than half were recorded as having been referred to smoking cessation services,
In NHSGGC, a post-treatment total cholesterol value of 5 mmol/l is achieved in only two thirds of
patients; this is lower (at 60%) among CHD patients living in the most deprived neighbourhoods
compared with residents of more affluent areas (67%).
7823 (13%) of the overall cohort had atrial fibrillation (AF), although its prevalence rises steeply with
increasing age. AF carries a four to five-fold increased risk for stroke, but this can be reduced with
systematic stroke risk assessment and anticoagulation when indicated. Approximately half of
NHSGGC’s CHD patients with AF were receiving warfarin therapy, however there were large variations
between practices in the proportion of their CHD cohorts receiving warfarin
3.1.1 Rationale for indicators
CHD remains the biggest single contributor to deaths and disability in NHSGGC, despite a substantial
reduction in mortality rates over the past four decades. Around two thirds of this reduction has been achieved
through preventative medical therapies and reduction of cardiac risk factors, including use of aspirin, Beta-
blockers, Angiotensin-converting enzyme inhibitors (ACEI), lipid-lowering therapies, smoking cessation and
physical activity promotion. The CDM programme aims to support practitioners to deliver these interventions
systematically in ways that fit with individual patients’ circumstances.
3.1.2 Demographic characteristics
A total of 59,352 patients were registered on the CHD disease register during the financial year 2013/14, of whom
33,869 (57.1%) were male and 25,483 (42.9%) female. The cohort’s age profile is shown in Figure 9.
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Figure 9: CHD patients: age distribution (n=59,352)
Although ethnicity recording has improved in recent years, this is still not complete, with no ethnicity recorded
in 4,987 (8.4%) patients. 20 patients declined to disclose their ethnicity. Of those with known ethnicity, the
proportion belonging to minority ethnic groups was highest in South Glasgow, at 18.3%, and lowest in N
Lanarkshire (Figure 10). Further detail of the composition of ethnic minority subgroups in each partnership
area is shown in Figure 11.
Figure 10: CHD patients: ethnicity recording & overview (n= 59,352)
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Figure 11: CHD patients: detail of non-white ethnic groups, by partnership area
Overall, 25,638 (43%) of CHD patients live in neighbourhoods classified by the Scottish Index of Multiple
Deprivation (SIMD) as the most intensely deprived in Scotland (SIMD Quintile 1). This proportion was highest
in NE Glasgow, where 70% of CHD patients live in SIMD Quintile 1 areas, and lowest in East Dunbartonshire,
at 7% (Figure 12).
Figure 12: CHD patients: deprivation profile, by partnership area (n=59,352)
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3.1.3 Access to CDM programme
8,005 (13.5%) patients were exception coded; this proportion was similar across partnerships (Figure 13). The
proportion of patients who were exception coded was highest among residents of SIMD quintile 1 (most
deprived) neighbourhoods, at 14.6%, falling linearly to 10.6% in those living in the least deprived areas. Reasons
for exception coding showed predictable differences that broadly reflect partnerships’ distinct age and social
structures (Figures 13 & 14).
Figure 13: CHD patients: exception coding, by partnership area (n=59,352)
Figure 14: CHD patients: reason for exception coding, by partnership area (n=8,005)
3.1.4 Clinical care
Smoking cessation in patients with existing CHD reduces the likelihood of a recurrent event, need for further
interventions and cardiovascular death by a factor of around half. Smoking cessation is probably the most
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important intervention the NHS can provide for a smoker with CHD, with the number of CHD smokers needed
to treat (NNT) of 13 to prevent one death. Unfortunately, 9,780 patients with CHD in NHSGGC continue to
smoke, with a high smoking prevalence (23.3%) in the most deprived neighbourhoods, dropping steeply to
5.9% in the least deprived (Figure 15).
Figure 15: CHD patients: smoking status (n=59,352)
The estimated number of CHD patients in each partnership area who were recorded as being smokers in the
2013/14 contract year is shown in Figure 16.
Figure 16: CHD patients: current smokers in each partnership area (n=59,352)
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However, a very small proportion (around 6%) of current smokers were assessed as ready to stop. Of these,
fewer than half appeared to have been referred to smoking cessation services, although considerable local
variability in referral rates is noted. More encouragingly, there was some evidence of higher referral rates
among smokers who wanted to stop living in the more deprived areas (Figures 17 & 18).
Figure 17: CHD patients who smoke: smoking cessation referrals, by deprivation quintile (n=9,780)
Figure 18: CHD patients who smoke: smoking cessation referrals, by partnership area (n=9,780)
Alcohol intake was poorly recorded, with documentation of current intake only available in around two thirds
of CHD patients; this raises a possibility of selection bias towards patients with lower intakes, as clinicians may
be more hesitant to explore detail in those with higher intakes; among those with documented values, 2,658
(7%) were noted as drinking over the recommended limits.
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Figure 19: CHD patients: alcohol use (n= 59,352)
NICE guidance (CG181) on secondary prevention of cardiovascular disease recommends high-intensity statin
treatment with the aim of achieving a reduction of at least 40% in non-HDL cholesterol values; European
guidelines specify a target post-therapy cholesterol level of 5 mmol/l. In NHSGGC, this is achieved in only two
thirds of patients and is lower (60%) among CHD patients living in the most deprived neighbourhoods than
among residents of more affluent areas (67%) (Figure 20).
