Read our end of year newsletter and learn about some of NICOR’s important work and achievements in 2018, such as the launch of our new website, the publication of our report and our work with ambulance data.
Category Archive: General
Report out today highlights progress in cardiovascular care and makes recommendations for improvement
The National Cardiac Audit Programme’s annual report details key information about the safety and clinical effectiveness of cardiovascular services, and also patient outcomes in England and Wales. The report from the National Institute for Cardiovascular Outcomes Research (NICOR) recognises areas of clinical excellence that can be adopted across the NHS, identifies areas where care falls below expected standards and makes 16 important recommendations to improve patient outcomes.
Professor John Deanfield, Director of NICOR, explains: “This report is the first National Cardiac Audit Programme report, bringing together the 6 major national cardiovascular audits for the first time in a single report. The programme has analysed data from over 300,000 patients. This report has been supported by UCL Partners and includes the results of five of these audits, covering the fields of Congenital Heart Disease, Heart Attack, Angioplasty, Adult Surgery and Heart Failure. The results of the Cardiac Rhythm Management audit will be presented later in a separate report. Hospitals are provided with their own data for each metric and can see how they compare with others. These results help determine national quality improvement aims for clinicians, service managers and commissioners.”
The full analyses, including hospital level data for all the sub audits, and a summary of the key messages and recommendations, can be accessed via NICOR’s website https://www.nicor.org.uk/national-cardiac-audit-programme/ from today, Thursday 22 November.
Treatment for heart failure patients in England and Wales continues to improve according to the latest National Heart Failure Audit, with more people receiving key tests and vital prescriptions and seeing specialist staff.
Acute heart failure necessitating hospital admission is a life threatening condition. The quality of care including specialist involvement during an admission, determines the immediate and long-term outcomes including likelihood of survival. Yet while the audit reports several improvements, it also found that the quality of care varies from one hospital to another, and within a hospital, between the specialist and other wards.
The audit is commissioned by the Health Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patients Outcomes Programme (NCAPOP).
The latest National Heart Failure (HF) Audit is the largest to date and is based on 66,695 admissions to hospitals in England and Wales between April 2015 and March 2016. This represents 82% of HF admissions as the patient’s primary diagnosis in England and 77% in Wales.
The National HF Audit monitors the treatment and care of people with an unscheduled admission to hospital who are discharged with a primary diagnosis of heart failure. This is the 9th National HF Audit report which reports data from 137 NHS Trusts in England and 6 Health Boards in Wales.
- During hospital admissions more than 90% of patients received an echocardiogram, a key diagnostic test. However, rates are higher for those admitted to cardiology (96%) than general medical (85%) wards. Specialist input irrespective of the place of admission is associated with higher rates (95%) of echocardiography.
- The prescription of key disease-modifying medicines for patients with HF and a reduced left ventricular ejection fraction (HF-REF) has increased, including beta- blockers (87%) and mineralocorticoid antagonists (53%); treatments that are both life-saving and inexpensive.
- Prescription rates for all three key disease modifying medications [angiotensin converting enzyme inhibitors (ACEI), beta-blockers (BB) and mineralocorticoid (aldosterone) receptor antagonist (MRA)] for patients with HF-REF has increased from 35% to 53% for those admitted to Cardiology wards over the last six years.
- Irrespective of the place of admission, 47% of patients with HF-REF seen by a member of the specialist HF team as an inpatient, were prescribed all three disease modifying drugs, a key performance indicator (KPI). This has increased from 45% in 2014-15, albeit with considerable room for further improvement.
- The number of patients seen by HF specialists remains high at 80% in 2015-16. In particular, HF nurses saw more HF patients admitted onto general medical wards (33%) than in 2014-15 (24%). This is important as specialist care improves mortality.
- The mortality of patients hospitalised with heart failure is significantly lower in 2015-16 at 8.9% compared to 9.6% in 2014-15. However, mortality remains high and there are large variations in mortality amongst hospitals.
- HF mortality rates in hospital are better for those admitted to cardiology wards.
