CVD: Primary Care Intelligence Packs...founded the pioneering Dartmouth Atlas of Health Care,...

CVD: Primary Care Intelligence

Packs

June 2017

Version 1

NHS Wolverhampton CCG

Contents 1. Introduction 3

2. CVD prevention

• The narrative 11

• The data 13

3. Hypertension


• The data 17

4. Stroke


• The data 28

5. Diabetes


• The data 43

6. Kidney


• The data 54

7. Heart


• The data 66

8. Outcomes 82

9. Appendix 88

2

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CVD: Primary Care Intelligence Packs

3

Introduction


4

This intelligence pack has been compiled by GPs and nurses and pharmacists in

the Primary Care CVD Leadership Forum in collaboration with the National

Cardiovascular Intelligence Network

Matt Kearney Sarit Ghosh Kathryn Griffith

George Kassianos Jo Whitmore Matthew Fay

Chris Harris Jan Procter-King Yassir Javaid

Ivan Benett Ruth Chambers Ahmet Fuat

Mike Kirby Peter Green Kamlesh Khunti

Helen Williams Quincy Chuhka Sheila McCorkindale

Nigel Rowell Ali Morgan Stephen Kirk

Sally Christie Clare Hawley Paul Wright

Bruce Taylor Mike Knapton John Robson

Richard Mendelsohn Chris Arden David Fitzmaurice


Local intelligence as a tool for clinicians and commissioners

to improve outcomes for our patients

Why should we use this CVD Intelligence Pack

The high risk conditions for cardiovascular disease (CVD) - such as hypertension, atrial fibrillation, high cholesterol,

diabetes, non-diabetic hyperglycaemia and chronic kidney disease - are the low hanging fruit for prevention in the NHS

because in each case late diagnosis and suboptimal treatment is common and there is substantial variation. High

quality primary care is central to improving outcomes in CVD because primary care is where much prevention and

most diagnosis and treatment is delivered.

This cardiovascular intelligence pack is a powerful resource for stimulating local conversations about quality

improvement in primary care. Across a number of vascular conditions, looking at prevention, diagnosis, care and

outcomes, the data allows comparison between clinical commissioning groups (CCGs) and between practices.

This is not about performance management because we know that variation can have more than one interpretation.

But patients have a right to expect that we will ask challenging questions about how the best practices are achieving

the best, what average or below average performers could do differently, and how they could be supported to perform

as well as the best.

How to use the CVD intelligence pack

The intelligence pack has several sections – CVD prevention, hypertension, stroke and atrial fibrillation (AF), diabetes,

kidney disease, heart disease and heart failure. Each section has one slide of narrative that makes the case and asks

some questions. This is followed by data for a number of indicators, each with benchmarked comparison between

CCGs and between practices.

Use the pack to identify where there is variation that needs exploring and to start asking challenging questions about

where and how quality could be improved. We suggest you then develop a local action plan for quality improvement –

this might include establishing communities of practice to build clinical leadership, systematic local audit to get a better

understanding of the gaps in care and outcomes, and developing new models of care that mobilise the wider primary

care team to reduce burden on general practice.

5 CVD: Primary Care Intelligence Packs

6

Data and methods

This slide pack compares the clinical commissioning group (CCG) with CCGs in its strategic transformation plan (STP) and

England. Where a CCG is in more than one STP, it has been allocated to the STP with the greatest geographical or

population coverage. The slide pack also compares the CCG to its 10 most similar CCGs in terms of demography, ethnicity

and deprivation. 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/

The 10 most similar CCGs to NHS Wolverhampton CCG are:

NHS Walsall CCG

NHS Stoke On Trent CCG

NHS Bolton CCG

NHS Hillingdon CCG

NHS Tameside and Glossop CCG

NHS Heywood, Middleton and Rochdale CCG

NHS Trafford CCG

NHS Rotherham CCG

NHS Coventry and Rugby CCG

NHS Greater Huddersfield CCG

The majority of data used in the packs is taken from the 2015/16 Quality and Outcomes Framework (QOF). Where this is

not the case, this is indicated in the slide. All GP practices that were included in the 2015/16 QOF are included. Full

source data are shown in the appendix.

For the majority of indicators, the additional number of people that would be treated if all practices were to achieve as well

as the average of the top achieving practices is calculated. This is calculated by taking an average of the intervention rates

(ie the denominator includes exceptions) for the best 50% of practices in the CCG and applying this rate to all practices in

the CCG. Note, this number is not intended to be proof of a realisable improvement; rather it gives an indication of the

magnitude of available opportunity.


Benchmarking is helpful because it highlights

variation.

Of course it has long been acknowledged that some

variation is inevitable in the healthcare and outcomes

experienced by patients.

But John Wennberg, who has championed research

into clinical variation over four decades and who

founded the pioneering Dartmouth Atlas of Health

Care, concluded that much variation is unwarranted –

ie it cannot be explained on the basis of illness,

medical evidence, or patient preference, but is

accounted for by the willingness and ability of doctors

to offer treatment.

Benchmarking may not be conclusive. Its strength lies not in

the answers it provides but in the questions it generates for

CCGs and practices.

For example:

1. How much variation is there in detection, management,

exception reporting and outcomes?

2. How many people would benefit if average performers

improved to the level of the best performers?

3. How many people would benefit if the lowest performers

matched the achievement of the average?

4. What are better performers doing differently in the way

they provide services in order to achieve better outcomes?

5. How can the CCG support low and average performers to

help them match the achievement of the best?

6. How can we build clinical leadership to drive quality

improvement?

A key observation about benchmarking data is

that it does not tell us why there is variation. Some of the

variation may be explained by population or case mix and

some may be unwarranted. We will not know unless we

investigate.

The variation that exists between

demographically similar CCGs and

between practices illustrates the local

potential to improve care and outcomes

for our patients

There are legitimate reasons for exception reporting. But …….

Excepting patients from indicators puts them at risk of not receiving optimal care and of having worse outcomes. It is also

likely to increase health inequalities. The substantial variation seen in exception reporting for some indicators suggests

that some practices are more effective than others at reaching their whole population. Benchmarking exception reporting

allows us to identify the practices that need support to implement the strategies adopted by low excepting practices.

Why does variation matter?

7

Cluster methodology: your most similar practices

Each practice has been grouped on the basis of demographic data into

15 national clusters. These demographic factors cover:

• deprivation (practice level)

• age profile (% < 5, % < 18, % 15-24, % 65+, % 75+, % 85+)

• ethnicity (% population of white ethnicity)

• practice population side

These demographic factors closely align with those used to calculate

the “Similar 10 CCGs”.

These demographic factors have been used to compare practices with

similar populations to account for potential factors which may drive

variation. Some local interpretation will need to be applied to the data

contained within the packs as practices with significant outlying

population characteristics e.g. university populations or care home

practices will need further contextualisation.

Further detailed information including full technical methodology and a

full PDF report on each of the 15 practice clusters is available here:

https://github.com/julianflowers/geopractice.


https://github.com/julianflowers/geopractice

7

9

22

21

17

31

14

15

12

9

3

5

1

1

1

-20%-15%-10%-5%0%5%

WELLINGTON ROAD SURGERY

EMERSONS GREEN MEDICAL CENTRE

LEAP VALLEY MEDICAL CENTRE

CHRISTCHURCH FAMILY MEDICAL CENTRE

CONISTON MEDICAL PRACTICE

FROME VALLEY MEDICAL CENTRE

ST MARY STREET SURGERY

KINGSWOOD HEALTH CENTRE

CONCORD MEDICAL CENTRE

KENNEDY WAY SURGERY

BRADLEY STOKE SURGERY

THE WILLOW SURGERY

CLOSE FARM SURGERY

PILNING SURGERY

COURTSIDE SURGERY

ALMONDSBURY SURGERY

STOKE GIFFORD MEDICAL CENTRE

ORCHARD MEDICAL CENTRE

WEST WALK SURGERY

THORNBURY HEALTH CENTRE - BURNEY

The performance of every practice in the GP cluster contributes to the average of the top performing

50% of practices to form a benchmark.

The difference between the benchmark and the selected practices is displayed on this chart. The benchmark will

most likely be different for different practices as they are in different clusters, so the difference is the key measure

here. If the practice performance is below the benchmark, the difference is applied to the denominator plus

exceptions to demonstrate potential gains on a practice basis. The potential gains on a CCG basis are calculated

based on the difference between the top 5 performing closest CCGs and the selected CCG, applied to the

denominator plus exceptions.