Figure 20: CHD patients: lipid control, by deprivation status (n= 59,352)
24
Variations were also observed between ethnic subgroups in proportion of patients with cholesterol values
within the ‘target’ range varied, although small numbers in Black and Chinese subgroups limit interpretation
of this observation (Figure 21).
Figure 21: CHD patients: lipid control, by ethnic subgroup (n= 59,352)
The proportion of patients with cholesterol values in the target range increased progressively with age, until
the age of 80 onwards. This is in line with current approaches to avoiding polypharmacy among older adults
(Figure 22).
Figure 22: CHD patients: lipid control, by age group (n= 59,352)
25
There were considerable variations across partnerships and also between individual practices in the proportion
of patients within the ‘target’ cholesterol range (Figures 23 and 24).
Figure 23: CHD patients: lipid control, by partnership area (n= 59,352)
Figure 24: CHD patients: % within target cholesterol range, by practice (n= 59,352)
26
Atrial fibrillation (AF) is a relatively common arrhythmia in the CHD population. 7823 (13%) of the overall
cohort had atrial fibrillation, however a steeply rising prevalence occurs in older age groups (Figure 25).
Figure 25: CHD patients: % with AF, by age group (n= 59,352)
Detection and management of AF is vitally important, because it carries a four to five-fold increased risk for
stroke, estimated to account for between 6 and 24% of all ischaemic strokes. For this reason, stroke risk
assessment and appropriate thromboprophylaxis is a central component of AF management. Various stroke
risk stratification schema have been developed to categorise patients into low, moderate and high risk strata,
so that the patients at highest risk can be identified for warfarin therapy. In the 2013/14 year, approximately
half of NHSGGC’s CHD patients with AF were receiving warfarin therapy, increasing with age until the age of
80 (in keeping with the rising prevalence of AF in older age groups) (Figure 26). There were large variations
between practices in the proportion of their cohorts receiving warfarin, although the data are not standardised
for age so could partly be attributed to differences in age structure (Figure 28).
Figure 26: CHD patients with AF: % receiving warfarin therapy, by age group (n=7,823)
27
Figure 27: CHD patients with AF: therapy by partnership area (n=7,823)
Figure 28: CHD patients with AF: % receiving warfarin therapy, by practice (n=7,823)
28
3.2 Type 2 Diabetes
Key points
A total of 57,738 patients were registered on the Type 2 diabetes register in 2013/14, of whom 26,010
(45%) were female and 31,728 (55%) male. There were striking variations in the ethnic composition of
Type 2 diabetic cohorts at local partnership level; in South Glasgow, one quarter of the cohort belonged
to non-white ethnic groups.
The distribution of Type 2 diabetes was less polarised towards SIMD quintile 1 areas than occurs with
other conditions, but still reflects a higher prevalence of underlying risk factors (particularly central
obesity and smoking) in areas with the most severe socio-economic deprivation.
Exception coding provides some insights into the proportion of patients who were not sought for
review. Overall, 15% of Type 2 diabetic patients living in NHSGGC’s most deprived neighbourhoods
were exception coded; this proportion declined, with decreasing levels of deprivation, to 11% in SIMD
quintile 5.
As previously discussed, smoking worsens clinical outcomes from diabetes, increasing risk of death,
CHD and stroke and also contributes independently to poorer overall disease control. Smoking
cessation is therefore a very powerful clinical intervention, reducing these risks to that of non-smokers
within 5-10 years. Smoking prevalence in Type 2 diabetics shows a similar social gradient to that for
other chronic conditions, however the proportion of patients who were smokers in each SIMD quintile
was slightly lower. Only a small proportion (around 6%) of Type 2 diabetic smokers were assessed as
ready to stop. Of this subgroup, referral rates to smoking cessation services varied between 18 and 73%
across different partnership areas.
Physical activity has a major beneficial effect on glycaemic control. Recommended levels of physical
activity were achieved in only 38% of the cohort in the most deprived SIMD quintile and 50% in the
least deprived. Formal referral rates to physical activity services were uniformly low (2%) across all
deprivation quintiles,
Overall, 18,760 (36%) of patients had HbA1c values compatible with good glycaemic control. There was
a modest socio-economic gradient in this proportion, but little difference between partnership areas.
Overall glycaemic control was poorer in black ethnic minority subgroup and also among those with no
recorded ethnicity; the latter may reflect gaps in structured, systematic care.
3.2.1 Rationale for indicators
Type 2 diabetes is an important cause of disability in its own right, as well as increasing risk of CHD and other
vascular disease. Its prevalence is increasing rapidly in NHSGGC, particularly in our most disadvantaged
subpopulations. Those who are least well educated are more likely to have diabetic retinopathy, heart disease
and poorer disease control. They are more likely to feel that their condition has an adverse effect on their lives
and be seen as non-adherent by healthcare professionals than those who are higher earners and educated to a
higher standard. The CDM programme aims to provide systematic coverage of the NHSGGC Type 2 diabetic
population with high impact clinical interventions which, delivered together and in a person-centred way,
substantially reduce morbidity and mortality; these interventions include: blood pressure monitoring and
control; effective lipid management; good long term glycaemic control (defined as maintenance of a target
HbA1c value of 48 - 59 mmol/l); and promotion of physical activity, which is increasingly recognised as having
a major clinically significant beneficial effect on glycemic control, independent of its weight loss.
