Commissioning for value focus pack

Commissioning for value focus pack Clinical commissioning group: NHS VALE OF YORK CCG Focus area: Cardiovascular disease (CVD) pathway PHE publications gateway number 2014600 December 2014 Version 3

Contents 1. Background and context About the packs Packs as part of transformation process: what and how to change 2. Methodology 3. Summary messages 4. Analysis Analysis by pathway stage Local data: bringing it all together Contents 5. Annexes Annexe 1: Detailed indicator spine charts Annexe 2: CCG benchmarks Annexe 3: Statistical methodology Annexe 4: Data sources Annexe 5: Glossary This document is valid only when viewed via the internet. If it is printed into hard copy or saved to another location, you must first check that the version number on your copy matches that of the one online. Printed copies are uncontrolled copies. 2

About the packs This focus pack or deep dive looks at an agreed programme area (CVD) to understand variation and improve the value of commissioned services across the pathway Commissioning for value insight packs were produced for every Clinical Commissioning Group (CCG) in autumn 2013 by Public Health England (PHE), NHS England and NHS Right Care. These packs identified programme areas with potential opportunities for improving outcome, quality and efficiency at CCG level for the ten areas of programme expenditure with the highest spend. These are available at: www.england.nhs.uk/resources/resources-for-ccgs/comm-for-value/ This CVD focus pack is available in two formats: a downloadable PDF providing national benchmarked data for heart and stroke together with a summary of key messages: www.ncvin.org.uk/ an unbranded PowerPoint slide set that is available to CCGs on request to add additional local information and comment. Email the National Cardiovascular Intelligence Network (NCVIN) to ask for a pack: ncvin@phe.gov.uk Background 3

What and how to change Phase 1 Where to look Indicative data eg: Atlas of variation This pack: Phase 2 What to change Evidential data Deep dive service reviews Engagement and case for change Phase 3 How to change Business processes Clinical leadership and engagement The NHS Right Care model has three basic steps: The commissioning for value insight pack supports Where to look by indicating the areas of care where your population can gain most benefit from your reform energies. This focus pack or deep dive supports What to change by helping you to define what the optimal value care looks like for your population. How to change helps you implement the changes to deliver the care. Support is available at: http://www.rightcare.nhs.uk/index.ph p/commissioning-for-value/ Background 4

Methodology used to produce this pack Analysed a wide range of indicators from across the pathway focussing on spend, quality and outcomes Identified cluster groups of 10 CCGs with similar characteristics to the CCG (see slide 21) Analysed wide range of national data to identify indicators where the CCG is below a benchmark value in its cluster group for that indicator and thus has an opportunity to improve Identified indicators where the CCG is in the worst quintile within its cluster for that indicator (see slide 22 for more information on methodology) Identified key opportunities for value improvement and quantified potential impact Quantified opportunity for the CCG if indicators below the benchmark were moved to the benchmark Quantification does not mean that the saving or improvement can actually be made but may answer the question Is it going to be worth focussing on this area? Methodology Identified evidence based guidance, quality standards and performance metrics for people providing and commissioning health, public health and social care services for the prevention and management of CVD related conditions. For more information see slide 15 5

Summary: overarching messages Overarching messages for the CCG Public health focus on prevention; specifically healthy eating, binge drinking Significant benefit to patients if improvement to primary care management indicators were made High cost for: CVD elective admissions, CHD elective admissions (male), stroke emergency admissions (female) High number of admissions for: CVD emergency admissions (male), CABG procedures (male) High length of stay for: stroke emergency admissions Note 1, these opportunities represent indicators that are in the worst quintile of their cluster group. Other opportunities may also be available. These can be found in Annexe 1. Note 2, opportunities highlight areas for further investigation, as variation may reflect genuine differences due to local demography and service provision. Not all opportunities therefore may be achievable. See indicator guide for further information on how the indicators were calculated. Summary on a page 6

Summary: prevention and prevalence Prevention 5 out of 5 prevention indicators are worse than the benchmark. 2 indicators are in the worst quintile. Estimated percentage binge drinkers is in the worst quintile. If the CCG were to achieve the benchmark then there would be 28,851 fewer binge drinkers. Estimated prevalence of adult healthy eating is in the worst quintile. If the CCG were to achieve the benchmark then there would be 10,265 more adults eating healthily. Summary Prevalence 1 out of 3 of the observed to expected prevalence ratios are worse than the benchmark. The prevalence in 4 disease groups out of 7 are higher than the benchmark. Note 3, These packs use two types of prevalence indicator. The observed prevalence diagnosed on practice registers and the ratio of observed to expected prevalence. The expected prevalence is a modelled estimate of total prevalence (diagnosed and undiagnosed) which uses the characteristics of the population to estimate the expected total prevalence of disease in that population. A low ratio may indicate a higher level of undiagnosed cases of disease and therefore unmet need. 7