Cluster methodology: calculating potential gains

Raw difference between the

practice value

and the average of the

highest or lowest 50% of

similar cluster practices

Potential opportunity if

the practice value was

to move to the average

of the highest 50% of

similar cluster practices

Potential opportunity if the

CCG value were to move

to the average of the top 5

performing closest CCGs


CVD prevention


CVD prevention “The NHS needs a radical upgrade

in prevention if it is to be

sustainable”

5 year Forward View 2014

The size of the prevention problem

• 2/3 of adults are obese or overweight

• 1/3 of adults are physically inactive

• average smoking prevalence is 17% but is much

higher in some communities

• in high risk conditions like atrial fibrillation, high blood

pressure, diabetes and high ten year CVD risk score,

up to half of all people do not receive preventive

treatments that are known to be highly effective at

preventing heart attacks and strokes

• around 90% of people with familial hypercholestero-

laemia are undiagnosed and untreated despite their

average 10 year reduction in life expectancy

This is because England faces an epidemic of largely

preventable non-communicable diseases, such as heart

disease and stroke, cancer, Type 2 diabetes and liver disease.

The Global Burden of Disease Study (next slide) shows us that

the leading causes of premature mortality include diet,

tobacco, obesity, raised blood pressure, physical inactivity and

raised cholesterol. The radical upgrade in prevention needs

population-level approaches. But it also needs interventions in

primary care for individuals with behavioural and clinical risk

factors.

0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12%

Unsafe water/ sanitation/ handwashing

Unsafe sex

Other environmental risks

Sexual abuse and violence

Child and maternal malnutrition

Low bone mineral density

Air pollution

Occupational risks

Low physical activity

Low glomerular filtration rate

High total cholesterol

High fasting plasma glucose

Alcohol and drug use

High systolic blood pressure

High body-mass index

Tobacco smoke

Dietary risks

HIV/AIDS and tuberculosis

Diarrhea, lower respiratory & other common infectious diseases

Neglected tropical diseases & malaria

Maternal disorders

Neonatal disorders

Nutritional deficiencies

Other communicable, maternal, neonatal, & nutritional diseases

Neoplasms

Cardiovascular diseases

Chronic respiratory diseases

Cirrhosis

Digestive diseases

Neurological disorders

Mental & substance use disorders

Diabetes, urogenital, blood, & endocrine diseases

Musculoskeletal disorders

Other non-communicable diseases

Transport injuries

Unintentional injuries

Self-harm and interpersonal violence

Forces of nature, war, & legal intervention

Percent of total disability-adjusted life-years (DALYs)

Social prescribing and wellbeing hubs offer new

models for supporting behaviour change while reducing

burden on general practice.

The NHS Health Check is a systematic approach to

identifying local people at high risk of CVD, offering

behaviour change support and early detection of the

high risk but often undiagnosed conditions such as

hypertension, atrial fibrillation, CKD, diabetes and pre-

diabetes.

Question: What proportion of our local eligible

population is receiving the NHS Health Check and how

effective is the follow-up management of their clinical

risk factors in primary care?

11 11 CVD: Primary Care Intelligence Packs

Global Burden of Disease Study 2015

Risk Factors for premature death and disability caused by CVD in England, expressed as a percentage of total disability-adjusted life-years

0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%

Other environmental risks

Low glomerular filtration rate

Air pollution

Low physical activity

High fasting plasma glucose

Tobacco smoke

High body-mass index

High total cholesterol

Dietary risks

High systolic blood pressure

Percentage of total CVD disability-adjusted life-years (DALYs)


15.9%

16.3%

18.7%

18.7%

20.2%

20.3%

20.5%

21.0%

21.9%

22.2%

22.6%

0% 5% 10% 15% 20% 25%

NHS Trafford CCG

NHS Hillingdon CCG




NHS Bolton CCG

NHS Rotherham CCG

NHS Walsall CCG




13

Estimated smoking prevalence (QOF) by CCG

Comparison with demographically similar CCGs

Note: It has been found that the proportion of

patients recorded as smokers correlates well

with IHS smoking prevalence and is a good

estimate of the actual smoking prevalence in

local areas,

http://bmjopen.bmj.com/content/4/7/e005217.abs

tract

Definition: denominator of QOF clinical indicator

SMOKE004 ( number of patients 15+ who are

recorded as current smokers) divided by GP

practice’s estimated number of patients 15+


• prevalence of 20.2% in NHS

Wolverhampton CCG

http://bmjopen.bmj.com/content/4/7/e005217.abstract

http://bmjopen.bmj.com/content/4/7/e005217.abstract

12.5%

12.8%

13.2%

14.6%

14.7%

15.7%

16.2%

16.3%

16.5%

16.5%

17.8%

17.9%

18.1%

18.3%

18.4%

19.2%

19.5%

19.5%

19.7%

19.7%

19.8%

20.6%

20.9%

21.2%

21.9%

22.1%

22.6%

22.8%

22.9%

23.5%

23.6%

24.0%

24.2%

24.8%

25.0%

25.2%

25.5%

25.6%

25.9%

26.5%

26.5%

26.9%

27.4%

28.9%

29.6%

31.7%

0% 5% 10% 15% 20% 25% 30% 35%

TETTENHALL MEDICAL PRACTICE M92010

CASTLECROFT MEDICAL PRACTICE M92008

PENN MANOR MEDICAL PRACTICE M92011

DRS PAHWA M92015

NEWBRIDGE SURGERY M92029

DRS DE ROSA & WILLIAMS M92044

ALL SAINTS SURGERY M92035

THE GROUP PRACTICE ALFRED SQUIRE ROAD M92002

PENN SURGERY M92043

DRS PASSI & HANDA M92031

PRESTBURY MEDICAL PRACTICE M92009

GROVE MEDICAL CENTRE M92612

DUNCAN STREET PRIMARY CARE PARTNERSHIP M92012

BRADLEY MEDICAL CENTRE M92647

COALWAY ROAD MEDICAL PRACTICE M92006

PRIMROSE LANE PRACTICE M92004

CAERLEON SURGERY M92027

ASHFIELD ROAD SURGERY M92609

80 TETTENHALL ROAD SURGERY M92042

PARKFIELD MEDICAL CENTRE M92024

DR ST PIERRE-LIBBERTON M92039

LEA ROAD MEDICAL PRACTICE M92007

WHITMORE REANS MEDICAL PRACTICE M92607

DR SHARMA M92627

DR BILAS M92026

MAYFIELD MEDICAL CENTRE M92040

DR MUDIGONDA M92649

DR FOWLER M92014

PROBERT ROAD SURGERY M92041

WODEN ROAD SURGERY M92013

DRS KHARWADKAR & MAJI M92629

TETTENHALL ROAD MEDICAL PRACTICE M92640

THORNLEY STREET MEDICAL CENTRE M92028

EAST PARK MEDICAL PRACTICE M92630

TUDOR MEDICAL CENTRE M92016

CHURCH STREET SURGERY M92030

DR SURYANI M92003

DRS RAJCHOLAN & GEORGE M92022

BILSTON URBAN VILLAGE MEDICAL CENTRE Y02757

KEATS GROVE SURGERY M92019

POPLARS MEDICAL CENTRE M92001

DR CHRISTOPHER M92643

ETTINGSHALL MEDICAL CENTRE Y02735

BAGARY'S MEDICAL PRACTICE M92654

SHOWELL PARK HEALTH & WALK IN CENTRE Y02736

INTRA HEALTH LIMITED Y02636

GP Practice CCG

14

Estimated smoking prevalence (QOF) by GP practice

Note: This method is thought to be a reasonably

robust method in estimating smoking prevalence

for the majority of GP practices. However,

caution is advised for extreme estimates of

smoking prevalence and those with high

numbers of smoking status not recorded and

exceptions.


• 44,300 people who are recorded as

smokers in NHS Wolverhampton

CCG

• GP practice range: 12.5% to 31.7%

Hypertension


16

The Missing Millions On average, each CCG in England has 26,000 residents with

undiagnosed hypertension – these individuals are unaware of

their increased cardiovascular risk and are untreated.

What might help? • support practices to share audit data and systematically

identify gaps and opportunities for improved detection and

management of hypertension

• work with practices and local authorities to maximise

uptake and follow up in the NHS Health Check

• support access to self-test BP stations in waiting rooms

and to ambulatory blood pressure monitoring.

• commission community pharmacists to offer blood

pressure measurement, diagnosis and management

support, including support for adherence to medication

What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement

and exception reporting?

2. how many people would benefit if all practices performed

as well as the best?