3.2.2 Demographic characteristics
A total of 57,738 patients were registered on the Type 2 diabetes register during the financial year 2013/14, of
whom 26,010 (45%) were female and 31,728 (55%) male. The cohort’s age profile is shown in Figure 29.
29
Figure 29: Type 2 diabetes: age distribution
There were striking variations in the ethnic composition of Type 2 diabetic cohorts at local partnership level;
in South Glasgow, one quarter of the cohort belonged to non-white ethnic groups (Figure 30). The specific
composition of non-white ethnic groups also varied considerably across partnerships (Figure 31).
Figure 30: Type 2 diabetes: ethnicity recording & overview
30
Figure 31: Type 2 diabetes: detail of non-white ethnic groups, by partnership area
Although less polarised towards SIMD quintile 1 areas than occurs with other conditions, the distribution of
Type 2 diabetes still reflects a higher prevalence of underlying risk factors (particularly central obesity and
smoking) in areas with the most severe socio-economic deprivation (Figure 32). Smoking is now proven to be
an independent risk factor for development of diabetes, as well as increasing the risk of complications in those
who already have the disease.
Figure 32: Type 2 diabetes: deprivation profile, by partnership area
31
3.2.3 Access to CDM programme 8,024 (14%) patients were exception coded, for one or more of the reasons listed below:
Informed dissent 4,401
Patient unsuitable 2,718
Housebound 1,389
Failure to attend diabetic clinic 381
Lives in a nursing home 225
Long stay hospital inpatient 18
15% of Type 2 diabetic patients living in NHSGGC’s most deprived neighbourhoods were exception coded; this
proportion declined with decreasing levels of deprivation, to 11% in quintile 5 (Figure 33). The proportion of
exception coded diabetic patients was highest in Renfrewshire (1,447 patients; 17% of cohort) and lowest in East
Renfrewshire (393 patients; 11% of cohort) (Figure 34).
Figure 33: Type 2 diabetes: exception coding, by deprivation quintile
Figure 34: Type 2 diabetes: exception coding, by partnership area
32
As previously discussed, smoking worsens clinical outcomes from diabetes, increasing risk of death, CHD and
stroke by 48%, 54% and 44% respectively and poorer overall disease control. Smoking cessation is therefore a
very powerful clinical intervention, reducing these risks to that of non-smokers within 5-10 years.
Smoking prevalence in Type 2 diabetics shows a similar social gradient to that for other chronic conditions,
however the proportion of patients who were smokers in each SIMD quintile was lower (Figure 35).
Figure 35: Type 2 diabetes: smoking status, by residential deprivation quintile
As with CHD, only a small proportion (around 6%) of current smokers were assessed as ready to stop. Of this
subgroup, referral rates to smoking cessation services ranged between 18 and 73% across different partnership
areas. Referral rates were highest, at 46%, for smokers living in the most deprived SIMD quintile (Figures 36
and 37).
Figure 36: Type 2 diabetic patients who smoke: smoking cessation referrals, by deprivation quintile
33
Figure 37: Type 2 diabetic patients who smoke: smoking cessation referrals, by partnership area
Moderate to heavy consumption of alcohol interferes with glycaemic control and increases the risk of some
diabetic complications, including peripheral neuropathy, dyslipidaemias, erectile dysfunction and, possibly,
retinopathy. However, in 2013/14, only 75% of the Type 2 diabetic cohort had a recorded level of alcohol intake
in 2013/14 (Figure 38). Of those, 2,552 (6%) exceeded usual recommended limits, although it should be noted
that ‘safe’ limits of alcohol consumption for diabetic patients are poorly defined and may be lower than for the
general population.
Figure 38: Type 2 diabetic patients: alcohol use
34
As previously noted, physical activity has a major clinically significant beneficial effect on glycaemic control.
Current guidelines recommend that patients with type 2 diabetes should undertake at least 150 minutes per
week of moderate-intensity aerobic exercise, however this was achieved in only 38% of the cohort in the most
deprived SIMD quintile and 50% in the least deprived (Figure 39). Formal referral rates to physical activity
services were uniformly low (2%) across all deprivation quintiles, with minor variations across partnerships,
although it should be noted that informal signposting towards physical activity opportunities may numerically
outnumber recorded referrals (Figure 40).
Figure 39: Type 2 diabetic patients: recorded levels of physical activity, by deprivation quintile
Figure 40: Type 2 diabetic patients: referrals to physical activity services, by partnership
35
3.2.4 Clinical care
HbA1c is an indicator of average blood glucose concentration over the previous three months and provides a
population-level proxy for level of disease control. Higher average HbA1c levels correlate strongly with all-cause
mortality and cardiovascular disease risk. Overall, 18,760 (36%) of patients had HbA1c values of between 48
mmol/l and 59 mmol/l (commensurate with ‘good’ glycaemic control). There was a modest socio-economic
gradient, but little difference between partnership areas (Figures 40 and 41). There were major differences
between individual practices in the proportion of their cohort with HbA1C values within this range (Figure 44).