Summary: primary care Primary care 26 out of 27 primary care indicators are worse than the benchmark. QOF indicators have been used but exceptions have been included in the denominator. The following 5 indicators are in the worst quintile, the potential benefits based on achieving the benchmark are shown in brackets: % CHD patients total cholesterol < 5mmol/l (1,149 more people) % stroke patients total cholesterol < 5mmol/l (527 more people) % MI patients treated with ACE-I, Anti-platelet, BB, statin (119 more people) AF & CHADS2 score of 1, % anti-coag/platelet drug therapy (49 more people) % HF patients due to LVSD treated with ACE-I or ARB (29 more people) Summary Note 4, For full QOF names, see indicator guide. 8

Summary: secondary care Secondary care 51 out of 54 secondary care indicators are worse than the benchmark. 8 indicators are in the worst quintile. The four in terms of money and the four in terms of admissions/procedures are listed below, the potential savings based on achieving the benchmark are shown in brackets: -CVD: average cost per male elective admission ( 576K) -CHD: average cost per male elective admission ( 354K) -CVD: average cost per female elective admission ( 210K) -Stroke: average cost per female emergency admission ( 18K) -Stroke: average female emergency LOS (1,964 fewer bed days) -Stroke: average male emergency LOS (1,466 fewer bed days) -CVD male emergency admissions (DSR) (320 fewer admissions) -CABG procedures: male (DSR) (43 fewer procedures) Summary Note 5, CCG length of stay averages may be influenced by extreme values. Further analysis may be needed to determine achievability of any related opportunity. Note 6, CABG indicators may be based on small numbers. Caution is advised on the use of these indicators. 9

Summary: social care Social care 0 out of 1 social care indicators are worse than the benchmark. There are no indicators in the worst quintile. Summary 10

Where does the CCG compare poorly against its cluster group? Number of Indicators where Analysis CCG has by room pathway stage (page 1 of 2) for improvement* Table1 5/5 prevention indicators 1/3 observed to expected prevalence ratios Indicators in the worst quintile versus benchmark group - difference between the CCG and the benchmark Estimated prevalence of adult healthy eating (-11.4 % lower) 10,265 people Estimated percentage binge drinkers (52.3 % higher) 28,851 people Opportunity - if the CCG were to equal the benchmark No indicators in the worst quintile No indicators in the worst quintile Analysis 26/27 primary care indicators AF & CHADS2 score of 1, % anti-coag/platelet drug therapy (-3.6 % lower) 49 people % CHD patients total cholesterol < 5mmol/l (-11.7 % lower) 1,149 people % MI patients treated with ACE-I, Anti-platelet, BB, statin (-17.2 % lower) 119 people % HF patients due to LVSD treated with ACE-I or ARB (-4.8 % lower) 29 people % stroke patients total cholesterol < 5mmol/l (-16.1 % lower) 527 people *below a benchmark value equal to the average of the top 5 ranked CCG values in their cluster group 11

Where does the CCG compare poorly against its cluster group? Number of Indicators where Analysis CCG has by room pathway stage (page 2 of 2) for improvement* Table2 Indicators in the worst quintile versus benchmark group - difference between the CCG and the benchmark CVD male emergency admissions (DSR) (21.6 % higher) CVD: average cost per male elective admission (22.3 % higher) 576K CVD: average cost per female elective admission (17.3 % higher) 210K CHD: average cost per male elective admission (33.4 % higher) 354K Stroke: average cost per female emergency admission (2 % higher) 18K Stroke: average male emergency LOS (68.6 % higher) Stroke: average female emergency LOS (72.9 % higher) CABG procedures: male (DSR) (65.4 % higher) Opportunity - if the CCG were to equal the benchmark 320 admissions 1,466 bed days 1,964 bed days 43 procedures Analysis 51/54 secondary care indicators 0/1 social care indicators No indicators in the worst quintile No indicators in the worst quintile *below a benchmark value equal to the average of the top 5 ranked CCG values in their cluster group 12

Where to focus: understanding practice variation The NCVIN can provide practice level data for CCGs on request: ncvin@phe.gov.uk. This will allow CCGs to better understand practice variation. Practices are clustered with other practices across the country with similar populations. The practice is then compared with the other practices within that cluster for all the indicators where the data is available at practice level. This information is not presented routinely in these packs as CCGs will want to use it sensitively as the basis of a discussion with practices to better understand the reasons for variation and the reduction of variation not explained by clinical need. Analysis 13