3. how can we support practices who are average or below

average to perform as well as the best in:

• detection of hypertension

• management of hypertension What do we know? • at least half of all heart attacks and strokes are

caused by high blood pressure and it is a major risk

factor for chronic kidney disease and cognitive decline

• treatment is very effective – every 10mmHg reduction

in systolic blood pressure lowers risk of heart attack

and stroke by 20%

• despite this 4 out of 10 adults with hypertension, over

5 and a half million people in England, remain

undiagnosed

• and even when the condition is identified, treatment is

often suboptimal, with blood pressure poorly

controlled in about 1 out of 3 individuals

Hypertension

High blood pressure is common and costly • it affects around a quarter of all adults

• the NHS costs of hypertension are around £2bn

• social costs are probably considerably higher


The Global Burden of Disease

Study confirmed high blood pressure as

a leading cause of premature death

and disability

0.59

0.59

0.59

0.61

0.64

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

England


NHS Sandwell And West Birmingham CCG

NHS Walsall CCG

NHS Dudley CCG

Ratio

0.59

0.59

0.59

0.61

0.64

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

England



NHS Walsall CCG

NHS Dudley CCG

Ratio

17

Hypertension observed prevalence compared with expected prevalence by CCG

Comparison with CCGs in the STP


Note: this slide shows Hypertension prevalence

estimates created using data from QOF

hypertension registers 2014/15 and

Undiagnosed hypertension estimates for adults

16 years and older. 2014. Department of Primary

Care & Public Health, Imperial College London

• the ratio of those diagnosed with

hypertension versus those expected

to have hypertension is 0.59. This

compares to 0.59 for England

• this suggests that 59% of people with

hypertension have been diagnosed

0.57

0.58

0.59

0.59

0.59

0.59

0.60

0.61

0.61

0.62

0.62

0% 10% 20% 30% 40% 50% 60% 70%


NHS Hillingdon CCG




NHS Bolton CCG

NHS Trafford CCG


NHS Walsall CCG

NHS Rotherham CCG


18

Hypertension observed prevalence compared with expected prevalence by CCG



0.36

0.37

0.43

0.46

0.47

0.48

0.48

0.49

0.51

0.52

0.53

0.53

0.53

0.53

0.54

0.54

0.55

0.55

0.55

0.56

0.57

0.57

0.58

0.58

0.59

0.60

0.62

0.62

0.62

0.63

0.63

0.63

0.64

0.64

0.64

0.65

0.65

0.66

0.68

0.68

0.70

0.70

0.71

0.72

0.74

0.85

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

DR BILAS M92026







PENN SURGERY M92043









DR FOWLER M92014











DR SHARMA M92627

DR SURYANI M92003


DR MUDIGONDA M92649










DRS PAHWA M92015






Ratio

GP practice CCG

19

Hypertension observed prevalence compared with expected prevalence by GP practice

• it is estimated that there are 27,287

people with undiagnosed

hypertension in NHS Wolverhampton

CCG

• GP practice range of observed to

expected hypertension prevalence

0.36 to 0.85


79.6%

77.7%

78.4%

78.5%

81.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

England

NHS Dudley CCG



NHS Walsall CCG

79.6%

77.7%

78.4%

78.5%

81.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

England

NHS Dudley CCG



NHS Walsall CCG

20

Percentage of patients with hypertension whose last blood pressure reading (measured in

the preceding 12 months) is 150/90 mmHg or less by CCG


*Using QOF clinical indicator HYP006

denominator plus exceptions

• 39,804 people with hypertension

(diagnosed)* in NHS Wolverhampton

CCG

• 31,218 (78.4%) people whose blood

pressure is <= 150/90

• 1,205 (3%) people who are excepted

from optimal control

• 7,381 (18.5%) additional people

whose blood pressure is not <=

150/90


78.4%

79.7%

79.7%

80.1%

80.8%

81.0%

81.2%

81.4%

81.4%

81.5%

81.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%


NHS Hillingdon CCG

NHS Trafford CCG




NHS Rotherham CCG

NHS Bolton CCG



NHS Walsall CCG

21

Percentage of patients with hypertension whose last blood pressure reading (measured in

the preceding 12 months) is 150/90 mmHg or less by CCG



31

52

65

64

86

284

45

71

80

64

77

139

126

162

158

375

155

162

151

337

426

45

212

145

101

49

145

174

147

76

180

104

253

104

156

209

411

148

553

211

468

110

464

383

365

263

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%







DR SURYANI M92003


DR SHARMA M92627















PENN SURGERY M92043



DR MUDIGONDA M92649



DR FOWLER M92014












DR BILAS M92026




DRS PAHWA M92015

No treatment Exceptions reported

22

Percentage of patients with hypertension whose last blood pressure reading

(measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice

• in total, including exceptions, there

are 8,586 people whose blood

pressure is not <= 150/90



66.5%

63.8%

75.0%

75.1%

79.4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

England

NHS Dudley CCG


NHS Walsall CCG


66.5%

63.8%

75.0%

75.1%

79.4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

England

NHS Dudley CCG


NHS Walsall CCG


23

New diagnosis of hypertension who have been given a CVD risk assessment whose

CVD risk exceeds 20% and treated with statins by CCG


• 100 people with a new diagnosis* of

hypertension with a CVD risk of 20%

or higher in NHS Wolverhampton

CCG

• 75 (75%) people who are currently

treated with statins

• 24 (24%) people who are exempted

from treatment with statins

• 1 (1%) additional people who are not

currently treated with statins

*Using the QOF clinical indicator CVD-PP001



58.2%

67.2%

68.8%

70.0%

71.4%

71.6%

71.7%

71.8%

74.4%

75.0%

75.1%

0% 10% 20% 30% 40% 50% 60% 70% 80%


NHS Bolton CCG




NHS Hillingdon CCG

NHS Rotherham CCG

NHS Trafford CCG



NHS Walsall CCG

58.2%

67.2%

68.8%

70.0%

71.4%

71.6%

71.7%

71.8%

74.4%

75.0%

75.1%

0% 10% 20% 30% 40% 50% 60% 70% 80%


NHS Bolton CCG




NHS Hillingdon CCG

NHS Rotherham CCG

NHS Trafford CCG



NHS Walsall CCG

24


CVD risk exceeds 20% and treated with statins by CCG



2

1

1

3

1

1

1

1

1

1

1

3

2

3

3

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


DR FOWLER M92014






DR MUDIGONDA M92649





DR SHARMA M92627



PENN SURGERY M92043






DR BILAS M92026




DRS PAHWA M92015





DR SURYANI M92003

















25


CVD risk exceeds 20% and not treated with statins by GP practice


are 25 people who are not treated

with statins



Stroke


27

Only a half of people with known

AF who then suffer a stroke have been

anticoagulated before their stroke.

Stroke is one of the leading causes of

premature death and disability. Stroke is

devastating for individuals and families, and

accounts for a substantial proportion of health

and social care expenditure.

What might help? • increase opportunistic pulse checking especially in over 65s

• support practices to share audit data and systematically

identify gaps and opportunities for improved detection and

management of AF - eg GRASP-AF

• promote systematic use of CHADS-VASC and HASBLED to

ensure those at high risk are offered stroke prevention

• promote systematic use of Warfarin Patient Safety Audit Tool

to ensure optimal time in therapeutic range for people on

warfarin

• develop local consensus statement on risk-benefit balance for

anticoagulants, including the newer treatments (NOACs)

• work with practices and local authorities to maximise uptake

and clinical follow up in the NHS Health Check

• commission community pharmacists to offer pulse checks,

anticoagulant monitoring, and support for adherence to

medication

What questions should we ask in our CCG? 1. for each indicator how wide is the variation in

detection, treatment and exception reporting?

2. how many people would benefit if all practices

performed as well as the best?

3. how can we support practices who are average

and below average to perform as well as the

best in detection of atrial fibrillation and stroke

prevention with anticoagulation.

Atrial fibrillation increases the risk of stroke

by a factor of 5, and strokes caused by AF are

often more severe, with higher mortality and

greater disability.

Anticoagulation reduces the risk of stroke in

people with AF by two thirds.

Despite this, AF is underdiagnosed and under

treated: up to a third of people with AF are

unaware they have the condition and even when

diagnosed inadequate treatment is common –

large numbers do not receive anticoagulants or

have poor anticoagulant control.