Figure 41: Type 2 diabetes: HbA1c status, by deprivation quintile
Figure 42: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by partnership area
36
Overall glycaemic control was poorer in black ethnic minority subgroup and also among those with no recorded
ethnicity; the latter may reflect gaps in structured, systematic care.
Figure 43: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by ethnic group
Figure 44: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by practice
37
3.3 Stroke/TIA
Key points
31,165 current patients were on the NHSGGC practices’ stroke/disease register, with equal distribution
between men and women. Around two thirds of patients were over 70, however almost 12,000 younger
adults in NHSGGC have this diagnosis, with premature stroke/TIA particularly concentrated in
disadvantaged areas. The vast majority of patients with stroke/TIA are white Caucasian.
The deprivation distribution of patients with stroke/TIA differed strikingly across partnerships, with
comparatively few patients in East Renfrewshire and East Dunbartonshire living in socio-economically
deprived neighbourhoods.
Exception coding provides some insights into the proportion of patients who were not sought for review
and the proportion of stroke/TIA patients who were exception coded was, together with COPD,
amongst the highest of all disease areas, which means that almost 1 in 5 (5,731; 18.4%) patients and their
carers did not receive the benefits of the LES CDM interventions.
Survivors of acute stroke are at a considerable risk of suffering additional cardiovascular events and
given the substantial evidence of smoking as a risk factor for first-ever stroke and ischaemic heart
disease, cessation of smoking is strongly recommended to reduce these risks. Unfortunately, 5221 (17%)
of the stroke/TIA cohort remain current smokers, reaching a prevalence of 24% in the most deprived
areas. Relatively few stroke/TIA patients were recorded as wanting to stop, with very small numbers of
referrals to services
A high proportion of stroke/TIA patients have functional problems which are highly amenable to
therapy, however recorded use of services was relatively low, although it should be noted that the full
range of relevant services is incompletely captured by available Read codes.
3.3.1 Rationale for indicators
Stroke and TIA are both manifestations of cerebrovascular disease, a disease which shares common risk factors
with CHD, including high blood pressure, high blood cholesterol, poor diet, obesity, smoking, physical
inactivity, excessive alcohol intake, diabetes and socio-economic deprivation. Its incidence and mortality rates
increase with age. The CDM programme aims to provide systematic coverage of the stroke and TIA patients
population with optimal lipid lowering therapy, monitor BP control, support patients with smoking cessation
and provide antithrombotic or anticoagulant therapy (dependent on the type of stroke); in combination, these
interventions reduce risk of recurrent stroke and also reduce mortality. Functional rehabilitation in patients
with specific disabilities also significantly reduces the odds of deterioration in personal activities of daily living.
3.3.2 Demographic characteristics
31,165 current patients were on the NHSGGC practices’ stroke/disease register in 2013/14, of whom 15,771 (50.6%)
were women. Around two thirds of patients were over 70, however it should be highlighted that almost 12,000
younger adults have this diagnosis and thus it should not be considered as an exclusively older person’s health
issue (Figure 45). As shown previously, premature chronic disease is particularly concentrated in disadvantaged
areas of NHSGGC, with early stroke in young adults a particularly challenging issue for families and services.
38
Figure 45: Stroke/TIA patients: age distribution
The vast majority of patients with stroke/TIA are white Caucasian (Figure 46).
Figure 46: Stroke/TIA patients: ethnicity
The deprivation distribution of patients with stroke/TIA differed strikingly across partnerships, with
comparatively few patients in East Renfrewshire and East Dunbartonshire living in socio-economically
deprived neighbourhoods (Figure 47).
39
Figure 47: Stroke/TIA patients: deprivation profile, by partnership area
3.3.3 Access to CDM programme
Exception coding in patients with stroke is, together with COPD, the highest of all disease areas, which means that substantial numbers of patients may not be receiving access to the enhanced CDM system supported by the LES. Overall, 5,731 (18.4%) patients were exception coded, for one or more of the reasons listed below:
Patient unsuitable 2,488
Informed dissent 2,155
Housebound 1,550
Lives in a nursing home 288
Failure to attend cardiac clinic 154
Long stay hospital inpatient 16 19% of stroke/TIA patients living in NHSGGC’s most deprived neighbourhoods were exception coded; this proportion declined slightly to 15% in quintile 5 (Figure 33). The proportion of exception coded diabetic patients was highest in South Lanarkshire (282 patients; 20% of cohort) and lowest in East Renfrewshire (291 patients; 15% of cohort) (Figure 48).
40
Figure 48: Stroke/TIA patients: exception coding, by deprivation quintile
Figure 49: Stroke/TIA patients: exception coding, by partnership area
3.3.4 Clinical care
Survivors of acute stroke are at a considerable risk of suffering additional cardiovascular events and given the
substantial evidence of smoking as a risk factor for first-ever stroke and ischaemic heart disease, cessation of
smoking is strongly recommended to reduce these risks. Unfortunately, 5221 (17%) of the stroke/TIA cohort
remain current smokers, reaching a prevalence of 24% in the most deprived areas (Figure 50)
41
Figure 50: Stroke/TIA patients: smoking status, by residential deprivation quintile
Relatively few stroke/TIA patients were recorded as wanting to stop, with very small numbers of referrals to
services (Figures 51 and 52).
