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C ARE AND E DUCATION R ESEARCH G ROUP. Keeping CR on the agenda Bob Lewin Professor of Rehabilitation [email protected]. Some terms Minimum dataset (MDS) – the information – that is collected by everyone in the audit – can be built into any database system – eg. Tomcat. - PowerPoint PPT Presentation
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CARE AND EDUCATION RESEARCH GROUP
Keeping CR on the agendaKeeping CR on the agenda
Bob LewinProfessor of Rehabilitation [email protected]
Some termsSome termsMinimum datasetMinimum dataset (MDS) – the information – that is collected by everyone in the audit – can be built into any database system – eg. Tomcat.
CCADCCAD – Central Cardiac Audit Datasets – the collection of UK audits for CARDIAC specialties - MI, Surgery, Stents, ICDs, Arrhythmia nursing (coming soon) and Cardiac Rehabilitation -
The NACR DatabaseThe NACR Database – Lotus notes database that is used to send the data up to CCAD who store the information
BenchmarkingBenchmarking – comparing your results with other programmes
Process BenchmarkingProcess Benchmarking – comparing how the outcomes of CR are effected by the different processes the patient has experienced
AuditAudit – reporting what is achieved by each programme, where needs are not being met (locality, gender, ethnicity, social class etc)
Principles of the NACRPrinciples of the NACR
• no unfair ‘league tables’ – improvement scores not raw outcomes
• record resources (staff) available to each programme to make fair comparisons as show how results depend on resources
• include local indices of deprivation and other health indices to ensure fair comparisons
• benchmarking confidential to each programme
• developed by CR for CR – it’s going to be as good as YOUYOU make it
Minimum DatasetMinimum Dataset
Literature search, international consultation, possible questionnaires tried out by a panel of 100 patients and clinician from 10 CR programmes focus groups to select best measures, dissemination to experts, professional bodies and the clinical community for comment.
Download papers, dataset, definitions and the questionnaires Download papers, dataset, definitions and the questionnaires from www.cardiacrehabilitation.org.uk/datasetsfrom www.cardiacrehabilitation.org.uk/datasets
BHF/BACR/CCAD Lotus DatabaseBHF/BACR/CCAD Lotus Database
All your data can be exported to Excel at any time for your own purposes
Many users can unite secondary and community care
Template letters or design your own
Built in ‘buttons’ for commonly requested reports
30 ‘spare fields’ for you to enter any other data you want or need to collect – e.g. repeat exercise tests, dietary assessment, etc.
Lots of free text ‘comments boxes’ for you to record notes – add as much information as you want.
Lists anxious and depressed patients automatically etc etc etc
And it is free courtesy of the BHFAnd it is free courtesy of the BHF
Cardiac Rehab PatientsCardiac Rehab Patients fill in questionnaires 3 times, before, after CR and at 12 months
Cardiac Rehab PatientsCardiac Rehab Patients fill in questionnaires 3 times, before, after CR and at 12 months
CR programme staff enter dataCR programme staff enter dataCR programme staff enter dataCR programme staff enter data
BHF YorkBHF YorkBHF YorkBHF York
Annual Audit Reports toAnnual Audit Reports toDH, HCC, BHF, Public, PatientsDH, HCC, BHF, Public, Patients
Annual Audit Reports toAnnual Audit Reports toDH, HCC, BHF, Public, PatientsDH, HCC, BHF, Public, Patients
CCADCCADCCADCCAD
April - Dec 2005
Year 2. 2006 Year 3. 2007 Year 4 2008
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Total
Newly enrolled
15 25 45 45 45 45 45 40 40 35
Target
ActualLinked
15 40 85 130
210
100
175 220 265 305 345 380 380
We need every CR programme to joinWe need every CR programme to joinPlaned to recruit 45 per quarter so that recruitment is complete end 2007Planed to recruit 45 per quarter so that recruitment is complete end 2007
projected figure by end of 2projected figure by end of 2ndnd quarter 2006 was 130 actual no. with software quarter 2006 was 130 actual no. with software committed to take part is 210committed to take part is 210
Number linked electronically 101 Number linked electronically 101
Not connected, Or, less than 12 months (April-March) data Not connected, Or, less than 12 months (April-March) data AND ANNUAL staffing questionnaire for everyoneAND ANNUAL staffing questionnaire for everyone
Not connected, Or, less than 12 months (April-March) data Not connected, Or, less than 12 months (April-March) data AND ANNUAL staffing questionnaire for everyoneAND ANNUAL staffing questionnaire for everyone
BHF YorkBHF YorkBHF YorkBHF York
Annual National Audit Reports toAnnual National Audit Reports toHCC, BHF, Public, Patients.HCC, BHF, Public, Patients.
Annual National Audit Reports toAnnual National Audit Reports toHCC, BHF, Public, Patients.HCC, BHF, Public, Patients.
