The problem
In East Sussex we have a very elderly population and a high prevalence of recognised heart failure, but we expect that true prevalence is even higher. For years, I've been trying to set up a service to encourage us to look for heart failure.
We had previously worked through the myocardial infarction register, of people without heart failure who had a history of a heart attack, and found we were picking up far more heart failure through looking at notes than by examining scans, so we got a feel there was lots of untapped disease out there.
Even if these patients were not yet symptomatic, they were at high risk of health problems later on.
What we did
Our community cardiology service was set up in April 2009 under practice-based commissioning, serving approximately 27,000 people through the Hailsham cluster.
The service now runs three clinics a week covering a population of 115,000. There are 80-90 referrals a month, of which about one-third are suspected heart failure. The service currently employs three specialist nurses, three physiotherapists and one GP (myself).
The service design and pathways were put together by a GP commissioner based in Hailsham, Dr Matthew Jackson, and a local cardiologist based at Eastbourne Hospital, Dr Guy Lloyd, and I took on the running of the service with the help of a nurse and cardiac physiotherapist.
The service follows NICE guidelines and pathways. We use B-type natriuretic peptide (BNP) testing to assess patients with suspected heart failure and make sure patients are referred from a doctor's opinion as well as an echocardiogram.
However, if a patient is suspected of having undiagnosed ischaemic heart disease they are triaged when they first arrive and go straight to the acute trust.
All patients without a history of MI are required to have BNP testing. Patients with normal BNP are not referred unless other causes of symptoms are excluded and the GP still suspects heart failure.
Patients with intermediate BNP levels will have a GPSI opinion and echocardiogram within six weeks and 100% of those with very high BNP levels or a history of MI have an opinion and echocardiogram in two weeks.
Once a patient is diagnosed with heart failure and left ventricular systolic dysfunction (LVSD), they are initiated on appropriate medication.
All heart failure patients are given the diagnosis and an initial personalised care plan, then referred to a heart failure nurse specialist for personalised care planning and up-titration of medication for LVSD if necessary.
The use of BNP testing was implemented across East Sussex in November 2010, and is now established in the heart failure diagnostic pathway in line with NICE guideline CG108.
I have also got involved with a clinician-led quality improvement programme called Enhancing Quality (EQ), which I thought was a good way to go beyond the QOF, especially for heart failure.
The importance of evidence-based clinical guidelines is well understood, but neither NICE nor the QOF provides a mechanism to drive and monitor achievements against their standards.
EQ is a programme that came from Advancing Quality in north-west England, and works by measuring patients and care in high-volume or high-cost pathways. It validates clinical coding with clinicians, validates the population through SUS data, uses clinical information owned by clinicians and tracks outcomes using the same populations.
Results are benchmarked at organisational level, which helps to develop targets for the future, and also at local and individual level, which helps the development of better-focused clinical teams in each area. By adopting EQ outcome measurement we had an opportunity to make a significant difference to the health of the local population in addition to boosting QOF points.
What we learned
With increased diagnosis and a pathway based on NICE and EQ measures, the number of patients referred to heart failure nurse specialists has increased significantly, so a further QIPP programme recruited additional nurses to ensure that all patients with heart failure, of whatever cause, could be cared for by a specialist.
These nurses bridge the primary-secondary divide and see patients prior to discharge with a new or previous diagnosis of heart failure, and then follow them out into the community for a period of about four weeks.
Prevalence is going up now as detection improves with increased access to diagnostics.
With our extra heart failure nurses we should be easily coping with work, but because so many more patients are being diagnosed – and being given written, personal care plans – they are still working flat out to cope.
What we found
To verify the safety of our BNP testing service, I audited patients between November 2010 and April 2011 with normal natriuretic peptides to make sure we were not missing significant conditions.
Of 341 patients tested, 42 were referred on, three of whom had heart failure, one who had LSVD and eight of whom had other significant abnormalities.
None were admitted and of three deaths in the group, none were fatal cardiac incidents.
An audit has shown that using the BNP test, over the last year nearly 700 patients with suspected heart failure have been spared referral for specialist opinion and echocardiography on our local tariffs for cardiology and care of the elderly.
BNP testing alone equates to an annual saving of £150-270,000, against an annual QIPP savings target for cardiology of £700,000.
Because EQ operates across Kent, Surrey and Sussex, we are able to monitor outcomes on a wider scale and compare different providers.
One of the EQ measures is the up-titration of ACE inhibitors, angiotensin receptor blockers and ß-blockers.
Initially, a snapshot comparison was made between 414 patients being managed by GPs across nine different practices and 506 patients under the care of heart failure specialist nurses in three counties.
Our analysis found the proportion of patients on the maximum licensed dose was 8.1 percentage points higher with heart failure nurses than GPs for ACE inhibitors/ARBs and 12.9 percentage points higher for ß-blockers (see box, below).
|
Up-titration of heart failure medication Proportion of the maximum licensed dose |
||
|---|---|---|
|
GP registers (%) n = 414 |
Heart failure nurses (%) n = 506 |
|
| ACE inhibitors/ARBs | 49.5 | 57.6 |
| ß-blockers | 29.0 | 41.9 |
Improvement targets have been established using CQUIN funding for heart failure specialist nurses to further up-titrate patients on their caseloads, and measurement has been in place for three months to track the doses of ACE inhibitors and ß-blockers.
Some 750 patients who are either newly diagnosed or discharged from hospital are being tracked in the first three months, with the average dose of ACE inhibitors being 58.3% and ß-blockers being 37.3%.
The future
In April, the service will cover the whole catchment area for the Eastbourne and Hailsham clusters – around 150-170,000 patients – and recruit two more nurses and two more (part-time) GPs.
The locally implemented community cardiology service plan has now been sent to the board of the local clinical commissioning group to consider embracing the EQ measures for heart failure management and personalised care planning into the QIPP strategy for 2012/13. We are currently waiting for a formal reply.
Dr Richard Blakey is a GP in Hailsham, East Sussex, a GPSI in cardiology, and the community heart failure lead on the Enhancing Quality programme, NHS Kent, Surrey and Sussex
More information about the use of EQ measures in NHS Kent, Surrey and Sussex is available at www.enhancingqualitycollaborative.nhs.uk