Figure 51: Stroke/TIA patients who smoke: smoking cessation referrals, by deprivation quintile
42
Figure 52: Stroke/TIA patients who smoke: smoking cessation referrals, by partnership area
The relationship between alcohol consumption and cardiovascular risk is a complex one, with a J-shaped
association between alcohol consumption and ischaemic stroke; light to moderate alcohol consumption
protects against ischaemic stroke, but heavier consumption substantially increases risk. The relationship is
different for haemorrhagic stroke, which has a more linear relationship with alcohol consumption. Episodic
heavy drinking (binge drinking) appears to confer additional independent risks for all types of stroke, doubling
risk compared with non-binge drinkers. Current recommendations advise patients with stroke/TIA to drink no
more than 3 units of alcohol a day for women and 4 for men. This appears to be broadly the case for the vast
majority of NHSGGC’s stroke/TIA cohort, although recording of alcohol intake remains suboptimal (Figure 53).
Figure 53: Stroke/TIA patients: alcohol use
43
A high proportion of stroke/TIA patients have functional problems which are highly amenable to therapy, however recorded use of services was relatively low, although the full range of relevant services is incompletely captured by available Read codes.
Figure 54: Stroke/TIA patients: functional problems, by age group
Figure 55: Stroke/TIA patients: recorded use of services relative to scale of functional problems
44
3.4 Chronic Obstructive Pulmonary Disease (COPD)
Key points
Of the 35,299 patients with COPD, the majority (19,865; 56%) were female and over half were younger
than 70. The overwhelming majority of COPD patients were white Caucasian. The epidemiology of
COPD closely mirrors that of tobacco smoking, both being highly concentrated in areas with severe
socio-economic deprivation. Over half of NHSGGC’s COPD patients live in SIMD quintile 1
neighbourhoods.
Exception coding provides some insights into the proportion of patients who were not sought for review. In patients with COPD, over 6,000 (almost one in five) patients were exception coded, thereby losing the opportunity to benefit from the COPD LES. This proportion was similar across all deprivation quintiles, however there was substantial variability between different partnerships
Smoking cessation is the single most effective and cost-effective therapy that can be offered to COPD
patients. It improves outcomes at all stages of COPD and is the only evidence-based treatment proven
to prevent further deterioration of lung function. However, only 939 (8%) of smokers with COPD were
recorded as being ‘ready to stop’. This proportion was similar in all deprivation quintiles. Fewer than
half of these patients had a record of referral to a smoking cessation service, although the proportion
referred was highest in patients living in the most deprived SIMD quintile
In NHSGGC, pulmonary rehabilitation is offered to all people with COPD at MRC Grade 3 and above
who consider themselves functionally disabled by their condition. However, only around half of
patients in this category are referred, with considerable variation between partnerships and individual
practices
3.4.1 Rationale for indicators
COPD is a progressive long term lung disease that causes cough, breathlessness, nutritional disturbances and
muscle wasting. COPD prevalence is strongly socially patterned, closely correlated with smoking rates, which
are much higher in disadvantaged neighbourhoods. Morbidity and mortality from COPD in NHSGGC remain
high and are disproportionately increasing in women relative to men. The clinical goals of CDM for patients
with COPD are to slow disease progression, minimise symptoms, improve health status, prevent and treat
exacerbations and reduce the risk of dying from the disease. Although there is no ‘cure’ for COPD, smoking
cessation and long term oxygen therapy for those with respiratory failure reduce mortality. Medicines
optimisation, pulmonary rehabilitation in patients with more advanced disease (MRC Grades 3 and above) and
other therapies also improve other important patient outcomes, including unscheduled hospitalisation.
3.4.2 Demographic characteristics
Of the 35,299 patients with COPD, the majority (19,865; 56%) were female and the remaining 15,434 (43.7%)
male. Just over half are younger than 70 (Figure 56).
45
Figure 56: COPD patients: age distribution
The overwhelming majority of COPD patients were white Caucasian (Figure 57).
Figure 57: COPD patients: ethnicity recording & overview
The epidemiology of COPD closely mirrors that of tobacco smoking, both being highly concentrated in areas
with severe socio-economic deprivation. Over half (19,919; 56%) of NHSGGC’s COPD patients live in SIMD
quintile 1 neighbourhoods (Figure 58).
46
Figure 58: COPD patients: deprivation profile, by partnership area
3.4.3 Access to CDM programme
Exception coding in patients with COPD is high, with almost one in five patients exception coded, suggesting suboptimal access to the clinical interventions provided by the COPD LES. Reasons for exception coding in the 6,525 patients affected were:
Informed dissent 3,651
Patient unsuitable 2,310
Housebound 1,178
Lives in a nursing home 113
Failure to attend respiratory clinic 134
Long stay hospital inpatient 12 The proportion of COPD patients who were exception coded was similar across all deprivation quintiles, however there was greater variability between different partnerships (Figures 59 & 60).