Annual / online / paper survey with Alton Annual / online / paper survey with Alton
Annual / online / paper survey
HCC – will use this data to assess trusts HCC – will use this data to assess trusts IF you IF you complete the paper survey and join the NACRcomplete the paper survey and join the NACR
BHF YorkBHF YorkBHF YorkBHF York
Smart group - Smart group - [email protected]@smartgroups.com Smart group - Smart group - [email protected]@smartgroups.com
CCAD CCAD HELPLINEHELPLINE
CCAD CCAD HELPLINEHELPLINE
CARDIAC NETWORKCARDIAC NETWORKLee, MargaretLee, Margaret
CARDIAC NETWORKCARDIAC NETWORKLee, MargaretLee, Margaret
Other UsersOther Users Other UsersOther Users YouYou YouYou
BHF BHF REGIONAL CRCsREGIONAL CRCs
BHF BHF REGIONAL CRCsREGIONAL CRCs
You’re never alone with the NACR!
BHF YorkBHF York (all part-time)(all part-time)Project Manager – Corinna PetreCorinna PetreData Manager / analysis - Simon CoultonSimon Coulton Data Quality officer – Jo OrchardJo Orchard Secretarial / Admin – Roz ThompsonStatistician – to be appointed
BHF regional Cardiac Rehabilitation Coordinators
Shirley Hall, Dianne Card, Steph Dilnot, Step Lillie, Elaine TannerShirley Hall, Dianne Card, Steph Dilnot, Step Lillie, Elaine Tanner
Cardiac Network
Lee PanterLee Panter, Margaret Leid
CCADHelp Desk at CCAD for your IT people
PeoplePeople
Organisations involvedOrganisations involved
BHFBHF - champion, financial sponsor
BACRBACR – part of core requirement for a CR programme?
DH Heart TeamDH Heart Team – Roger Boyle has put resource in
Cardiac NetworksCardiac Networks – Lee, Margaret
Health & Social Care Information Systems - Health & Social Care Information Systems - mother organisation mother organisation forfor CCAD, HES and other NHS and social datasetsCCAD, HES and other NHS and social datasets
HCC – HCC – will use our data to assess trusts IF you complete the paper will use our data to assess trusts IF you complete the paper survey and join the NACRsurvey and join the NACR
The audit will provide you withThe audit will provide you with • automatic reporting of NSF targets & many other reportsNSF targets & many other reports about
your programme
• evidenceevidence about what you achieve as a health gain for your local population
• evidence to inform local plannerevidence to inform local plannerss as to the adequacy of CR provision in your patch
• an understanding of how well funded you are compared to the national norms
• the ability to compare what your programme achieves with the national averages on a range of outcomes – national benchmarking
Descriptive overview of patients on the databaseDescriptive overview of patients on the database
Number of patients on the database 25,557
% Male 70
Mean age at initiating event 65 yrs
% White 91%
Mean time from initiating event to referral 14.2 days
Mean time from initiating event to invitation 36.4 days
Mean time from initiating event to start47.9 days
Rehab Processes across 4 ‘stages’Rehab Processes across 4 ‘stages’
31.9
19.522.9
53.1
43.1
28.7
25.1
28.7
17.2
3.20.6
9.4
1.1 0.5
12.4
01.8 1
16.3
10.6
0
10
20
30
40
50
60
70
80
90
100
%
NSF targets measured at 12 weeks…NSF targets measured at 12 weeks…
NSF Target Week
0
Week
12
50% will be non-smokers 81% 90%
50% will have BMI <30kg/m2 73% 77%
50% will be exercising 30 minutes 5 times per week
22% 50%
those who attend – Quality of life indicators…those who attend – Quality of life indicators…
3.61
2.29 2.32
2.11
2.48
2.33
3.13
2.36
2.97
1.971.86
1.66
2.162.26
2.71
1.87
1
2
3
4
5
Fitness Feelings Daily activities Social activities Pain Change in health Overall health Overall quality oflife
Da
rtm
ou
th C
OO
P s
co
re
Of those who do attend – anxiety and depression…Of those who do attend – anxiety and depression…
5.98
4.41
5.08
3.69
0
1
2
3
4
5
6
7
8
9
10
Anxiety Depression
HA
DS
Quality & Service Delivery
Descriptives of CR programme - logistic regression modelling assessing factors associated with factors associated with successsuccess. – (inc. disability, age, programme staffing level etc.
Weighted comparison of uptake for cardiac events (acute MI, PTCA, CABG) stratified by Acute Trust, PCT, SHA, age, gender, ethnicity. Additional PCT, Acute Trust & SHA factors - regression modelling assessing external factors associated with uptakefactors associated with uptake
Additional demographic factors, social social deprivation and health indices factors added deprivation and health indices factors added to regression model to explore factors to regression model to explore factors associated with success.associated with success.
ONSONS
HESHES
CR-MDSCR-MDS
Analysis
By 2002 85% of MI and revasc patients will be offered cardiac rehabilitation
After that all except unstable angina patients should receive CR.
Best guestimate 25-30% of patients getting CR in 2005-6.