- If the patients identified within this audit cycle as having HF-REF, who left hospital on none of the three disease modifying drugs had been prescribed all three, then upwards of an additional 212 patients would likely have been alive at the time of census. With more comprehensive prescription and dose optimisation across the audit there is the ability to prevent numerous additional deaths.
Professor Theresa McDonagh, Clinical Lead for Cardiology and Heart Failure at King’s College Hospital, London and the HF Audit Clinical Lead said, “These results from our National Audit, are encouraging but leave room for further improvement. For the first time we have seen a small improvement in mortality in hospital, at 30 days and at one year. Hopefully we are now beginning to see the effects of better management of Heart Failure in hospital. We know how to diagnose it, investigate it and (for the majority of patients with reduced ejection fraction), we have effective treatments. Specialist care in hospital matters. Getting onto the correct drugs matters and coordinated specialist care post discharge matters. There is still much to do! The audit provides the data to allow health care providers to engineer change to deliver better care.”
Dr Suzanna Hardman, Consultant Cardiologist and Whittington Health HF lead said, “The audit provides a wealth of hospital specific data alongside stark overall messages and has the potential to drive improvements in the quality of care. We have seen this in the most recent cycle with reductions in inpatient and subsequent mortality, attributed to early access to diagnosis with HF specialist care involving cardiologists and HF nurses, the prescription of disease modifying drugs and HF specialist follow up within two weeks of leaving hospital. But this pattern of care, which follows the most recent NICE guidance, and related standards, is still not accessed by all. This failure to implement current guidance continues to contribute to avoidable premature deaths. Variations in care both within a hospital and between hospitals are reported. It is time to ensure that all HF patients have a higher priority and timely access to the specialist unit and all that follows”.
The report authors also recommend all services dealing with heart failure patients (virtually all hospitals), and those commissioning HF services, study these findings and develop robust pathways where all patients are seen by a specialist who supervises their medication, both in hospital and, especially, on discharge and on review. Otherwise these patients will continue to experience excess readmission and mortality, they warn.
Further evidence of effective treatment for Heart Attack
The latest Myocardial Ischaemia National Audit Project (MINAP) report, published today, contains information about the care provided to 85,000 people with heart attack by 13 ambulance services and 212 hospitals in England, Wales and Northern Ireland. It demonstrates sustained high quality care in key indicators for heart attack patients, identifies areas for further improvement and continued vigilance, and also highlights the serious impact of smoking on the age of onset of heart attack.
Commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme, the MINAP report analysed care between April 2015 and March 2016. Participation of nearly all acute hospitals allows us to provide a reliable representation of the treatment of heart attack across the country, enabling clinicians, clinical leaders/managers and commissioners to assure the quality of care provided, and to plan and implement quality improvement initiatives that should improve the experience of patients and lead to better outcomes.
Treatment for Heart Attack
Immediate Primary PCI (Percutaneous Coronary Intervention) at a specialised interventional hospital is established as best practice for re-opening the blocked arteries that cause heart attack. Almost every patient (99%) in England and Northern Ireland who receives reperfusion therapy are now offered primary PCI. This was similar last year in England, but represents an increase (from 92%) in Northern Ireland. In Wales the rate of primary PCI is 86%, up from 80% in 2015, as more centres establish PCI capability.
Over the last decade there has been a significant improvement in the timeliness of such treatment. A key performance measure, the ‘call-to-balloon’ time (CTB), is the interval between the call for professional help (ambulance) and the start of primary PCI treatment. In 2015/16, 80% of patients were receiving primary PCI in hospital within 150 minutes of alerting the emergency services, with a little over half getting the treatment within 120 minutes. The MINAP audit found that 90% of patients are treated with primary PCI within 90 minutes of arrival at hospital – the equivalent figure being 52% in 2004/05.
However, there has been a slight lengthening of the median CTB time over the last 5 years. Given that median in-hospital treatment times have improved over this period, it follows that lengthening of the time spent outside hospital following a call for help has resulted in increasing CTB. The median call to door time has increased, year-on-year, by 10 minutes between 2010/11 and 2015/16.