47
Figure 59: COPD patients: exception coding, by deprivation quintile
Figure 60: COPD patients: exception coding, by partnership area
48
3.4.4 Clinical care
Smoking cessation is the single most effective and cost-effective therapy that can be offered to COPD patients. It improves outcomes at all stages of COPD and is the only evidence-based treatment proven to prevent further deterioration of lung function. Following smoking cessation, the annual decline in FEV1 is usually reduced, sometimes to the level of non-smokers. As previously indicated, the overwhelming majority of COPD patients are living in deprived circumstances (Figure 61).
Figure 61: COPD patients: smoking status, by residential deprivation quintile
Only 939 (8%) of smokers with COPD were recorded as being ‘ready to stop’. This proportion was similar in all
deprivation quintiles. Fewer than half of these patients had a record of referral to a smoking cessation service,
although the proportion referred was highest in patients living in the most deprived SIMD quintile (Figures 62
& 63).
49
Figure 62: COPD patients who smoke: smoking cessation referrals, by deprivation quintile
Figure 63: COPD patients who smoke: smoking cessation referrals, by partnership area
50
Recording of alcohol intake was relatively complete and the proportion of patients exceeding recommended
limits 5% overall, with little variation between areas (Figure 64).
Figure 64: COPD patients: alcohol use
The MRC dyspnoea scale is a well validated, clinically meaningful scale that quantifies disability resulting from
COPD. It extends from Grade 1 (not troubled by breathlessness except on strenuous exercise) to Grade 5 (too
breathless to leave the house, or breathless when dressing or undressing). Unfortunately, over one quarter of
COPD patients did not have a recorded MRC Grade. Of the remainder, the largest single category was Grade 2
(short of breath when hurrying or walking up a slight hill). The age distribution of patients was similar at each
MRC Grade (Figure 65).
Figure 65: COPD patients: MRC grade, by age group
51
Pulmonary rehabilitation is an important component of management of more advanced COPD. It relieves
dyspneoa and fatigue, improves emotional function and enhances patients' control over their condition. These
improvements are substantial and clinically significant. Pulmonary rehabilitation has been shown to improve
exercise capacity, reduce breathlessness, improve health-related quality of life and decrease healthcare
utilisation. In NHSGGC, pulmonary rehabilitation is offered to all people with COPD at MRC Grade 3 and above
who consider themselves functionally disabled by their condition. However, only around half of patients in this
category are referred, with considerable variation between partnerships and individual practices (Figures 66 &
67).
Figure 66: COPD patients: referral to pulmonary rehabilitation, by partnership area
Figure 67: COPD patients: referral to pulmonary rehabilitation, by practice
52
3.5 Left Ventricular Systolic Dysfunction (LVSD)
Key points
Diagnostic precision of Read coding: A separate, detailed audit undertaken within the local CDM
programme in 2013 identified considerable variability in Read coding for heart failure. This highlighted
two broad types of issues: firstly, the extent to which patients with heart failure were captured on any
heart failure register; and secondly, the validity and precision of documented subtypes of heart failure
diagnoses. This will not be further addressed here (separate report is available on request), but should
be borne in mind when considering the data presented. A separate piece of work is now being
undertaken in early 2015 to clean practice registers, make standardise secondary care discharge letters
and provide enhanced support to maintain accurate coding across the system in the future.
Of the 11,160 patients with LVSD, 6,936 (62.2%) were male and 4,224 (37.8%) female. The majority were
aged 70 years or more. Most patients had a record of their ethnic group and in most areas white
Caucasian ethnic subgroups accounted for well over 90% of the local LVSD cohort; South Glasgow was
a notable exception, where 9% of patients belonged to non-white ethnic groups. 4,876 (44%) LVSD
patients lived in areas of very high deprivation, although, as for other conditions, this was highly
variable across different partnerships
Exception coding provides some insights into the proportion of patients who were not sought for
review. Levels of exception coding were lower for LVSD than for other conditions within the CDM
programme; 1218 (10.9%) patients were exception coded, with higher proportions among more socio-
economically deprived patient subgroups and considerable variability between different partnerships
1,603 patients were current smokers. In keeping with the other chronic disease conditions, however, a
very small proportion of these (82; 5%) were assessed as ‘ready to stop’, with a further drop-off in the
proportion of these patients who actually received a referral and considerable variability at local level
Functional capacity assessment is a central component of clinical care for patients with heart failure. In
NHSGGC, however, over one third of LVSD patients within the primary care CDM programme had no
recorded NYHA class, although this proportion varied from 20 to 49% across different partnerships.
Therapeutic management requires more detailed analysis and it is conceivable that the anomalies noted
below may be partly a result of inaccurate disease coding (see above). 4,600 (41%) patients did not
appear to have been recently (ie in the previous three months) prescribed a beta blocker and 3,426 (31%)
patients appeared to have been prescribed neither an ACE-I nor an ARB in the same period. Over a
longer period of 12 months, 3,083 (28%) of patients appeared not to have been prescribed a beta blocker
and 2,185 (20%) did not appear to be receiving either an ACE-I or ARB. Overall, 94% of the entire cohort
was prescribed at least one of the listed cardiac drugs, however this proportion showed marked
variation across NHSGGC practices.