Stroke prevention


0.70

0.60

0.65

0.72

0.76

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

England



NHS Walsall CCG

NHS Dudley CCG

0.70

0.60

0.65

0.72

0.76

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

England



NHS Walsall CCG

NHS Dudley CCG

28

Atrial fibrillation observed prevalence compared to expected prevalence by CCG


Note: This slide compares the prevalence of

atrial fibrillation recorded in QOF in 2015/16 to

the estimated prevalence of atrial fibrillation,

taken from National Cardiovascular Intelligence

Network estimates produced in 2017. The

estimates were developed by applying age-sex

specific prevalence rates as reported by Norberg

et al (2013) to GP population estimates from

NHS Digital. Estimates reported are adjusted for

age and sex of the local population.

• the ratio of those diagnosed with atrial

fibrillation versus those expected to

have atrial fibrillation is 0.65. This

compares to 0.7 for England


atrial fibrillation have been diagnosed.


0.62

0.64

0.64

0.65

0.66

0.67

0.70

0.72

0.73

0.75

0.75

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8


NHS Hillingdon CCG




NHS Bolton CCG


NHS Walsall CCG

NHS Rotherham CCG

NHS Trafford CCG


29

Atrial fibrillation observed prevalence compared to expected prevalence by CCG



0.3

0.3

0.4

0.4

0.5

0.5

0.5

0.5

0.5

0.6

0.6

0.6

0.6

0.6

0.6

0.6

0.6

0.6

0.6

0.6

0.6

0.6

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.7

0.8

0.8

0.8

0.8

0.8

0.8

0.8

0.8

0.8

0.8

0.9

0.9

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0








DR FOWLER M92014





DR MUDIGONDA M92649






DRS PAHWA M92015







PENN SURGERY M92043












DR SHARMA M92627




DR BILAS M92026




DR SURYANI M92003

Ratio

GP practice CCG

30

Atrial fibrillation observed prevalence compared with expected prevalence by GP practice


people with undiagnosed atrial

fibrillation in NHS Wolverhampton

CCG

• GP practice range of observed to

expected atrial fibrillation prevalence

0.3 to 0.9


77.9%

73.9%

79.5%

80.3%

82.8%

0% 20% 40% 60% 80% 100%

England



NHS Walsall CCG

NHS Dudley CCG

Optimal management No treatment Exceptions reported

31

In patients with AF with a CHA2DS2-VASc score of 2 or more,

the percentage treated with anti-coagulation therapy by CCG


• 3,597 people with atrial fibrillation*

with a CHA2DS2-VASc score >= 2 in


• 2,659 (73.9%) people treated with

anti-coagulation therapy

• 418 (11.6%) people who are

exceptions

• 520 (14.5%) additional people with a

recorded CHA2DS2-VASc score >= 2

who are not treated

*Using the QOF clinical indicator AF007



72.2%

73.1%

73.9%

74.4%

76.5%

77.6%

79.0%

79.7%

80.3%

80.9%

83.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Hillingdon CCG




NHS Rotherham CCG

NHS Trafford CCG



NHS Walsall CCG


NHS Bolton CCG


32

In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage

treated with anti-coagulation therapy by CCG



1

1

2

3

1

7

33

18

11

13

32

19

15

22

50

16

5

15

30

45

14

8

16

23

19

18

9

15

16

14

14

71

28

24

16

7

68

35

32

33

21

19

35

15

16

13

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%






DR SURYANI M92003















DR SHARMA M92627



PENN SURGERY M92043



DR FOWLER M92014



DR MUDIGONDA M92649




DR BILAS M92026








DRS PAHWA M92015






33

In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated

with anti-coagulation therapy by GP practice


are 938 people with a recorded

CHA2DS2-VASc score >= 2 who are

not treated



9

10

10

22

12

12

18

17

19

4

2

3

2

1

1

-35%-30%-25%-20%-15%-10%-5%0%5%10%15%

SHOWELL PARK HEALTH & WALK IN CENTRE

ETTINGSHALL MEDICAL CENTRE

DRS PASSI & HANDA

LEA ROAD MEDICAL PRACTICE

DRS PAHWA

DRS RAJCHOLAN & GEORGE

NEWBRIDGE SURGERY

THORNLEY STREET MEDICAL CENTRE

WODEN ROAD SURGERY

BILSTON URBAN VILLAGE MEDICAL CENTRE

DRS DE ROSA & WILLIAMS

COALWAY ROAD MEDICAL PRACTICE

80 TETTENHALL ROAD SURGERY

DR SURYANI

PENN MANOR MEDICAL PRACTICE

DR CHRISTOPHER

POPLARS MEDICAL CENTRE

ALL SAINTS SURGERY

GROVE MEDICAL CENTRE

TETTENHALL ROAD MEDICAL PRACTICE

34 34 CVD: Primary Care Intelligence Packs

In patients with AF with a CHA2DS2-VASc score of 2 or more, the percentage treated

with anti-coagulation therapy by GP practice – opportunities compared to GP cluster

• using the GP cluster method of

calculating potential gains, if each

practice was to achieve as well as the

upper quartile of its national cluster,

then an additional 370 people would

be treated

Details of this methodology are available on slide

9. Click here to view them.

83.8%

82.3%

83.1%

83.6%

86.2%

0% 20% 40% 60% 80% 100%

England

NHS Dudley CCG



NHS Walsall CCG

Below 150/90 Not below 150/90 Exceptions reported

35

Percentage of patients with a history of stroke whose last blood pressure reading

(measured in the preceding 12 months) is 150/90 mmHg or less by CCG


*Using the QOF clinical indicator STIA003


• 4,736 people with a history of stroke

or TIA* in NHS Wolverhampton CCG


pressure is <= 150 / 90


exceptions

• 617 (13%) additional people whose

blood pressure is not <= 150 / 90


83.1%

83.3%

84.2%

84.5%

84.9%

85.1%

86.0%

86.2%

86.2%

86.4%

87.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


NHS Hillingdon CCG

NHS Trafford CCG



NHS Rotherham CCG


NHS Walsall CCG



NHS Bolton CCG


36

Percentage of patients with a history of stroke whose last blood pressure reading




1

6

5

5

4

9

5

9

19

4

5

7

14

2

33

7

11

36

11

8

11

6

14

13

15

18

32

12

18

14

13

16

60

14

55

31

24

31

33

57

7

25

21

37

23

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%




DR SHARMA M92627


DR SURYANI M92003

















DR FOWLER M92014


DR BILAS M92026





PENN SURGERY M92043


DR MUDIGONDA M92649














DRS PAHWA M92015


37

Percentage of patients with a history of stroke whose last blood pressure reading (measured

in the preceding 12 months) is not 150/90 mmHg or less by GP practice


are 801 people whose blood pressure

is not <= 150 / 90



91.8%

90.9%

91.3%

92.1%

93.6%

0% 20% 40% 60% 80% 100%

England

NHS Dudley CCG



NHS Walsall CCG


38

Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA,

who have a record in the preceding 12 months that an anti-platelet agent, or an

anti-coagulant is being taken by CCG


*Using the QOF clinical indicator STIA007



• 3,104 people with a stroke shown to

be non-haemorrhagic* in NHS

Wolverhampton CCG

• 2,858 (92.1%) people who are taking

an anti-platetet agent or anti-

coagulant

• 154 (5%) people who are exceptions

• 92 (3%) additional people with no

treatment

90.8%

91.9%

92.0%

92.1%

92.2%

92.4%

92.5%

92.6%

92.6%

93.1%

93.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Hillingdon CCG

NHS Rotherham CCG




NHS Trafford CCG



NHS Bolton CCG


NHS Walsall CCG


39


who have a record in the preceding 12 months that an anti-platelet agent,

or an anti-coagulant is being taken by CCG



2

1

1

2

2

1

2

1

7

2

2

2

1

4

4

5

7

4

4

6

2

2

4

7

14

8

5

13

3

8

5

15

5

16

6

13

4

6

11

13

6

2

18

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%



DR SURYANI M92003











DR MUDIGONDA M92649

DR SHARMA M92627


PENN SURGERY M92043

DR BILAS M92026






DRS PAHWA M92015








DR FOWLER M92014
















40


who do not have a record in the preceding 12 months that an anti-platelet agent,

or an anti-coagulant is being taken by GP practice



are 246 people who are not taking an

anti-platelet agent or anti-coagulant


Diabetes


Type 2 Diabetes in numbers • diagnosed prevalence – 3.0 million

• undiagnosed diabetes – 900,000

• non-diabetic hyperglycaemia (high risk of diabetes) – 5 million

What might help • ensure universal participation by practices in the National

Diabetes Audit (NDA)

• benchmark practice level data from the NDA – and support

practices to explore variation

• increase support for patient education and shared

management

• maximise uptake of the NHS Health Check to aid detection of

diabetes and Non Diabetic Hyperglycaemia

• maximise uptake of the NHS Diabetes Prevention Programme

What questions should we ask in our CCG? 1. for each indicator how wide is the variation in achievement and

exception reporting?

