Excellence in Stroke Management Excellence in Stroke Management - - North Central Cardiac & Stroke Network North Central Cardiac & Stroke Network - Royal Free Hospital, Hampstead – 30/7/9- Royal Free Hospital, Hampstead – 30/7/9

Ameet Bakhai – Physician, Cardiologist, Clinical Trials,

Health Economics, HTAsBarnet & Chase Farm NHS Trust

Royal Free NHS Trust, University of HertfordshireBushey Spire

Conflict of Interest: Consultant to companies, Research GrantsAdvisor to NICE, Director AMORE Health, CSO Health Smart UK

Thank YouThank You

• Attendees

• Education Support - North Central London Cardiac and Stroke Network

• Education Grant without conditions - Sanofi-Aventis & BMS

• Educational Facilitation - Barnet Hospital Cardiology Research & Education Team

• Brianna Davidson, Lai Lim, Susan Collett & Catering

Close of the meeting9.45pm

Thank you & Summary from the Chair Return Evaluation Forms

9.30pm

Panel DiscussionStroke services development - progress and barrier breakingPrevious Speakers as well as:Dr Robert LuderStroke Physician & Stroke Strategy Lead North Middlesex Hospital Dr Bal Athwal Neurologist and Stroke Strategy Barnet & Chase Farm Hospital NHS Trust Ms Margaret BruceNorth Central London Cardiac and Stroke Network Director (Interim)Dr Gerry Coghlan Cardiologist & Clinical cardiac lead - North Central London Cardiac and Stroke Network & Royal Free Hospital

8.45pm

Dr David Werring Old & New Anti-platelets and Anti-thrombotics for stroke reduction

8.15pm

Coffee, Drinks, Fruit and Dessert8.00pm

Dr Sheela ShahTransient Ischemic Attacks (TIA) ServicesWho to refer and what to expect

7.30pm

Dr Charles DavieUpdate on the Stroke Network across North Central London What's happening now? What needs to happen?

7.00pm

Dr Ameet Bakhai Welcome, Introductions, Update on Health Checks - Vascular Risk Assessment Program

6.45pm

The Burden of Stroke Continues After the Acute Event

• Stroke progression during hospitalization 24%

• Mortality

30 days 8–20%

1 year 15–25%

5 years 40–60%

• Complete or partial dependence 27–53%

• Dementia persisting at 1 year 34%

Source: Sacco. Neurology. 1997; 49 (Suppl 4): S39–S44

Cost of CardioVascular Disease £14.4 Billion or £250 per head in 2006

£30.7 Billion economic impact.

BHF Coronary Heart Disease Statistics 2008 – Chapter 13www.heartstats.org

Cost of Stroke Care per Rankin Scale Score at Day 10 in France codes I60-64, I67, G45-46

37 965 €87Rankin 5 Bedrinned

16 403 €41Rankin 4 Assist to walk

12 242 €73Rankin 3 Able to walk

4 616 €122Rankin 2 Minor disability

3 449 €111Rankin 0-1 No - Minimal

disability

Average Cost at 18/12N (Sum 434) ECIC Study 2004 Costs

Stroke Has a Major Impact on Quality of Life

1

0

• Gage BF et al. JAMA 1995; 274: 1839–1845• Burstrom K et al. Qual Lif Res 2001; 10: 621–635

Best possible health state

Death

Mild stroke [0.75]1Asthma [0.79]2

Low back pain [0.66]2 Moderate/severe stroke [0.39]1

Recurrent stroke [0.12]1

Europe - 7 main factors leading to death

High blood pressure (25%) High cholesterol (2/3 – 66%) Tobacco use (25%) Overweight or obese (2/3 – 66%) Low fruit & vegetable intake* (20-50%) Physical inactivity (2/3 – 66%) Alcohol excess (38%/24%)

WHO 2004

X

Unal et al BMJ 2005

Atherothrombosis Significantly Shortens

Life Expectancy (Prognosis) at 60

Framingham Heart Study

Peeters et al. Eur Heart J 2002; 23: 458–466

Healthy History of

Angina

History of MI

History of CVA

02

46

8

10

12

14

16

1820

Yea

rs

9.27.4 12

Well 60 yr M

1st MI

1st MI + MI

1st MI + CVA

1st CVA

1st CVA + MI

1st CVA + CVA

1st PAD

PAD + MI

PAD + CVA

0 5 10 15 20

Reduction

77%

78%

32%

56%

80%

45%

63%

68%

36%

0%

Background

• Guidelines recommend preventive treatment in high risk patients

• Population screening

• Lifelong treatment. Or not.