ProblemsProblems
under treatment
inequalities – women, poor, ethnic minorities, depressed, smokers, elderly, all believed to be under-represented, postcode lottery
failure to invite all indicated in NSF – angina, heart failure, ICD, arrhythmia
dropout – varies widely from programme to programme
staffing – from single-handed, part-time, coordinator for 600 patients to a full multi-disciplinary team. Only 50% of programmes have an identifiable budget.
poor outcomes?- pragmatic’ RCT by Robert West
Can Cardiac rehabilitation survive? Can Cardiac rehabilitation survive? 2000/2001 £31m for revascularisation2000/2001 £31m for revascularisation2002/2003 £161m. 400% increase2002/2003 £161m. 400% increaseProbably 2-5% reduction in mortality from Probably 2-5% reduction in mortality from CABG vs. medical treatmentCABG vs. medical treatmentNo increase in funding of CR apart No increase in funding of CR apart from BHF Lottery £4m from BHF Lottery £4m
not costed in ‘payment per treatment’ not costed in ‘payment per treatment’
Been rejected by GPs as a QOF target.Been rejected by GPs as a QOF target.
In the new age of ‘self-management’ and In the new age of ‘self-management’ and ‘Chronic Disease Management’ why have ‘Chronic Disease Management’ why have we not seen a single mention of CR in we not seen a single mention of CR in Government literature?Government literature?
Using NSF criteria for those expected to Using NSF criteria for those expected to benefit, guesstimated shortfall of benefit, guesstimated shortfall of 330,000 patients a year330,000 patients a year
Evidence based Evidence based HealthcareHealthcare
CentralCardiacAuditDatabase
NationalPacemaker &ICD DatabaseRegional variations in ICDimplantation rate.
Only health authorities shown in orange reach the new implant rate required by N.I.C.E. guidelines.
How do others get funding?
NACRed or wot? The good news is…NACRed or wot? The good news is…
The technology works and is helping programmes all over the The technology works and is helping programmes all over the country organise and communicate bettercountry organise and communicate better
information sharing between trusts and across primary/secondary information sharing between trusts and across primary/secondary care may be about to become very simple making the project even care may be about to become very simple making the project even more effectivemore effective
around 50% of UK programmes have already committedaround 50% of UK programmes have already committed
there is solid support from major stakeholders, BHF, DH, HCCthere is solid support from major stakeholders, BHF, DH, HCC
NICE guidance on MI and secondary prevention strongly supports NICE guidance on MI and secondary prevention strongly supports CR, indeed treats it as obvious that all patients including heart CR, indeed treats it as obvious that all patients including heart failure patients should take partfailure patients should take part
Amanda Hutchinson – Healthcare Commission Amanda Hutchinson – Healthcare Commission
““I was involved in a large project about the National Service I was involved in a large project about the National Service Framework and I became increasingly passionate about the Framework and I became increasingly passionate about the importance of cardiac rehabilitation. importance of cardiac rehabilitation.
We identified that it was one of the standards where less progress We identified that it was one of the standards where less progress had been made despite the enormous commitment of staff and the had been made despite the enormous commitment of staff and the effort that was being made to try and make it work given the effort that was being made to try and make it work given the historic lack of priority that cardiac rehabilitation services have historic lack of priority that cardiac rehabilitation services have been given.been given.
… … patients were extremely positive about this as a service and it patients were extremely positive about this as a service and it was something that was valued by everyone we spoke to and was something that was valued by everyone we spoke to and surveyed.surveyed.
A key finding was that only 16% of Trusts were able to provide the A key finding was that only 16% of Trusts were able to provide the data we required ... data we required ... This is why the audit database is so important, This is why the audit database is so important, because without the data, it is extremely difficult to make a case for because without the data, it is extremely difficult to make a case for service improvement and why the audit is such an exciting service improvement and why the audit is such an exciting prospect.”prospect.”
Change the futureChange the future
COULD be the beginning of the best period yet for CR – BUT it COULD be the beginning of the best period yet for CR – BUT it could also be the beginning of the end - replaced by leaflet bearing could also be the beginning of the end - replaced by leaflet bearing lay health trainers in primary care.lay health trainers in primary care.
We have powerful friends but We have powerful friends but NO active championsNO active champions – we are going – we are going to have to to have to DO IT OURSELVES working with charities (BHF), DO IT OURSELVES working with charities (BHF), patients, the media and politicianspatients, the media and politicians..
Proposal - we should join together in a sustained 5 year campaign Proposal - we should join together in a sustained 5 year campaign using NACRed to draw attention to the unmet need.using NACRed to draw attention to the unmet need.
We should show what we can achieve and how much more we We should show what we can achieve and how much more we couldcould achieve achieve if we were all adequately fundedif we were all adequately funded..
And we must all do it all together – have a moan, whinge all you And we must all do it all together – have a moan, whinge all you want complain about the extra work - but do it – join NACR today want complain about the extra work - but do it – join NACR today and change the future.and change the future.
WE WILL WIN! WE WILL WIN!