2. how many people would benefit if all practices performed as well

as the best?

3. how can we support practices who are average and below

average to perform as well as the best in:

• detection of diabetes

• delivery of the 8 care processes and achievement of the 3

treatment targets

• identification and management of Non-diabetic hyperglycaemia

Type 2 diabetes is often preventable People at high risk of developing type 2 diabetes

can be identified through the NHS Health Check,

and the disease can be prevented or delayed in

many through intensive behaviour change support.

Complications of diabetes are preventable Diabetes is a major cause of premature death and

disability and greatly increases the risk of heart

disease and stroke, kidney failure, amputations and

blindness. 80% of NHS spending on diabetes goes

on managing these complications, most of which

could be prevented. There are 8 essential care

processes, in addition to retinal screening, that

together substantially reduce complication rates.

Despite this, around a half of people with diabetes

do not receive all 8 care processes, and there is

widespread variation between CCGs and practices

in levels of achievement

Diabetes prevention and management


Diabetes costs the NHS

£9.8 billion per year – and the

prevalence is rising

0.77

0.74

0.79

0.81

0.87

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

England


NHS Dudley CCG


NHS Walsall CCG

0.77

0.74

0.79

0.81

0.87

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

England


NHS Dudley CCG


NHS Walsall CCG

43

Diabetes observed prevalence compared with expected prevalence by CCG



Note: This slide compares the prevalence of

Diabetes recorded in QOF in 2015/16 to the

expected prevalence of Diabetes in 2016 taken

from the NCVIN diabetes prevalence model

produced in 2015.

• 0.74 ratio of observed to expected

diabetes prevalence in NHS

Wolverhampton CCG, compared to

0.77 in England

• this suggests 74% of people have

been diagnosed

0.70

0.74

0.78

0.78

0.79

0.81

0.85

0.86

0.87

0.89

0.89

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0




NHS Rotherham CCG

NHS Trafford CCG

NHS Hillingdon CCG



NHS Walsall CCG

NHS Bolton CCG


44

Diabetes observed prevalence compared with expected prevalence by CCG



4.7%

4.8%

5.3%

5.5%

5.5%

5.6%

6.6%

6.9%

6.9%

7.0%

7.0%

7.3%

7.3%

7.4%

7.4%

7.5%

7.6%

7.6%

7.8%

7.8%

7.9%

7.9%

7.9%

8.0%

8.0%

8.0%

8.2%

8.3%

8.4%

8.4%

8.7%

8.7%

8.8%

8.9%

9.0%

9.2%

9.6%

10.1%

10.4%

10.5%

10.6%

10.7%

11.3%

11.3%

11.7%

12.2%

0% 2% 4% 6% 8% 10% 12% 14%








PENN SURGERY M92043










DR FOWLER M92014







DR MUDIGONDA M92649

DR BILAS M92026





DR SHARMA M92627











DR SURYANI M92003


DRS PAHWA M92015



GP practice CCG

45

Diabetes prevalence by GP practice

• GP practice range of observed

diabetes 4.7% to 12.2%

• there are an estimated 6,092 people

with undiagnosed diabetes in NHS

Wolverhampton CCG


Note: The estimated number of undiagnosed

people with diabetes has been calculated by

multiplying the estimated prevalence rate to the

2015/16 QOF list size and subtracting the

number of people on the diabetes register.

6.5%

7.3%

8.8%

9.2%

8.2%

1.9%

2.0%

1.3%

2.1%

2.9%

11.2%

12.4%

12.6%

12.4%

13.0%

0% 5% 10% 15% 20% 25% 30%

England

NHS Dudley CCG

NHS Walsall CCG



Diabetes prevalence Undiagnosed diabetes prevalence

Expected non-diabetic hyperglycaemia prevalence

6.5%

7.3%

8.8%

9.2%

8.2%

1.9%

2.0%

1.3%

2.1%

2.9%

11.2%

12.4%

12.6%

12.4%

13.0%

0% 5% 10% 15% 20% 25% 30%

England

NHS Dudley CCG

NHS Walsall CCG



Diabetes prevalence Undiagnosed diabetes prevalence

Expected non-diabetic hyperglycaemia prevalence

46

Expected total prevalence of diabetes and non-diabetic hyperglycaemia

• the estimated total prevalence of

diabetes in NHS Wolverhampton

CCG is 11.0% (diagnosed and

undiagnosed)

• in addition, there are an estimated

13.0% of people in NHS

Wolverhampton CCG who are at

increased risk of developing diabetes

(i.e. with non-diabetic

hyperglycaemia)

Note: Prevalence estimates of non-diabetic

hyperglycaemia were developed using Health

Survey for England (HSE) data. Five years of

HSE data were combined, 2009- 2013. The

estimates take into account the age, ethnic group

and estimated body mass index of the population.

These estimates were produced using the GP

registered population.


• this means that 24.0% of the

population in NHS Wolverhampton

CCG are estimated to have diabetes,

or at high risk of developing of

diabetes

52.6%

45.5%

45.6%

57.6%

57.7%

0% 10% 20% 30% 40% 50% 60% 70%

England



NHS Walsall CCG

NHS Dudley CCG

52.6%

45.5%

45.6%

57.6%

57.7%

0% 10% 20% 30% 40% 50% 60% 70%

England



NHS Walsall CCG

NHS Dudley CCG

47

People with diabetes who had eight care processes by CCG 2015/16

• overall practice participation in the

2015/16 audit was 81.4% in England

• data on care processes and treatment

targets are taken from the National


• in NHS Wolverhampton CCG, 46 out

of 46 practices (100.0%) participated

in the NDA


• 45.5% of people with diabetes (of

practices who participated in the

audit) had the eight recommended

care processes in NHS

Wolverhampton CCG, compared to

52.6% in England

5.7%

11.6%

11.7%

11.8%

15.0%

15.3%

16.7%

21.1%

21.8%

23.5%

25.4%

26.0%

26.2%

26.7%

28.1%

29.8%

31.1%

34.5%

36.2%

39.1%

39.2%

40.5%

41.3%

41.8%

45.0%

45.5%

46.6%

46.8%

48.5%

50.2%

55.9%

56.5%

57.7%

58.7%

60.9%

61.2%

63.9%

64.8%

66.3%

67.0%

67.0%

70.3%

72.5%

72.7%

72.8%

75.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%



DR MUDIGONDA M92649

DR SHARMA M92627





DRS PAHWA M92015


DR FOWLER M92014

























DR SURYANI M92003



PENN SURGERY M92043







DR BILAS M92026

GP practice Average of practices in the CCG who participated in the audit

48

People with diabetes who had eight care processes by GP practice, 2015/16


• achievement - 8 care processes: in

practices who provided data via the

NDA, between 5.7% and 75.3% of

patients received all 8 care processes

• at least 9,456 people did not receive

the eight care processes

39.0%

35.7%

41.6%

42.7%

43.3%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

England


NHS Dudley CCG


NHS Walsall CCG

39.0%

35.7%

41.6%

42.7%

43.3%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

England


NHS Dudley CCG


NHS Walsall CCG

49

People with diabetes who met all 3 treatment targets by CCG, 2015/16


• 35.7% of people with diabetes (of

practices who participated in the

audit) met the three treatment targets

in NHS Wolverhampton CCG,

compared to 39.0% in England

24.2%

24.7%

24.9%

26.2%

26.8%

26.8%

27.2%

27.2%

27.5%

27.6%

27.6%

28.0%

28.2%

29.4%

31.5%

32.6%

32.9%

33.8%

34.0%

34.1%

34.6%

35.1%

35.9%

35.9%

36.6%

37.6%

37.7%

37.9%

38.5%

38.7%

39.1%

39.3%

39.3%

39.5%

39.8%

40.0%

40.4%

44.9%

45.1%

47.9%

48.0%

49.5%

49.7%

50.5%

52.6%

59.9%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%











DRS PAHWA M92015


DR FOWLER M92014



PENN SURGERY M92043






















DR MUDIGONDA M92649

DR BILAS M92026





DR SHARMA M92627


DR SURYANI M92003

GP practice Average of practices in the CCG who participated in the audit

50

People with diabetes who met all 3 treatment targets by GP practice, 2015/16


• achievement - 3 treatment targets: in

practices who provided data via the

NDA, between 24.2% and 59.9% of

patients achieved all 3 treatment

targets

• at least 9,817 people did not meet the

three treatment targets

86

42

19

54

115

56

50

59

85

20

5

19

1

-25%-20%-15%-10%-5%0%5%10%15%

WODEN ROAD SURGERY

DRS PAHWA

DR CHRISTOPHER

PROBERT ROAD SURGERY

DUNCAN STREET PRIMARY CARE PARTNERSHIP

ASHFIELD ROAD SURGERY


THORNLEY STREET MEDICAL CENTRE


DR FOWLER

DR BILAS

WHITMORE REANS MEDICAL PRACTICE

DR MUDIGONDA



EAST PARK MEDICAL PRACTICE

MAYFIELD MEDICAL CENTRE

DR SHARMA

CHURCH STREET SURGERY

DR SURYANI

51

People with diabetes who met all 3 treatment targets by GP practice, 2015/16

- opportunities compared to GP cluster






then an additional 1,473 people would

be treated



Kidney


Chronic Kidney Disease can

progress to kidney failure and it

substantially increases the risk

of heart attack and stroke.