Where to focus: adding local data An unbranded power point slide set is available to CCGs on request to add additional local information and comment. These can be requested through the NCVIN: ncvin@phe.gov.uk CCGs may want to consider adding local intelligence to triangulate with the intelligence in this pack. This may include: Up to date intelligence from providers Contract monitoring data Local prescribing data Joint Strategic Needs Assessment (JSNA) Preventative activity commissioned by local authorities Data on inequalities Analysis Local data can be particularly useful when: Testing the size of the opportunities identified from the national data in this pack Linking to identified needs of the population Testing whether plans introduced since this data was collected have worked Testing whether commissioned services are accessed by those in greatest need 14

Bring it all together: what works, what could work, who should we speak to NICE Guidance, Quality Standards etc Prevention of cardiovascular disease Hypertension Atrial fibrillation Stroke Chronic heart failure Lipid modification Myocardial infarction with ST segment elevation Lower limb peripheral arterial disease Smoking prevention and cessation Obesity Physical activity Contact the NICE field team for support and advice on implementing NICE guidance The quality and productivity collection provides quality assured examples of improvements across NHS and social care and include cardiovascular and stroke. Look at NICE shared learning examples from organisations that have put guidance into practice. Examples include peripheral arterial disease, hypertension and obesity. Analysis 15

Annexe 1: spine charts Key: Prevention Estimated percentage of binge drinkers Smoking prevalence Estimated prevalence of adult healthy eating Percentage of adults classified as overweight or obese Percentage of adults with low levels of physical activity England worst Worst quintile in cluster England best Worse outcome \ High prevalence Better outcome \ Low prevalence Opportunity 28,851 people 3,373 people 10,265 people 15,822 people 1,872 people Annexes Prevalence CHD CHD observed to expected prevalence ratio Stroke Stroke observed to expected prevalence ratio Hypertension Hypertension observed to expected prevalence ratio Heart Failure Peripheral arterial disease Atrial fibrillation CVD prevention register See indicator guide for methodology used to calculate the indicators 1,715 people - 663 people - - 4,148 people - 714 people 105 people - For data sources used, see slide 23 16

Annexe 1: spine charts Key: Primary care England worst Worst quintile in cluster England best Worse outcome Better outcome Opportunity % AF patients stroke risk assessed using CHADS2 122 people AF & CHADS2 score of 1, % anti-coag/platelet drug therapy 49 people AF & CHADS2 score >1, % anti-coagulation drug therapy 40 people % CHD patients last BP <150/90 211 people % CHD patients total cholesterol < 5mmol/l 1,149 people % CHD patients influenza immunisation 63 people % CHD patients, alternative anti-platelet therapy taken 106 people % MI patients treated with ACE-I, Anti-platelet, BB, statin 119 people % HF patients confirmed by echocardiogram 10 people % HF patients due to LVSD treated with ACE-I or ARB 29 people % HF patients due to LVSD treated with ACE-I or ARB and BB 11 people % patients >= 40 who have a record of BP 5,355 people % hypertension patients last BP < 150/90 811 people % hypertension patients <= 79 years BP < 140/90 4,482 people % hypertension patients <75 years physical activity assessment 2,452 people % hypertension patients <75 years brief intervention 229 people % stroke patients referred for further investigation 9 people % stroke patients BP <150/90 144 people % stroke patients record of cholesterol 442 people % stroke patients total cholesterol < 5mmol/l 527 people % stroke patients influenza immunisation 74 people % stroke patients with a record of anti-platelet agent 16 people % new hypertension CVD risk assessment, % treated statins <1 person % hypertension patients given lifestyle advice 643 people % PAD patients BP < 150/90 45 people % PAD patients total cholesterol < 5 mmol/l 269 people % PAD patients record aspirin or anti-platelet taken - See indicator guide for methodology used to calculate the indicators For data sources used, see slide 23 Annexes 17

Annexe 1: spine charts Key: Secondary care England worst Worst quintile in cluster England best Worse outcome Better outcome Opportunity CVD: average cost per male emergency admission 157K CVD: average cost per female emergency admission 185K CVD male emergency admissions (DSR) 320 admissions CVD female emergency admissions (DSR) 246 admissions CVD: average male emergency LOS 2,405 bed days CVD: average female emergency LOS 1,738 bed days CVD: average cost per male elective admission 576K CVD: average cost per female elective admission 210K CVD male elective admissions (DSR) 102 admissions CVD female elective admissions (DSR) 68 admissions CVD: average male elective LOS 753 bed days CVD: average female elective LOS 352 bed days CHD: average cost per male emergency admission 174K CHD: average cost per female emergency admission 84K CHD male emergency admissions (DSR) 135 admissions CHD female emergency admissions (DSR) 84 admissions CHD: average male emergency LOS 358 bed days CHD: average female emergency LOS 350 bed days CHD: average cost per male elective admission 354K CHD: average cost per female elective admission 20K CHD male elective admissions (DSR) 88 admissions CHD female elective admissions (DSR) 25 admissions CHD: average male elective LOS 750 bed days CHD: average female elective LOS 67 bed days Annexes See indicator guide for methodology used to calculate the indicators For data sources used, see slide 23 18

