European 4th Joint Task Force on CVD Prevention in Clinical Practice in the context of the National

Cardiovascular Health Policy 2010-2019 Hannah McGee, PhD, FEHPS, FESC

Royal College of Surgeons in IrelandColáiste Ríoga na Máinleá in Éirinn

“Changing Cardiovascular Health” [10 year plan: 2010-2019]

CVH Policy Group Terms of Reference

‘…to develop a policy framework for the prevention, detection and treatment of cardiovascular disease including stroke and peripheral arterial disease, which will ensure an

integrated and quality assured approach to their management’.

CVD Medication Use - GMS Scheme (1998-2006)

Prescribing frequency of CVD drugs in Ireland under the GMS scheme 1998-2006

0

500

1000

1500

2000

2500

1998 1999 2000 2001 2002 2003 2004 2005 2006

1000 prescriptions

Aspirin (Anti-thromb) Diuretics BB ACE i CCB LLD

(N=1207, aged 45+)

• Normotensive (<140/90mmHg)(no meds) 40%

• Hypertensive– On medication (<140/90mmHg) 8%– On medication (>140/90mmHg) 18%– NOT on medication (>140/90mmHg) 34%

SLÁN 2007: Hypertension management

• Normotensive (<140/90mmHg)(no meds) 40%• Hypertensive

– On medication (<140/90mmHg) 8%– On medication (>140/90mmHg) 18%– NOT on medication (>140/90mmHg) 34%

Not Treated:– Men/women: 40 / 27%– Age 45-64 / 65+ 34 / 33%– Social class (1-2/3-4/5-6): 35 / 33 /39%

SLÁN 2007: Hypertension management

• 69 recommendations– Recommendation– Lead agency

POLICY: Structure and Recommendations

• 69 recommendations– Recommendation– Lead agency

SIX SECTIONS• Prevention and Health Promotion• Primary Care• Hospital and Emergency Care Services• Cardiac and Stroke Care and Rehabilititon• Workforce Planning for the Policy• A National Framework for Quality in

Cardiovascular Health

POLICY: Structure and Recommendations

• 10-year population targets:• Smoking

- annual 1% reduction prevalence- Annual 1% reduction in initiation rates

• Healthy body weight [Healthy eating /physical activity]- halt rise in 5 years

- restore 1998 levels by 2019

• Salt consumption • EU 2012 Directive (16% reduction)

• Alcohol use • Strategic Task Force on Alcohol targets (2007)

POLICY: Prevention and Health Promotion

• Patient/public awareness – blood pressure & cholesterol levels, family history, waist

circumference, stroke signs/symptoms

• High risk approach - extend definition using ESC’s 4th Joint SocietiesTask Force (2007) approach

– established disease, family members - premature atherosclerosis/multiple risk factors

• Risk identification & management– Single nationally agreed protocol– Opportunistic assessment (with systematic approach)– Phased evaluation of systematic assessment model

POLICY: Primary Care I

SLÁN 2007: Attending GP in the previous year (gender, age and social class (%))

Population risk: systematic opportunistic assessment in general practice?

• Stroke prevention– blood pressure

- rigorous assessment, treatment, monitoring– atrial fibrillation

- age 65+: pulse assessment in GP

- anticoagulation services

• Heart failure management – Early detection:

- education of primary care teams

- liaison specialist HF nurses •

POLICY: Primary Care II

Commonalities - cardiac & stroke

• Secondary prevention for all– from TIA/mild strokes to complex cardiac cases - heart failure/PAD

• Step-down strategies from hospital to primary care services

• Staff training - chronic disease model: build on CR experience

POLICY: Rehabilitation

• Standards– Evidence-based guidelines/ performance indicators/ information &

data requirements/updating guidelines– National Guidelines Coordination (liaise DoHC/HIQA)

• Surveillance– Information systems - registers, data standards, population

surveys, audit– ICT - infrastructure, capacity & training

• Research and evaluation – Health Technology Assessment agenda

POLICY: National Framework for Quality in Cardiovascular Health

• Policy delivery

1. HSE Service Plan - Clinical Directorate priorities set

Appointments: Stroke, Acute cardiac, Heart failure, Primary care

2. Cabinet Sub-Committee on Health: monitor population targets

3. Overall: CVH Policy Monitoring Group to be established

• Full formal review at 5 years (2015)– CVH Policy Monitoring Group

POLICY: What happens next?