3.5.1 Rationale for indicators
Heart failure (impaired efficiency of the heart as a pump) affects 1-2% of the adult population in the UK, rising to a prevalence of 10% in patients aged 70 or older. Left ventricular systolic dysfunction (LVSD) is the commonest underlying cardiac abnormality and outcomes for patients with this type of heart failure have improved enormously in recent years as a result of more systematic use of ACE inhibitors and beta-blockers, both of which have been shown to increase both duration and quality of life. Cardiac rehabilitation also improves functional capacity and quality of life. The CDM programme in NHSGGC is intended to provide more structured care for this patient group.
3.5.2 Demographic characteristics
Of the 11,160 patients with LVSD, 6,936 (62.2%) were male and 4,224 (37.8%) female. The majority were aged
70 years or more (Figure 68).
53
Figure 68: LVSD patients: age distribution
Documentation of the underlying aetiology was poor; this information was missing (and conceivably unknown)
in 4,359 (39%) patients (Figure 69). Of the remainder, the vast majority of cases were attributed to ischaemic
heart disease.
Figure 69: LVSD patients: aetiology
Most patients had a record of their ethnic group and in most areas white Caucasian ethnic subgroups accounted
for well over 90% of the local LVSD cohort; South Glasgow was a notable exception, where 9% of patients
belonged to non-white ethnic groups (Figure 70).
54
Figure 70: LVSD patients: ethnicity
Socio-economic disadvantage increases incidence of heart failure by 30-50% and is also associated with higher
hospital readmission rates and shorter survival. In NHSGGC, 4,876 (44%) LVSD patients lived in areas of very
high deprivation, although, as for other conditions, this was highly variable across different partnerships
(Figure 71).
Figure 71: LVSD patients: deprivation profile, by partnership area
55
3.5.3 Access to CDM programme
Levels of exception coding were lower for LVSD than for other conditions within the CDM programme; 1218 (10.9%) patients were exception coded. Reasons for exception coding in these patients were:
Housebound 533
Patient unsuitable 417
Informed dissent 330
Lives in a nursing home 63
Failure to attend cardiac clinic 46
Long stay hospital inpatient 7 The proportion of LVSD patients who were exception coded was higher among more socio-economically deprived patient subgroups and there was also major variability between different partnerships (Figures 72 & 73).
Figure 72: LVSD patients: exception coding, by deprivation quintile
Figure 73: LVSD patients: exception coding, by partnership area
56
3.5.4 Clinical care
Although no prospective studies have quantified the effects of a smoking cessation intervention on outcomes
in patients with heart failure, observational data support the association between continued smoking and both
increased heart failure mortality and increased rates of hospital admissions due to worsening heart failure
compared with non-smokers. Accordingly, every effort should be made to support LVSD patients with smoking
cessation. The proportions of current smokers declined with each SIMD quintile (Figure 74).
Figure 74: LVSD patients: smoking status, by residential deprivation quintile
In keeping with the other chronic disease conditions, of the 1603 smokers, a very small proportion (82; 5%)
were assessed as ready to stop and there was a further drop-off in the proportion of these patients who
actually received a referral, with considerable variability at local level (Figures 75 & 76).
Figure 75: LVSD patients who smoke: smoking cessation referrals, by deprivation quintile
57
Figure 76: LVSD patients who smoke: smoking cessation referrals, by partnership area
Alcohol intake was not recorded in 4,272 (38%) patients. Of the remainder, few were consuming above the maximum recommended alcohol intake for their gender (Figure 77).
Figure 77: LVSD patients: alcohol use
Functional capacity is a powerful important predictor of prognosis in heart failure; the New York Heart
Association (NYHA) functional class is a central component of clinical care for patients with heart failure. It
ranges from Class I (known cardiac disease, but no symptoms or limitation in ordinary physical activity) to
Class IV (severe limitations; symptoms at rest and mostly bedbound). In NHSGGC, however, 4,044 (36.2%) of
LVSD patients within the primary care CDM programme had no recorded NYHA class, although this
proportion varied from 20 to 49% across different partnerships (Figure 78).
58
Figure 78: LVSD patients: NYHA class, by partnership area
Angiotensin-converting Enzyme Inhibitor (ACE-I) pharmacotherapy significantly reduces mortality and
hospitalisation rates in patients with chronic heart failure. Angiotensin II receptor blockers (ARBs) mimic the
effect of ACE inhibitors and are generally used in patients who cannot tolerate an ACE inhibitor, usually due
to cough. Beta blocker therapy also reduces both all-cause and cardiovascular mortality and is strongly
recommended for all patients with heart failure due to left ventricular systolic dysfunction. SIGN guidelines
currently recommend that LVSD patients in all NYHA functional classes should be started on both beta blocker
therapy as soon as their condition is stable, as well as either an ACE-I or ARB. There is also evidence that
patients with moderate to severe heart failure due to LVSD may receive benefit from spironolactone.