Chronic Kidney Disease (CKD) is common.

It is one of the commonest co-morbidities and affects a third

of people over 75. In 2010 it was estimated to cost the NHS

around £1.5bn. Average length of stay in hospital tends to

be longer and outcomes are considerably worse:

approximately 7,000 excess strokes and 12,000 excess

heart attacks occur each year in people with CKD

compared to those without.

Individuals with CKD are also at much higher risk of

developing acute kidney injury when they have an

intercurrent illness such as pneumonia What might help • Support practices to share audit data and systematically

identify gaps and opportunities for improved detection

and management of CKD.

• Promote uptake of and follow up from the NHS Health

Check to aid detection and management of CKD

• Offer local training and education in the detection and

management of CKD


achievement and exception reporting?

2. how many people would benefit if all practices

performed as well as the best?

3. how can we support practices who are average and

below average to perform as well as the best in:

• detection of CKD

• more systematic delivery of evidence based care

Late diagnosis of CKD is common. Around a third of people with CKD are undiagnosed. More

opportunistic testing and improved uptake of the NHS

Health Check will increase detection rates.

Evidence based guidance from NICE highlights CVD

risk reduction, good blood pressure control and

management of proteinuria as essential steps to reduce the

risk of cardiovascular events and progression to kidney

failure. Despite this there is often significant variation

between practices in achievement and exception reporting.

Management of chronic kidney disease


0.68

0.67

0.69

0.82

0.93

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

England



NHS Walsall CCG

NHS Dudley CCG

Ratio

0.68

0.67

0.69

0.82

0.93

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

England



NHS Walsall CCG

NHS Dudley CCG

Ratio

54

Chronic kidney disease (CKD) observed prevalence (2015/16) compared

with expected prevalence (2011) by CCG


Note: This slide compares the prevalence of CKD

recorded in QOF in 2015/16 to the expected

prevalence of CKD produced by the University of

Southampton in 2011. A small number of CCGs

have a ratio greater than 1. It is unlikely that all

people with CKD will be diagnosed in any CCG

and therefore a ratio greater than 1 suggests that

the figures are underestimating the true CKD

prevalence in the area. These ratios should be

taken as an indication of the comparative scale of

undiagnosed CKD rather than absolute figures.

• the ratio of those diagnosed with

chronic kidney disease versus those

expected to have chronic kidney

disease is 0.67. This compares to

0.68 for England


chronic kidney disease have been

diagnosed


0.50

0.52

0.57

0.65

0.66

0.67

0.68

0.72

0.75

0.82

0.98

0.0 0.2 0.4 0.6 0.8 1.0 1.2

NHS Hillingdon CCG






NHS Trafford CCG

NHS Rotherham CCG


NHS Walsall CCG

NHS Bolton CCG

Ratio

55

Chronic kidney disease (CKD) observed prevalence (2015/16)

compared with expected prevalence (2011) by CCG



0.7%

1.2%

1.4%

2.1%

2.4%

2.5%

2.6%

2.8%

2.9%

3.0%

3.0%

3.2%

3.3%

3.3%

3.7%

3.8%

3.8%

3.9%

4.0%

4.2%

4.2%

4.2%

4.3%

4.3%

4.4%

4.4%

4.4%

4.4%

4.6%

4.7%

4.7%

4.8%

4.9%

5.0%

5.4%

5.4%

5.4%

5.8%

5.9%

5.9%

5.9%

6.2%

6.4%

6.5%

7.4%

7.7%

0% 1% 2% 3% 4% 5% 6% 7% 8% 9%







DR FOWLER M92014








DR BILAS M92026









PENN SURGERY M92043









DR MUDIGONDA M92649


DRS PAHWA M92015








DR SHARMA M92627



DR SURYANI M92003

GP practice CCG

56

CKD prevalence by GP practice, 2015/16

Note: CCG estimates for the estimated

number of people with CKD are based on

applying a proportion from a resident based

population estimate to a GP registered

population. The characteristics of registered

and resident populations may vary in some

CCGs, and local interpretation is required.


people with undiagnosed chronic

kidney disease in NHS

Wolverhampton CCG

• GP practice range of observed CKD:

0.7% to 7.7%


74.4%

73.0%

74.5%

74.6%

79.2%

0% 20% 40% 60% 80% 100%

England



NHS Dudley CCG

NHS Walsall CCG


57

Percentage of patients on the CKD register whose last blood pressure reading (measured in

the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15


*Using the QOF clinical indicator CKD002

denominator plus exceptions. Note: as

the CKD002 indicator was removed from

the QOF in 15/16 this is historic data

taken from the 2014/15 QOF.

• 9,052 people with CKD (diagnosed*)

in NHS Wolverhampton CCG

• 6,605 (73%) people whose blood

pressure is <= 140 /85


exceptions

• 1,840 (20.3%) additional people

whose blood pressure is not <= 140 /

85


73.0%

73.8%

74.0%

75.4%

76.2%

77.1%

77.2%

78.1%

78.3%

79.2%

79.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


NHS Rotherham CCG



NHS Trafford CCG

NHS Hillingdon CCG

NHS Bolton CCG



NHS Walsall CCG



58

Percentage of patients on the CKD register whose last blood pressure reading (measured

in the preceding 12 months) is 140/85 mmHg or less by CCG, 2014/15



17

22

62

15

19

12

23

32

48

35

23

31

18

21

20

25

14

37

35

95

46

23

13

43

28

46

7

62

21

12

61

65

141

128

109

15

179

100

54

58

6

106

230

102

78

52

58

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

OHRI & PARTNERS M92040

DR SHARMA M92627



LAL M92647


DR MUDIGONDA M92649


DR LINNEMANN M92039






DR SURYANI M92003

DR BILAS M92026

WHITEHOUSE M92640


DRS PAHWA M92015

ASHTON AND PARTNERS M92010


KEHLER & PARTNER M92019


PENN SURGERY M92043


DR ASGHAR M92027


MGS MEDICAL PRACTICE M92654



DR RICHARDSON & PARTNERS M92028



WAGSTAFF & PARTNERS M92008

WHITE & PARTNERS M92011

DR FOWLER M92014

PARKES & PARTNERS M92002

DR AGARWAL & PARTNERS M92012

RAJCHOLAN & GEORGE M92022



DRS MANLEY GUEST AND COWEN M92006

PRESTWOOD ROAD WEST SURGERY M92009

DR SIDHU & PARTNERS M92007

DR JONES & PARTNERS M92013

MUNDLUR & PARTNERS M92642


Not below 140/85 Exceptions reported

59

Percentage of patients on the CKD register whose last blood pressure reading (measured in

the preceding 12 months) is not 140/85 mmHg or less by GP practice, 2014/15



pressure is not <= 140 / 85



44

50

64

4

59

58

118

32

30

86

0

-60%-50%-40%-30%-20%-10%0%10%


DR JONES & PARTNERS

DR SIDHU & PARTNERS

DR CHRISTOPHER

DRS MANLEY GUEST AND COWEN

DR AGARWAL & PARTNERS

PRESTWOOD ROAD WEST SURGERY

PROBERT ROAD SURGERY

RAJCHOLAN & GEORGE

PARKES & PARTNERS

ASHTON AND PARTNERS

DR LINNEMANN

CHURCH STREET SURGERY

DR MUDIGONDA

ETTINGSHALL MEDICAL CENTRE

PRIMROSE LANE PRACTICE

LAL

DR SHARMA

OHRI & PARTNERS


60

Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding

12 months) is not 140/85 mmHg or less by GP practice, 2014/15 – opportunities compared to GP cluster






be treated




75.4%

75.9%

76.6%

76.8%

81.2%

0% 20% 40% 60% 80% 100%

England

NHS Dudley CCG



NHS Walsall CCG

Recorded Not recorded Exceptions reported

61

Percentage of patients on the CKD register whose notes have a record of a

urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15


• 9,016 people with CKD (diagnosed*)

in NHS Wolverhampton CCG

• 6,903 (76.6%) people who have a

record of urine albumin:creatinine

ratio test


exceptions

• 1,740 (19.3%) additional people who

have no record of urine

albumin:creatinine ratio test

*Using the QOF clinical indicator CKD004

denominator plus exceptions. Note: as

the CKD004 indicator was removed from

the QOF in 15/16 this is historic data

taken from the 2014/15 QOF.


