Very proud that our National Cardiac Audit Programme Annual Report for Patients and the Public 2019 was commended by the Healthcare Quality Improvement Partnership (HQIP) in their Richard Driscoll Memorial Award which celebrates excellence in patient and public engagement in clinical audit. Read it here
Category Archive: General
The National Cardiac Audit Programme’s 2019 annual report (2017/18 data) details key information about cardiovascular services and patient outcomes in England and Wales. The report launched today by the National Institute for Cardiovascular Outcomes Research (NICOR), the national cardiac audit provider hosted at Barts Health NHS Trust, also highlights quality improvement opportunities by recommending actions for clinicians, service managers and commissioners of healthcare services.
Nationally the report shows that there has been particular progress in areas relating to the specialist care of congenital heart disease, heart failure and heart attack patients in the last few years.
* The overall rate of antenatal detection of fetal cardiovascular abnormalities which require intervention in the first year of life has risen to over 50%, with particularly good improvements in complex conditions. The report suggests reviewing staffing levels, the availability of the necessary ultrasonography equipment and ensuring that obstetric sonography staff are receiving appropriate education and training.
* 96% of patients admitted with NSTEMI (lower-risk) heart attacks and 82% of those admitted with heart failure were seen by specialist teams in 2017/18 (all STEMI (high-risk) heart attack patients undergoing emergency treatment are necessarily managed by interventional cardiologists on admission to hospital). Hospitals are recommended to ensure that all such patients have equal access to specialist care, either by admitting more patients to a cardiology ward or by using specialised nursing cardiac ‘outreach’ teams to support patients on other types of wards.
The report paints a more challenging picture of timeliness of care, with large variations between hospitals for time to treatment of heart attacks with angioplasty (PCI) and coronary artery bypass graft surgery, as well as diagnosis of non-emergency heart attack cases by angiography.
* The median ‘call-to-balloon’ time to treatment of heart attacks with emergency percutaneous coronary intervention (primary PCI) has increased by 9 minutes over the last 3 years. There are also sizeable variations between hospitals in the proportion of patients that undergo treatment within 60 minutes of admission. There are Quality Improvement actions for hospitals, ambulance services and STPs/local health systems to address this, particularly around the logistics of admitting patients. Patients themselves can assist by calling for an ambulance rather than attempting to get themselves to hospital.
* Times to coronary artery bypass graft (CABG) surgery have not improved significantly at a national level. Just over a third of patients have the procedure within 7 days of the diagnostic angiogram. Hospitals are advised to ensure that at least 75% of patients requiring urgent CABG receive this treatment within 7 days of the angiogram which, in most circumstances, implies the patients should undergo the procedure as an in-patient.
Geographical variation is also apparent when considering whether evidence-based treatment (such as that supported by national and international guidelines) is delivered equitably to patients. This is marked in the case of heart failure patients being discharged on the recommended package of three medicines. The situation is more encouraging in the case of percutaneous coronary interventions. Advances in practice such as radial access and the use of modern drug-eluting stents have meant that treatment is safer and more effective. There has been a rise in elective PCI performed as a day-case.
* Well over half of hospitals are not achieving the target of offering the triple package of heart failure medicines to at least 60% of patients. These hospitals should especially look to increase the use of mineralocorticoid receptor antagonist (MRA) drugs.
* Use of day-case angioplasty is growing. There is, though, extremely wide variation between hospitals, with some centres performing day-case angioplasty in almost all elective cases, and some where almost all patients are kept in overnight following their procedure. Hospitals should aim to offer day-case angioplasty to at least 75% of their elective cases.
Professor John Deanfield, Director of NICOR, said:
This report builds on last year’s first National Cardiac Audit Programme report, which brought together 5 major national cardiovascular audits for the first time in a single report. The programme has analysed data from over 300,000 patients. This 2019 annual report, supported by UCL Partners, covers the fields of Congenital Heart Disease, Heart Attack, Percutaneous Coronary Interventions (PCI), Adult Surgery and Heart Failure. The results of the National Cardiac Rhythm Management audit for 2017/18 will be brought into next year’s 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.
Access the full analyses here
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.
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.