Prescribing of this group of cardiac therapies (ACE-Inhibitors, ARBs, beta blockers, loop diuretics and/or
spironolactone) in the preceding 12 months in the LVSD cohort is shown in Figures 79-81. This showed a
predictable rise in number of co-prescribed pharmacotherapies with increasing NHYA class (Figure 79).
Specific detail of the different combinations of drugs prescribed in the most recent three months is shown in
Table 2. It is obviously not appropriate to comment in detail on the types of drug combinations in the absence
of more detailed clinical information, however it is noteworthy that 4,600 (41%) patients did not appear to have
been recently (ie in the previous three months) prescribed a beta blocker and 3,426 (31%) patients appeared to
have been prescribed neither an ACE-I nor an ARB in the same period. Over a longer period of 12 months,
3,083 (28%) of patients appeared not to have been prescribed a beta blocker and 2,185 (20%) did not appear to
be receiving either an ACE-I or ARB. Overall, 94% of the entire cohort was prescribed at least one of the listed
cardiac drugs, however this proportion showed marked variation across NHSGGC practices (Figures 80 & 81).
59
Figure 79: LVSD patients: cardiac therapy prescribed within last 12 months, by NYHA Class
60
Table 2: Drug therapy prescribed in last 3 months, by NYHA Class
No of Drugs
Drug combination
No NYHA class
recorded
Class 1 Class 2 Class 3 Class 4 Total
No drugs prescribed in period (subtotal) 931 267 486 159 19 1,862 1 Spironolactone only 0 0 0 0 0 0
1 Loop diuretic only 197 46 128 47 9 427
1 Beta blocker Only 180 114 142 20 0 456
1 ARB Only 60 67 72 10 0 209
1 ACE Inhibitor Only 297 252 222 28 1 800
1 drug prescribed in period (subtotal) 734 479 564 105 10 1,892 2 Spironolactone & diuretic 19 5 23 22 3 72
2 Spironolactone & beta blocker 0 0 0 1 0 1
2 Spironolactone & ARB 0 0 0 0 0 0
2 Spironolactone & ACEI 0 0 3 2 0 5
2 Diuretic & beta blocker 205 67 159 67 4 502
2 Diuretic & ARB 66 52 115 19 2 254
2 Diuretic & ACEI 270 113 281 67 6 737
2 Beta blocker & ARB 116 129 144 18 3 410
2 Beta blocker & ACEI 649 648 513 53 4 1,867
2 ARB & ACEI 7 4 3 1 0 15
2 drugs prescribed in period (subtotal) 1,332 1,018 1,241 250 22 3,863 3 Spironolactone, diuretic & beta blocker 33 13 28 29 3 106
3 Spironolactone, diuretic & ARB 8 10 11 8 0 37
3 Spironolactone, diuretic & ACEI 58 25 53 31 6 173
3 Spironolactone, beta blocker & ARB 0 0 1 0 0 1
3 Spironolactone, beta blocker & ACEI 1 0 7 2 0 10
3 Spironolactone, ARB & ACEI 0 0 0 0 0 0
3 Diuretic, beta blocker & ARB 150 92 197 49 3 491
3 Diuretic, beta blocker & ACEI 518 327 638 177 3 1,663
3 Diuretic, ARB & ACEI 10 1 8 2 1 22
3 Beta blocker, ARB, ACEI 14 9 8 2 0 33
3 drugs prescribed in period (subtotal) 792 477 951 300 16 2,536 4 Spironolactone, diuretic, beta blocker & ARB 42 26 94 33 3 198
4 Spironolactone, diuretic, beta blocker & ACEI 187 113 288 124 1 713
4 Spironolactone, diuretic, ARB & ACEI 2 0 0 0 0 2
4 Spironolactone, beta blocker, ARB & ACEI 0 0 0 0 0 0
4 Diuretic, beta blocker, ARB & ACEI 19 12 41 7 0 79
4 drugs prescribed in period (subtotal) 250 151 423 164 4 992 5 Spironolactone, diuretic, beta blocker, ARB & ACEI 5 1 8 0 1 15
5 drugs prescribed in period (subtotal) 5 1 8 0 1 15
GRAND TOTAL
4,044
2,393
3,673
978
72
11,160
61
Figure 80: LVSD patients: overview of drug therapy over preceding year, by number of agents
Figure 81: Percentage of practice LVSD cohort receiving one or more therapies
62
IV Conclusion
In summary, this report provides local intelligence on the scale and clinical performance of the CDM programme in each of the five disease areas. Specific topics are highlighted for a possible future improvement focus; these include addressing variations in access to the programme, new, locally tailored approaches to smoking cessation support and quality improvement initiatives focusing on the numerous areas of clinical variation that are highlighted in this report. Overall, greater emphasis is required on optimising coverage and delivery of clearly defined, evidence based interventions that hold the greatest potential to change clinical outcomes. Investment of dedicated clinician time in person-centred consultations, alongside workforce development to ensure that the most effective use is made of that time, will both help to drive up performance. ‘Whole system’ supportive infrastructure must continue to work towards a well organised, structured approach to community based care for chronic disease in NHSGGC.
V Appendix
CDM LES Review Final report, December 2013:
CDM ENHANCED
SERVICES REVIEW_161213.pdf