Dr Clive Weston (Consultant Cardiologist & MINAP clinical lead) said:
“MINAP provides tangible evidence of hospital performance across key measures in the treatment for heart attack. For those requiring reperfusion, hospitals are consistently providing rapid treatment once the patient arrives at hospital. The small increase in the overall time to treatment appears to reflect a longer interval between a call for help and arrival at hospital. This may reflect a “roll-out” of primary PCI services during the last few years to more rural areas, with corresponding increased distance and transport times between home and hospital. It might also reflect changes in the categorisation of urgent 999 ambulance calls from people reporting symptoms of possible heart attack. Leaders of Ambulance Trusts should continue to monitor the effect of new types of response to emergency calls to ensure an efficient use of their resources and the provision of appropriate and equitable care to all that require their services, while assuring the timeliness of care for patients with heart attack.”
For those patients whose heart attacks do not require immediate PCI, there has been a steady improvement in care. In line with key recommendations, 96% of patients are assessed by a cardiologist compared with 90% in 2011; 57% are now admitted to a cardiac ward compared with 49% in 2011, and 84% of patients have access to a diagnostic coronary angiogram (compared with 68% in 2011) to determine whether PCI or cardiac surgery is required.
However, the delay from admission to angiography in these patients has not improved. For those admitted directly to hospitals that are capable of providing on-site angiography, 17.5% received an angiogram within 24 hours; 53% within 72 hours; 66.3% within 96 hours. In 2010/11 the equivalent figures were 21% within 24 hours, 55% within 72 hours and 67% within 96 hours.
Dr Weston commented: “Centres have an opportunity to provide more timely treatment, which may lead to shorter lengths of stay, reducing the burden on the health system. Recognising the need to improve this aspect of care, NHS England is introducing a Best Practice Tariff for angiography in this type of heart attack in the 2016-17 financial year. Participating hospitals will receive a higher reimbursement for service where at least 60% of all patients receive angiography within 72 hours.
Recommendations from the Report
The Myocardial Ischaemia National Audit Project (MINAP) measures the performance of hospitals that treat heart attack in the UK against best practice. The 15th annual report covers 94,800 patient episodes, of which 85,123 had a final diagnosis of heart attack (myocardial infarction).
The MINAP provides valuable information on the performance of hospitals on an individual level while also having the scope to illustrate performance trends on a national scale. This wealth of data allows Medical Directors to identify areas for improvement, to effect change within their trust; while giving direction to commissioners and policy makers to implement initiatives on a regional or national scale, leading to better patient outcomes.
We should seek to continue an open dialogue with the general public, to increase the awareness of the risk factors for heart attack, and most importantly, to increase recognition of the early symptoms of heart attack so that care can be given sooner and a better outcome achieved.
A group of clinical experts, led by Professor Huon Gray, National Clinical Director for Heart Disease, NHS England, released a national framework to improve the care of people following an out-of-hospital cardiac arrest.
‘Resuscitation to Recovery,’ The newly published report provides a single consensus on the most effective care pathway when responding to out-of-hospital cardiac arrest (OHCA).
NICOR welcomes the publication of this National Framework, which is endorsed by over 20 medical and professional societies.
The report highlights the extent of OCHA in the community, where the survival rate is fewer than 1 in 10 in the UK.
Recommendations from the report address the need for greater collaboration between all that provide care, be it clinical networks, emergency services, A&E staff, first responders, and the general public.
Professor Huon Gray, National Clinical Director for Heart Disease, NHS England, said:
“Thousands of deaths from cardiac arrests could be prevented every year, but we need to work with the public, the emergency services and hospitals in order to achieve this.
“This new guidance recommends a pathway of care for a patient, from the moment they’re found collapsed, to their recovery in hospital and subsequent rehabilitation.
“Currently, there is significant variation in treatment around the country so it is vital that we provide all people with the best possible chances of survival, wherever they live. This report offers the recently established Urgent & Emergency Networks a blueprint for how this could be achieved.”
NICOR are pleased to announce that Barts Health has been awarded the contract for the National Cardiac Audit Programme (NCAP). This follows successful negotiations with HQIP for the 2017-20 National Cardiac Audit contract extension. The programme will be hosted at the Barts Heart Centre, one of Europe’s largest clinical cardiac treatment centres. Quality Improvement will focus heavily in our new programme of work and we will be working closely with UCL Partners, an organisation that has successfully delivered improvement programmes. We will also have continued links with UCL via the Department of Statistical Science who will be providing statistical oversight, advice and input into the development of risk models.
