Data, Outcomes and Population Health Management. CPPEG January 2016

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1 Data, Outcomes and Population Health Management CPPEG January 216

2 NHS Outcomes Framework There are national outcome measures which the CCG is held to account on. In conjunction to monitoring these the CCG also monitors local outcomes which have been developed with patients, some of which are shown on the following page.

3 Local outcome indicators Long Term Condition Outcome Change from previous year CKD COPD Percentage of population in practice CKD Register Percentage of patients with (High Risk) COPD referred to pulmonary rehabilitation Percentage of people meeting NICE criteria who have had handheld spirometry screening Percentage of people with COPD who have had Flu Vaccination Percentage of population in practice COPD Register Diabetes If microalbumin abnormal and correctly treated (%) Heart Failure Hypertension Patients on practice register with coded Pre-diabetes, IGT or IFG Percentage of all diabetics with blood pressures <= 14/8 in the last 12 months Percentage of all diabetics with blood pressures <= 15/9 in the last 12 months Percentage of all diabetics with Hba1c <= 7.5% (58mmol/mol) Percentage of all diabetics with Hba1c > 9% (75mmol/mol) Percentage of diabetics who have had diabetic retinopathy screening through approved service Percentage of diabetics who have had urine microalbumin screening in the previous 12 months Percentage of population in practice Diabetes Register Total Cholesterol <=4 mmol/l Percentage of people on HF register with coded LVSD Percentage of people with HF who have had HF review in last six months Percentage of people with LVSD on a beta blocker Percentage of people with LVSD on ACE-I or A2 antagonist Percentage of people with LVSD on beta blocker target dose Percentage of people with LVSD on recommended ACE-I or A2 antagonist dose Percentage of population in practice Heart Failure Register Percentage of people not on practice hypertension register with (Latest) BP>14/9 who have had 24 hour BP test (or 3 B.. Percentage of people on hypertension register with BP to target (under < BP 14/9) Percentage of population in practice Hypertension Register

4 Camden Male life expectancy by ward When we look at outcomes in Camden we can see that there are health inequalities. Camden has a very diverse population and there can be variance in health outcomes.

5 Impact of primary care registers Impact of LCS programmes in first 6 months (emergency admissions to ACS conditions) Heart Failure Diabetes COPD % 49-32% 51 The charts show activity before and after being added to the disease registers (diseases with LCS programmes). The activity considered in the analysis is emergency activity for chronic ambulatory conditions which are considered avoidable (Influenza and pneumonia, Other Vaccine Preventable diseases, Congestive heart failure, Diabetes complications, COPD, CHD, Angina, Hypertension, CKD & Asthma). Activity also excludes patients from the three practices mentioned above. CKD Hypertension % 2 4% 17 26% 39 There appears to be a decrease in emergency ACS activity for conditions Diabetes, COPD and Heart Failure. For the other two conditions shown here, this impact is not seen in the first 6 months. It s important to note that the patient cohort considered for each disease register may or may not have other comorbidities. This aspect may particularly have an influence on Hypertension. adding to register adding 6 month to 6 months after

6 6 25 Over 65 population by practice 2 15 Half of Camden s over 65 population is registered at 8 practices 1 5 Camden s practices have significant variation on their demographic profiles.

7 Camden over 65 population compared with proportion of frailty register 1.% 9.% 8.% 7.% 6.% 5.% 4.% 3.% 2.% 1.%.% Evidence suggests that being on a primary care disease register will have a positive impact on outcomes. The CCG therefore encourages practices to add patients to their register, along with associated tasks such as creating care plans. % of Over 65years % of Patients on FR

8 Frequent A&E attenders 214/15 attendances 25,66 patients 79% of population The evidence suggests that being on a primary care disease register has a positive impact for patients. There still remains in Camden a cohort of patients who use a significant amount of acute resources compared with the overall population. 1.3% of Camden s population (3342 patients) had 4 or more A&E attendances in 214/15, which represents 22% of the total number of A&E attendances. 3 attendances 3,766 patients 1.4% of population 4+ attendances 3,342 patients 1.3% of population 2 attendance 1,547 patients 4.1% of population 1 attendance 37,2 patients 14.3% of population

9 Ethnicity of people on the frailty register The Ethnicity of Patients on the Frailty Register 3/9/15 Mixed Background 1.78% Other Ethnic Group 1.36% Unknown /Not Recorded 2.57% 1% 9% 8% Comparison of Frailty Register ethnicity with Camden Over 65 Years Registered Population 2.57% 1.36% 1.78% 4.64% 9.49% 5.93% 2.11% 1.53% 5.14% 9.5% Black 4.64% 7% 13.7% 15.23% Asian 9.49% 6% 5% White European/ Other White 13.4% White British 66.45% 4% 3% 2% 66.45% 6.99% 1% % Frailty Over 65 Years White British White European/Other White Asian Black Mixed Background Other Ethnic Group Unknown /Not Recorded Work has been done to check that the demographic of primary care registers, such as the frailty register, are representative of the overall Camden population. These are however people who have already been identified, the next page show some of the work the CCG is doing to look at unidentified patients.

10 Population health management tool The CCG has developed it s own population health management tool to identify segments of population by developing groups based on similar health needs. The aim is to understand what drives patients to fit into one of the groups, for example a combination of disease and demographic factors. Demographic composition of each segment is shown here with each icon representing 1 people in Camden. Older people are overrepresented in the higher usage segments. (6) High secondary healthcare need: population with 2 or more LTCs, high usage of emergency care (4) Healthy population with LTCs: population with one or more LTCs, limited use of secondary healthcare (e.g. outpatient care) (2) Healthy Population: Limited use of secondary healthcare (e.g. outpatient care) Camden Whole Population segments (5) Intermediate secondary healthcare need: population with 1 or more LTCs, higher use of planned care (3) Generally Healthy population: have no LTCs but irregular access to secondary physical care Age 15 Note: >people shown on the left hand side of each segment are Males and on the right hand side are Females >Each icon represents 1 people. (1) Healthy Population: No access to secondarycare