Vehicles of Changehttp://www.improvement.nhs.uk/nhshealthcheck/

Vascular Disease

Briefing Pack for Strategic Health Authorities – NHS London

Spring 2009

Early '90's Mid-90's Late 90's 2001

Acute Coronary Syndrome Therapies

ASA

Hep / Nit

ASA

Hep / Nit

BB / Ca++

Statins

ASA

Hep / Nit

BB / Ca++

Statins

ACE Inhib

ASA

Hep / Nit

BB / Ca++

Statins

ACE Inhib

Clopidogrel2b/3a blocker

Drug-Eluting Stents

Anti-Aldosterone

HDL agents

Direct AntiXa

Stem Cells

Plaque Stabilisers

2005-9

Learning Points - Marketing

• Branding – appealing, recognised, catchy

• Launch event success

• Publicity

• Media involvement

• Banners

• Cost

www.sahf.org.uk

Learning Points - Health Trainers

• Vital

• Moveable resource

• Adaptable

• Flexible

• Resilient

• Enthusiastic

CardioPod launched at NHS Camden

All tests are carried out at the point of care and patients receive instant feedback using the QRISK 2 risk assessment tool.

Information from the Health Check is uploaded to a secure database for analysis and review. The results of the discussion between patient and care provider are recorded by the CardioPod, with a print out for the patient to take away. The action points can also be stored on the secure server for follow up when the next Health Check is carried out.

CardioPods had already been installed in NHS Camden and it had plans to extend installations in the rest of the UK in the coming months.

Web link: http://www.ehiprimarycare.com/news/4990/cardiopod_launched_at_nhs_camden

Assistive technology company Telehealth Solutions has launched a touch-screen CardioPod which it says will help GP practices and pharmacists deliver the NHS Health Check programme.

The CardioPod is a standalone unit that comes with scales and sphygmomanometer to capture basic vital signs information. A Cholestech LDX blood chemistry analyser is available as an option to add a lipid profile and blood glucose measurement in less than five minutes.

CardioPod installed in a pharmacy

After!

Results

• Preventing Heart Disease• Improved performance ‘Beyond QOF’• Better Diabetes, Hypertension, CKD registers• Better Primary Health Care Teams• Better Primary Prevention Registers

• 9,097 on register at 2007• Currently 17,646 @ January 2009 • 24,000 expected on register…….eventually

Learning Points - Clinical Engagement

• Clinical Leadership is essential

• Time to build relationships

• Understand your Primary Care

• Get a lead in each practice

• Culture and ethos determines the success

Final Learning Points 2

Health Inequalities:

74.3%11<20

75.2%1220 – 30

73.7%1830 – 40

79.4%14>40

% AchievedNo. of Practices

Deprivation Score

Risk Pyramid for CVD

Compliance and Relative Risk Reduction of Compliance and Relative Risk Reduction of interventionsinterventions

Death rates are higher in the more deprived areas

Three year rolling average of CHD death rate under 75 years for Barnet censussuper-output areas ranked by deprivation index and grouped in tertiles

Dea

ths

per

100

,000

po

pu

lati

on

0

10

20

30

40

50

60

2004 2005 2006 2007

Low deprivation SOAs

Medium deprivation SOAs

High deprivation SOAs

Low deprivation wards in Barnet

Medium deprivation wards in Barnet

High deprivation wards in Barnet

0

20

40

60

80

100

120

140

160

180

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Dea

ths

per

100

,000

po

pu

lati

on

Low deprivation wards in BarnetLow deprivation wards in Barnet

Medium deprivation wards in BarnetMedium deprivation wards in Barnet

High deprivation wards in BarnetHigh deprivation wards in Barnet

0

20

40

60

80

100

120

140

160

180

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Dea

ths

per

100

,000

po

pu

lati

on

0

20

40

60

80

100

120

140

160

180

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Dea

ths

per

100

,000

po

pu

lati

on

Copyright © NHS Barnet 2009 All rights reserved

• Of more than 4,000 Which? members found that 30 per cent would consider a private health check to set their mind at ease. • Which? researchers aged 46 to 62, with no known health problems, paid 12 visits to six healthcare companies - Bupa, Nuffield Health and BMI Healthcare and three independent firms. • They bought comprehensive health MoTs, not including scans or X-rays, paying an average of £423, while researchers posing as customers phoned another four companies which offered scans. • In eight cases, researchers - none of whom had a major problem identified - were advised to get further GP tests within six months. • One researcher got conflicting information about his heart disease risk - ranging from higher-than-average to lower - and another had an abnormal urine test at two of her three MoTs. • The report found some companies failed to discuss possible downsides of testing, such as false alarms. • The Which? panel of experts also concluded that consumers were getting too little information about the pros and cons of scans. http://www.dailymail.co.uk/news/article-1201510/The-private-health-checks-bad-you.html#ixzz0Mkhgi0LD

Social marketing pilot

Social marketing pilot run by London Social Marketing Group (National Social Marketing Centre and the Central Office for Information Funded by NHS London

Copyright © NHS Barnet 2009 All rights reserved