Annexe 1: spine charts Key: England worst Worst quintile in cluster England best Secondary care continued Worse outcome Better outcome Opportunity Angiography procedures: male average cost 136K Angiography procedures: female average cost 92K Angiography procedures: male (DSR) 64 procedures Angiography procedures: female (DSR) 15 procedures Angiography procedures: male LOS - Angiography procedures: female LOS 52 bed days Angioplasty procedures: male average cost 20K Angioplasty procedures: female average cost 28K Angioplasty procedures: male (DSR) 45 procedures Angioplasty procedures: female (DSR) 11 procedures Angioplasty procedures: male LOS 67 bed days Angioplasty procedures: female LOS 60 bed days CABG procedures: male average cost - CABG procedures: female average cost 0K CABG procedures: male (DSR) 43 procedures CABG procedures: female (DSR) 1 procedure CABG procedures: male (LOS) 227 bed days CABG procedures: female (LOS) 76 bed days Annexes See indicator guide for methodology used to calculate the indicators For data sources used, see slide 23 19

Annexe 1: spine charts Key: Secondary care continued England worst Worst quintile in cluster England best Worse outcome Better outcome Opportunity Stroke: average cost per male emergency admission 9K Stroke: average cost per female emergency admission 18K Stroke male emergency admissions (DSR) 11 admissions Stroke female emergency admissions (DSR) 19 admissions Stroke: average male emergency LOS 1,466 bed days Stroke: average female emergency LOS 1,964 bed days Heart Failure: average cost per male emergency admission - Heart Failure: average cost per female emergency admission 11K Heart Failure male emergency admissions (DSR) 40 admissions Heart Failure Female emergency admissions (DSR) 21 admissions Heart Failure: average male emergency LOS 297 bed days Heart Failure: average female emergency LOS 251 bed days Annexes Social care % stroke patients discharged usual residence - See indicator guide for methodology used to calculate the indicators For data sources used, see slide 23 20

Annexe 2: similar CCGs The 10 most similar CCGs to NHS VALE OF YORK CCG are: NHS WEST LEICESTERSHIRE CCG NHS LINCOLNSHIRE WEST CCG NHS EAST RIDING OF YORKSHIRE CCG NHS BATH AND NORTH EAST SOMERSET CCG NHS SOUTH WORCESTERSHIRE CCG NHS GUILDFORD AND WAVERLEY CCG NHS WEST CHESHIRE CCG NHS NORTH EAST ESSEX CCG NHS SOUTH WARWICKSHIRE CCG NHS CANTERBURY AND COASTAL CCG Annexes For information on the methodology used to calculate the 10 most similar CCGS please go to: http://www.england.nhs.uk/resources/resources-for-ccgs/comm-for-value/ 21

Annexe 3: Statistical methodology Statistical methodology The methodology used in this pack consisted of the following steps: For each indicator: Data were ranked within the cluster A benchmark value was calculated as the average of the top 5 ranked CCG values The opportunity that could be gained if the CCG were to improve to the benchmark value was calculated The worst quintile was identified as the worst 2 ranked values If the indicator lay in the worst quintile then it was highlighted as a potential area for investigation Annexes For more information, see indicator guide. This is a non-parametric statistical approach which was designed to be easy to understand and interpret. While the comparison does not necessarily prove statistical significance it does provide a robust indication of the most promising areas for further investigation. 22

Annexe 4: Data sources Data sources used: Quality and Outcomes Framework (QOF), 2013/14, Copyright 2014, Reused with the permission of the Health and Social Care Information Centre. All rights reserved Number of Patients registered at a GP practice April 2013, Copyright 2014, Re-used with the permission of the Health and Social Care Information Centre. All rights reserved Modelled estimates of prevalence, December 2011, East of England Public Health Observatory Mid-2012 Population Estimates for Clinical Commissioning Groups, Office for National Statistics (ONS), Crown Copyright 2014 Hospital Episode Statistics (HES), 2012/13, Copyright 2014, Re used with the permission of The Health and Social Care Information Centre. All rights reserved. Model-based estimates (based on Health Survey for England), 2006-08 and 2007/08 Integrated Household Survey, 2012 Active people survey, Sport England, 2012 Annexes 23

Annexe 5: Glossary AF BP CABG CCG CHADS2 CHD CVD DSR LOS LVSD PAD QOF Atrial fibrillation Blood pressure Coronary artery bypass graft Clinical Commissioning Group A method of calculating the risk of stroke in patients with atrial fibrillation (AF) Coronary heart disease Cardiovascular disease Directly standardised rate Length of stay Left ventricular systolic dysfunction Peripheral Arterial Disease Quality Outcomes Framework Annexes 24