72.5%

76.6%

78.2%

78.5%

78.6%

79.2%

79.2%

79.8%

80.5%

80.8%

81.2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Rotherham CCG


NHS Trafford CCG


NHS Hillingdon CCG




NHS Bolton CCG


NHS Walsall CCG

Recorded Not recorded Exceptions reported

62

Percentage of patients on the CKD register whose notes have a record of a

urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2014/15



11

15

15

10

21

13

16

2

63

4

35

11

17

28

25

31

15

17

76

8

15

38

36

26

25

49

22

101

114

17

75

13

55

44

47

50

65

83

152

44

31

84

74

64

245

29

82

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


DR SHARMA M92627

DR JONES & PARTNERS M92013

DR SURYANI M92003



OHRI & PARTNERS M92040


ASHTON AND PARTNERS M92010


MGS MEDICAL PRACTICE M92654

WHITEHOUSE M92640


PENN SURGERY M92043



MUNDLUR & PARTNERS M92642







LAL M92647

DR BILAS M92026

DRS MANLEY GUEST AND COWEN M92006



PRESTWOOD ROAD WEST SURGERY M92009


WHITE & PARTNERS M92011



DR ASGHAR M92027


DRS PAHWA M92015

DR SIDHU & PARTNERS M92007

DR LINNEMANN M92039

PARKES & PARTNERS M92002

DR MUDIGONDA M92649

KEHLER & PARTNER M92019

DR AGARWAL & PARTNERS M92012

DR RICHARDSON & PARTNERS M92028

RAJCHOLAN & GEORGE M92022

WAGSTAFF & PARTNERS M92008

DR FOWLER M92014


Not recorded Exceptions reported

63

Percentage of patients on the CKD register whose notes do not have a record of a

urine albumin: creatinine ratio test in the preceding 12 months by GP practice, 2014/15


are 2,113 people who have no record

of urine albumin:creatinine ratio test



Heart


Coronary Heart Disease is one of the principal causes of

premature death and disability. The key elements of management for

an individual who has already had a heart attack or angina are

symptom control and secondary prevention of further cardiovascular

events and premature mortality. There is robust evidence to support the

use of anti-platelet treatment, statins, beta-blockers and angiotensin

converting enzyme inhibitors or angiotensin receptor blockers. There is

also robust evidence to support good control of blood pressure. Each of

these interventions is incentivised in QOF but variation in achievement

and exception reporting at practice level shows that there is often

considerable potential for improving management and outcomes.

What might help 1. roll out of GRASP-Heart Failure audit tool

that identifies people with heart failure who

are undiagnosed or under treated

2. education for health professionals to

promote evidence based management of

CHD and high quality measurement of

blood pressure

3. ensure access to rapid access diagnostic

clinics and specialist support for

management of angina and heart failure

4. ensure access to cardiac rehab for

individuals with CHD and heart failure


achievement and exception reporting?

2. how many people would benefit if all

practices performed as well as the best?

3. how can we support practices who are

average and below average to perform as

well as the best in:

• more systematic delivery of evidence

based care for people with CHD

• improved detection and management

of heart failure

Heart failure is a common and an important complication of

coronary heart disease and other conditions. Appropriate treatment

including up-titration of ace inhibitors and beta blockers in heart failure

due to LVSD can significantly improve symptom control and quality of

life, and improve outcomes for patients. Despite this, around a quarter

of people with heart failure are undetected and untreated. And amongst

those who are diagnosed, there is significant variation in the quality of

care.

Management of Heart Disease


Premature death and disability in people with

CHD can be reduced significantly by systematic

evidence based management in primary care

0.76%

0.68%

0.84%

0.88%

1.00%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2%

England


NHS Dudley CCG


NHS Walsall CCG

0.76%

0.68%

0.84%

0.88%

1.00%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2%

England


NHS Dudley CCG


NHS Walsall CCG

66

Heart failure prevalence by CCG


• prevalence of 0.88% in NHS

Wolverhampton CCG compared to

0.76% in England


0.49%

0.65%

0.74%

0.78%

0.80%

0.83%

0.85%

0.85%

0.87%

0.88%

1.00%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2%

NHS Hillingdon CCG



NHS Bolton CCG




NHS Rotherham CCG

NHS Trafford CCG


NHS Walsall CCG

67

Heart failure prevalence by CCG



0.2%

0.3%

0.3%

0.3%

0.3%

0.4%

0.5%

0.5%

0.5%

0.6%

0.6%

0.6%

0.7%

0.7%

0.7%

0.7%

0.8%

0.8%

0.8%

0.8%

0.8%

0.8%

0.9%

0.9%

0.9%

0.9%

0.9%

0.9%

0.9%

0.9%

1.0%

1.0%

1.0%

1.0%

1.1%

1.1%

1.1%

1.1%

1.2%

1.2%

1.4%

1.5%

1.5%

1.5%

1.6%

1.8%

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8% 2.0%
































DR MUDIGONDA M92649



PENN SURGERY M92043


DR FOWLER M92014

DR SHARMA M92627

DR BILAS M92026



DR SURYANI M92003



DRS PAHWA M92015


GP practice CCG

68

Heart failure prevalence by GP practice

• 2,383 people with diagnosed heart

failure in NHS Wolverhampton CCG



84.7%

81.7%

84.3%

85.4%

87.2%

0% 20% 40% 60% 80% 100%

England


NHS Walsall CCG

NHS Dudley CCG


Treatment No treatment Exceptions reported

69

Percentage of patients with heart failure due to left ventricular systolic dysfunction

(LVSD) who are treated with ACE-I / ARB by CCG


• 1,122 people with heart failure* with

LVSD in NHS Wolverhampton CCG

• 917 (81.7%) people treated with ACE-

I or ARB


exceptions

• 6 (0.5%) additional people who are

not treated with ACE-I or ARB

*Using the QOF clinical indicator HF003



80.4%

81.7%

84.1%

84.3%

84.8%

85.1%

85.6%

86.4%

87.6%

88.2%

89.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Rotherham CCG



NHS Walsall CCG

NHS Trafford CCG

NHS Bolton CCG



NHS Hillingdon CCG




70


(LVSD) who are treated with ACE-I / ARB by CCG



1

1

1

3

2

2

1

1

2

1

3

4

4

1

2

5

11

11

6

3

5

7

16

3

4

3

7

3

5

3

13

8

3

16

7

9

1

4

8

10

5

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%




DR SURYANI M92003








DRS PAHWA M92015












DR BILAS M92026





DR MUDIGONDA M92649

DR SHARMA M92627










PENN SURGERY M92043



DR FOWLER M92014





71


(LVSD) who are not treated with ACE-I / ARB by GP practice



with ACE-I or ARB



77.7%

70.6%

75.7%

78.0%

81.7%

0% 20% 40% 60% 80% 100%

England



NHS Dudley CCG

NHS Walsall CCG


72

Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD)

who are treated with ACE-I / ARB and BB by CCG


• 910 people with heart failure* with

LVSD treated with ACE-I/ARB in NHS

Wolverhampton CCG

• 689 (75.7%) people treated with ACE-

I/ARB and BB

• 146 (16%) people who are exceptions

• 75 (8.2%) additional people who are

not treated with ACE-I/ARB and BB

*Using the QOF clinical indicator HF004



72.6%

75.7%

76.0%

76.8%

77.5%

79.8%

81.7%

82.2%

82.5%

83.0%

83.0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NHS Hillingdon CCG




NHS Bolton CCG


NHS Walsall CCG

NHS Rotherham CCG



NHS Trafford CCG


73

Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD)