Hospital discharges by CVD diagnosis (1998-2008)

discharges

1998 discharges

2008 Discharges:

% Change

CHD 21,435 22,046 3

Heart Failure 22,073 20,872 -5

PAD 7,413 7,740 4

Stroke 6,876 7,509 9

TIA 2,377 2,689 13

All 60,174 60,856 1

Hospital discharges by CVD diagnosis (1998-2008)

discharges

1998 discharges

2008 Discharges:

% Change

CHD 21,435 22,046 3

Heart Failure 22,073 20,872 -5

PAD 7,413 7,740 4

Stroke 6,876 7,509 9

TIA 2,377 2,689 13

All 60,174 60,856 1

Hospital discharges by CVD diagnosis (1998-2008)

discharges

1998 discharges

2008 Discharges:

% Change

CHD 21,435 22,046 3

Heart Failure 22,073 20,872 -5

PAD 7,413 7,740 4

Stroke 6,876 7,509 9

TIA 2,377 2,689 13

All 60,174 60,856 1

Hospital bed days by CVD diagnosis (1998-2008)

Bed days

1998

Bed days

2008

Discharge:

% Change

Bed Days:

% Change

CHD 156,231 119,059 3 -24

Heart Failure 261,499 291,988 -5 12

PAD 98,323 112,588 4 14

Stroke 127,672 145,510 9 14

TIA 16,236 16,419 13 1

BED DAYS 659,961 685,564 1 4

Hospital bed days by CVD diagnosis (1998-2008)

Bed days

1998

Bed days

2008

Discharge:

% Change

Bed Days:

% Change

CHD 156,231 119,059 3 -24

Heart Failure 261,499 291,988 -5 12

PAD 98,323 112,588 4 14

Stroke 127,672 145,510 9 14

TIA 16,236 16,419 13 1

BED DAYS 659,961 685,564 1 4

Hospital bed days by CVD diagnosis (1998-2008)

Bed days

1998

Bed days

2008

Discharge:

% Change

Bed Days:

% Change

CHD 156,231 119,059 3 -24

Heart Failure 261,499 291,988 -5 12

PAD 98,323 112,588 4 14

Stroke 127,672 145,510 9 14

TIA 16,236 16,419 13 1

BED DAYS 659,961 685,564 1 4

Hospital bed days by CVD diagnosis (1998-2008)

Bed days

1998

Bed days

2008

Discharge:

% Change

Bed Days:

% Change

CHD 156,231 119,059 3 -24

Heart Failure 261,499 291,988 -5 12

PAD 98,323 112,588 4 14

Stroke 127,672 145,510 9 14

TIA 16,236 16,419 13 1

BED DAYS 659,961 685,564 1 4

Medical Staffing• Consultant workforce:

– Cardiology: Joint Working Group (2004) – 10 per 500,000 needed

– (preventive cardiology & heart failure expertise for network coverage)

– Stroke: combination geriatric medicine/neurology with special interest in stroke/geriatric medicine/rehabilititon medicine

– (5 acute stroke, 2-3 for other services, additional rehabilitiation physician expertise per 500,000)

• NCHD workforce: service need/capacity for next generation

Multidisciplinary Team Staffing (+ICT)

Primary Care Staffing (PCTs)

POLICY: Workforce Planning

Regional networks• Serving populations of c.500,000• Every hospital provides a complete range of services

(cardiac or stroke) either on-site or in formal partnership with others in the network)

• Equitable - all can access same range of services

Hospitals Two types:– GENERAL cardiac(stroke) centre (provides sub-acute and chronic care)

– COMPREHENSIVE cardiac(stroke) centre (provides acute care)

• Some consultant and other staff with ‘network’ responsibilities

POLICY: Structures - Networks

• Clinical management - cardiac (ACS)STEMI & treatable within 180 mins: primary PCI– Centres with access, workforce expertise and adequate cover

STEMI & not treatable within 180 mins: thrombolysis– Timely provision = priority

• Structures - cardiac– PCI: full range of imaging facilities/ 2 labs for timely access– CCU reconfigured - Critical Cardiac Care focus– Thrombolysis: pre-hospital/advanced paramedic and hospital

combination

POLICY: Hospital Care I

• Services– Emergency services: advanced paramedics/ICT essential

– Rapid Access Chest Pain Services

– Heart failure - ambulatory services: shared care model

– PAD services: vascular service access

– Cardiac surgery: workforce adequate

- Protected ICU beds (single room) the priority

– Congenital heart disease /GUCH: needs separate focus

POLICY: Hospital Care II

• Clinical management - stroke– Thrombolysis: ‘consultant stroke physician’ administered

24/7 cover needed

• Structures - stroke– Stroke units: capacity, MD Teams, care protocols, early start to

rehabilitation; discharge plan– TIA/Stroke Prevention Clinics: same day assessment; timely

access to vascular surgery where needed– Neuroradiology/Vascular Surgery: services access

POLICY: Hospital Care III

Philosophy - REDUCING THE INCIDENCE OF CVD: The European Heart Health Charter

“Every child born in the new millenium has the rightto live until the age of at least 65 without suffering from

avoidable cardiovascular disease” (June 2007)