The transition of the current audit programme to Barts Heart Centre from UCL is due to take place on 1 July 2017. We will be in touch with more information and details of new contacts shortly. Please note as we are already situated at Barts we do not anticipate any disruption to the data collection service.
The year ahead will be an exciting time for NICOR, and we very much look forward to working with Barts Health, UCLP and UCL.
NICOR collects data and produces analysis to enable hospitals and healthcare improvement bodies to monitor and improve the quality of care and outcomes of cardiovascular patients.
We have produced a newsletter with highlights of 2016 and looking forward into 2017.
NICOR has written the ‘Best Practice Tariff Reporting Guidance: Using National Audit Data to Develop Validation Reports (NHFA and MINAP)’ to assist hospital trusts to produce summary reports to facilitate commissioner validation of the Heart Failure Best Practice Tariff and the NSTEMI Best Practice Tariff.
With Immediate Effect, NICOR are no longer able to share derived life status data with any third party
Following discussions between HQIP, the data controller and funder for our National Cardiovascular Clinical Audits, NHS Digital and NICOR we regret to advise you that the NHS Digital position on sharing derived life status data, for some inexplicable reason, has changed. With immediate effect, NICOR are no longer able to share derived life status data with any third party. This has implications for all data access requests that have:
1) been approved by HQIP and NICOR but still to be released and
2) for all new applications.
Until the current situation is resolved we can only process data access requests for data items collected as part of the audit. In terms of life status this is limited to in-hospital deaths as reported by the hospital. Until this issue is resolved, you may contact NHS Digital direct, via the following link, to discuss your requirements for linkage to life status, with NHS digital acting as the trusted third party: http://content.digital.nhs.uk/media/19239/DARS-products-and-services/pdf/DARS_Products_and_services.pdf
NHS Digital will also be able to advise you of the fee that they charge for death data, its linkage and other services that they offer.
If you have submitted a data application request to NICOR would you please advise Anthony Bradley at NICOR by email (firstname.lastname@example.org) regarding what action you would like to take about your application, whether you would like to:
1) put your application on hold until the situation is resolved,
2) revise your application and limit life status to hospital reported deaths or
3) Withdraw your application.
We apologise for any inconvenience and delays this may cause your project. However, although we are working with HQIP and NHS Digital to resolve this issue, this decision is out of our hands and undoubtedly will take some time to resolve.
|Professor John Deanfield||Professor Chris Gale|
|Director of NICOR||Co-Chair, NICOR Research Committee|
NICOR (The National Institute for Cardiovascular Outcomes Research) collects patient information from hospitals across the UK to try and improve the quality of care and outcomes for patients that have heart problems and treatments. These include adult heart surgery, heart attack, heart procedures, heart devices (for example pacemakers), heart failure and congenital heart surgery.
NICOR publishes reports every year from each of these areas and wants to ensure that it is providing information to patients in a meaningful and accessible way that is useful to them and their families. The NICOR team wants your help to improve the information it provides for patients and the public and this is the reason they would like you to join them at their Patient and Public Open Day on the 8th of May.
The Open Day will allow you to find out what NICOR do and how you can get involved in their work. The Patient and Public Open Day will be a great opportunity to meet the NICOR team and for us to hear your views and experiences. The NICOR team wants patients and carers, relatives and friends of those with heart problems, to join them and they don’t expect you to have a deep understanding of the clinical detail, just a keen desire to improve heart care and reporting.
Event: NICOR Patient and Public Open Day
Date: 8th of May 2014
Venue: 3rd Floor, 170 Tottenham Court Road, W1T 7HA
All travel expenses will be paid for and lunch and refreshments will be provided for those who are invited to attend.
If you would like to Register your Interest for this event or find out more, please contact Carol Porteous, NICOR Patient and Public Engagement Co-ordinator via e-mail: c.porteous [at] ucl.ac.uk or call: 0203 108 3895
The NICOR Patient and Public Open Day has been supported by a bursary from the UCL Public Engagement Unit.