who are treated with ACE-I / ARB and BB by CCG



1

1

1

1

2

1

5

11

4

2

3

3

6

1

1

1

6

5

10

5

2

3

7

5

7

5

7

15

2

6

13

5

4

4

10

23

5

5

14

9

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%





DR FOWLER M92014


DR MUDIGONDA M92649



DRS PAHWA M92015








DR SHARMA M92627




DR SURYANI M92003









DR BILAS M92026







PENN SURGERY M92043










74

Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who

are not treated with ACE-I / ARB and BB by GP practice



with ACE-I or ARB



88.2%

86.2%

86.8%

87.0%

90.8%

0% 20% 40% 60% 80% 100%

England

NHS Dudley CCG



NHS Walsall CCG


75

Percentage of patients with CHD whose blood pressure reading



*Using the QOF clinical indicator CHD002


• 9,017 people with coronary heart

disease* in NHS Wolverhampton

CCG


pressure <= 150 / 90


exceptions

• 890 (9.9%) additional people whose

blood pressure is not <= 150 / 90


86.8%

88.3%

88.4%

88.9%

89.1%

89.3%

89.9%

90.1%

90.1%

90.2%

90.8%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


NHS Rotherham CCG

NHS Trafford CCG


NHS Hillingdon CCG



NHS Bolton CCG



NHS Walsall CCG


76





3

4

26

11

4

25

11

8

9

13

12

35

20

12

10

9

12

11

16

20

7

12

10

8

20

4

18

12

21

18

31

29

7

67

17

83

34

101

36

55

44

48

66

109

61

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%









DR MUDIGONDA M92649








DR SHARMA M92627





DR SURYANI M92003



DR FOWLER M92014







PENN SURGERY M92043








DR BILAS M92026






DRS PAHWA M92015

Not below 150/90 Exceptions reported

77


(measured in the preceding 12 months) is not 150/90 mmHg or less by GP practice



pressure is not <= 150 / 90



49

78

46

33

38

29

24

20

10

4

-30%-25%-20%-15%-10%-5%0%5%10%

DRS PAHWA

THE GROUP PRACTICE ALFRED SQUIRE ROAD

WODEN ROAD SURGERY


DUNCAN STREET PRIMARY CARE PARTNERSHIP


DR BILAS

KEATS GROVE SURGERY

BILSTON URBAN VILLAGE MEDICAL CENTRE

INTRA HEALTH LIMITED

TETTENHALL MEDICAL PRACTICE

DR MUDIGONDA

MAYFIELD MEDICAL CENTRE

DRS KHARWADKAR & MAJI

DRS DE ROSA & WILLIAMS

PENN MANOR MEDICAL PRACTICE





78

Percentage of patients with CHD whose blood pressure reading (measured

in the preceding 12 months) is not 150/90 mmHg or less by GP practice –

opportunities compared to GP cluster






be treated




91.8%

90.6%

90.7%

91.6%

93.5%

0% 20% 40% 60% 80% 100%

England

NHS Dudley CCG



NHS Walsall CCG


79

Percentage of patients with CHD with a record in the preceding 12 months that aspirin,

an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG


*Using the QOF clinical indicator CHD005


• 9,029 people with coronary heart

disease* in NHS Wolverhampton

CCG

• 8,270 (91.6%) people who are taking

aspirin, an alternative anti-platelet

therapy, or an anti-coagulant


exceptions

• 364 (4%) additional people who are

not taking aspirin, an alternative anti-

platelet therapy, or an anti-coagulant


90.5%

91.6%

91.6%

92.4%

92.4%

92.6%

92.6%

93.4%

93.5%

93.5%

93.8%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


NHS Rotherham CCG


NHS Bolton CCG



NHS Trafford CCG


NHS Hillingdon CCG

NHS Walsall CCG



80

Percentage of patients with CHD with a record in the preceding 12 months that aspirin,

an alternative anti-platelet therapy, or an anti-coagulant is being taken by CCG



7

3

2

2

6

7

4

4

6

5

21

7

9

9

4

5

10

10

29

14

9

13

10

10

19

12

14

4

43

15

21

4

64

22

20

33

29

57

14

50

13

31

29

42

17

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%



DR SHARMA M92627


DR SURYANI M92003











DR FOWLER M92014


DRS PAHWA M92015






DR MUDIGONDA M92649












DR BILAS M92026







PENN SURGERY M92043





81

Percentage of patients with CHD without a record in the preceding 12 months that aspirin,

an alternative anti-platelet therapy, or an anti-coagulant is being taken by GP practice


are 759 people are not taking aspirin,

an alternative anti-platelet therapy, or

an anti-coagulant



Some data on outcomes for people with

cardiovascular disease


0

200

400

600

800

1000

1200

2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16

Ag

e s

tand

ard

ise

d r

ate

(p

er

100

,00

0)

NHS Wolverhampton CCG England

83

Hospital admissions for coronary heart disease for all ages 2002/03 – 2015/16

Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved

• in NHS Wolverhampton CCG, the

hospital admission rate for coronary

heart disease in 2015/16 was 486.3

(1,079) compared to 527.9 for

England


0

50

100

150

200

250

300

2002/032003/042004/052005/062006/072007/082008/092009/102010/112011/122012/132013/142014/152015/16

Age s

tandard

ised r

ate

(p

er

100,0

00)


84

Hospital admissions for stroke for all ages 2002/03 – 2015/16

Source: Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights reserved


hospital admission rate for stroke in

2015/16 was 222.8 (506) compared

to 172.8 for England


293.0%

753.5%

445.8%

81.3%

150.0%

108.6%

136.8%

259.9%

703.8%

456.7%

76.0%

142.7%

115.7%

137.9%

0% 100% 200% 300% 400% 500% 600% 700% 800%

RRT

Minor amputation

Major amputation

Stroke

Heart failure

Heart Attack

Angina


85

Additional risk of complications for people with diabetes, three year follow up, 2013/14

Note: This slide uses data from the National


• The risk of a stroke was 76% higher

and the risk of a heart attack was

115.7% higher compared to people

without diabetes. The risk of a major

amputation was 456.7% higher.


0

20

40

60

80

100

120

2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15

Ag

e s

tand

ard

ise

d r

ate

(p

er

100

0,0

00

)


86

Deaths from coronary heart disease, under 75s

Source: Office for National Statistics (ONS) mortality data 2002 - 2015


early mortality rate for coronary heart

disease in 2013-15 was 54.6,

compared to 40.6 for England


0

5

10

15

20

25

30

35

40

2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15

Ag

e s

tand

ard

ise

d r

ate

(p

er

100

,00

0)


87

Deaths from stroke, under 75s

Source: Office for National Statistics (ONS) mortality data 2002 - 2015


early mortality rate for stroke in 2013-

15 was 16.2, compared to 13.6 for

England


88

Appendix Data sources

• Quality and Outcomes Framework (QOF), 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights

reserved

• Non-diabetic hyperglycaemia prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/nhs-diabetes-

prevention-programme-non-diabetic-hyperglycaemia

• Diabetes prevalence estimates, NCVIN, PHE: https://www.gov.uk/government/publications/diabetes-prevalence-estimates-for-

local-populations

• CKD Prevalence model, G.Aitken, University of Southampton , 2014 https://www.gov.uk/government/publications/ckd-

prevalence-estimates-for-local-and-regional-populations

• Hypertension prevalence estimates for local CCG populations. Created using data from: QOF hypertension registers 2014/15

and; Undiagnosed hypertension estimates for adults 16 years and older. 2014. Department of Primary Care & Public Health,

Imperial College London https://www.gov.uk/government/publications/hypertension-prevalence-estimates-for-local-populations

• NHS Stop smoking services Copyright © 2014, NHS Digital

• Norberg J, Bäckström S , Jansson J-H, Johansson L. Estimating the prevalence of atrial fibrillation in a general population

using validated electronic health data. Clin Epidemiol 2013 ; 5 475 – 81.

• National Diabetes Audit, 2013/14 and 2015/16, Copyright © 2016, re-used with the permission of NHS Digital. All rights

reserved

• Hospital Episode Statistics (HES), 2002/03 - 2015/16, Copyright © 2017, Re‐used with the permission of NHS Digital. All rights

reserved

• Office for National Statistics (ONS) mortality data 2002 – 2015, Copyright © 2017, Re-used with the permission of the Office for

National Statistics. All rights reserved


https://www.gov.uk/government/publications/nhs-diabetes-prevention-programme-non-diabetic-hyperglycaemia














https://www.gov.uk/government/publications/diabetes-prevalence-estimates-for-local-populations











https://www.gov.uk/government/publications/ckd-prevalence-estimates-for-local-and-regional-populations
















https://www.gov.uk/government/publications/hypertension-prevalence-estimates-for-local-populations












89

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organisation with operational autonomy to advise and support government, local authorities and the NHS in a

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