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Value Based Commissioning for elective procedures: Nene CCG
Transcript of Value Based Commissioning for elective procedures: Nene CCG
for elective procedures Healthcare variation: Individual and healthcare system factors Patient Demand Prepare for surgery to reduce the likelihood of readmission GP Variation efficiency potential Whole system Health Need
Potential health gain Individual exceptions Spend & Outcome Patient information
Social marketing Shared care, supported self-management
Threshold based contracts
Map of Medicine
GP peer review groups
GPSIs Integrated pathway implementation
Accountable Lead Provider Prior Approvals Process
IFR Cardiology Referrals & Outcomes The Strong for Surgery initiative aims to identify and improve
evidence-based practices for elective surgical patients in
four target areas.
Includes pre-surgery checklists for
Smoking cessation Cardiology Choose and Book referrals Nene CCG registered patients have a higher crude rate of cardiology 1st outpatient attendances than the Northamptonshire, East Midlands and National average.
Over the last three years similar to the trend seen nationally the number of 1st outpatient attendances have increased. In 2010/11 this was 21 cardiology attendances per 1000 Nene CCG registered patients.
Cardiology Choose and Book referrals pilots showed substantially higher referral rates for KGH compared with NGH. Value-based commissioning:
Cardiovascular disease Variation by GP practice Analysis of variation by
CCG: Cardiovascular Nene Dashboard – Cardiovascular Benchmarking:
In 2011/12 Cardiac Resynchronisation Nene CCG's level of activity is statistically high when compared to the national average, 3 standard deviations from the mean.
In 2010/11 Nene activity was significantly high compared to the national average. In 2009/10 activity was similar to the average. The trend data from RY Q1 2010/11 to the RY Q4 2011/12 displays an initial increase during 2010/11 followed by a drop. Activity then returned levels comparable to Q2 2010/11. These are areas where variation needs to be addressed. Benchmarking:
In 2011/12 549 Coronary artery stent
Nene CCG's level of activity is statistically high when compared to the national average, 3 standard deviations from the mean.
In 2009/10 & 2010/11 Nene activity was significantly high compared to the national average. Cardiac Resynchronisation Coronary artery stents The trend data from RY Q1 2010/11 to the RY Q4 2011/12 displays an increasing trend. This would indicate that there has been consistent growth in the number of stents being carried out. Examination of the spend and outcome analysis for all circulation for Nene CCG shows that Nene is in the higher spend better outcome sector. Spend on circulation in 2010/11 was £145.25 per head of population for Nene which is higher than the national average of £133.44. There is significant variation within Nene compared to the National average of 18.8 attendances per 1000 population.
There are a large number of practices the attendance levels 3 standard deviations from the mean. Options for action Systematic management of stable angina including lifestyle change and medicine optimisation
-disseminate NICE CG95 Chest Pain of recent onset issued March 2012
- implement NICE QS 21 and NICE CG126 for stable angina
- Consider CQUIN payments as incentive for QS21 implementation
Use GPwSI or ECR programme as needed
Agree eligibility criteria of use of cardiac resynchronization devices and monitor against plan or prior approvals Risk management Provide Information Standard certified patient information to promote self-management of risks.
Integrate Health Checks programme into general practice
Offer a supervised exercise programme to all people with intermittent claudication (NICE CG147) and chronic heart failure (NICE QS 9).
Provide brief interventions for modification of individual risk factors including alcohol and smoking. Stable angina vs. unstable angina /Acute Coronary Syndrome (ACS) Predictable symptoms, more than two months duration.
May occur only when doing physical activity or when under a lot of stress.
Symptoms that get worse with physical activity often pass within a few minutes of rest.
If previously prescribed, take one dose of nitroglycerine sublingually to relieve chest pain. Stable angina Unstable angina People with chest pain at rest or on minimal exertion may have unstable angina and should be considered for hospital admission Red Flag go to
ACS Suspected Acute Coronary
Syndrome (ACS) Rapid clinical assessment
Check immediately for current or recent (past 12 hours) chest pain
Determine whether the chest pain may be cardiac by considering:
- the history of the chest pain
- the presence of cardiovascular risk factors
- history of ischaemic heart disease and any previous treatment
- previous investigations for chest pain Pain in the chest and/or other areas, e.g. the arms, back or jaw, lasting longer than 15 minutes
chest pain associated with (alone or in combination):
nausea and vomiting
breathlessness Chest pain associated with haemodynamic instability
new onset chest pain, or abrupt deterioration in previously stable angina, with:
recurrent chest pain occurring frequently and with little or no exertion; and
episodes often lasting longer than 15 minutes Clinical Indicators Suspected Acute Coronary Syndrome (ACS) DO NOT
Use response to glyceryl trinitrate (GTN) to make a diagnosis DO NOT
use biochemical markers such as natriuretic peptides and high sensitivity C-reactive protein to diagnose an acute coronary syndrome (ACS). DO NOT routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94% -98%. DO NOT use magnetic resonance (MR) coronary angiography for diagnosing stable angina. NICE CG95 DO NOT use exercise electrocardiogram (ECG) to diagnose or exclude stable angina for people without known coronary artery disease (CAD). Stable angina Systematic management of
stable angina 1. People with features of typical or atypical angina and an estimated likelihood of coronary artery disease of 10–90% are offered diagnostic investigation according to that likelihood.
2. People with stable angina are offered a short-acting nitrate and either a beta-blocker or calcium-channel blocker as first-line treatment.
3. People with stable angina are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.
4. People with stable angina who have had coronary angiography, have their treatment options discussed by a multidisciplinary team if there is left main stem disease, anatomically complex three-vessel disease, or doubt about the best method of revascularisation.
5. People with stable angina whose symptoms have not responded to treatment are offered re-evaluation of their diagnosis and treatment. Benchmarking:
In 2011/12 elective vascular lower limb arterial procedures Nene CCG's level of activity is statistically high compared to the national average, 3 standard deviations from the mean.
In 2009/10 & 2010/11 Nene activity was significantly high compared to the national average. The trend data from RY Q1 2010/11 to the RY Q4 2011/12 displays an overall downward direction of travel. However in 2011/12 there was an increase in activity in Q2 and Q3 but by Q4 it was decreasing. Elective vascular lower limb arterial procedures Policy for action to reduce procedures for intermittent claudication Most people currently operated on have critical ischemia, i.e. limb lost patients (rest pain or gangrene). Opportunities to prevent or defer surgery rest with c 10% of patients with severe claudication (walking distance down to less than 50 yards).
For people with intermittent claudication, closely monitored exercise programmes have been shown to be as good as angioplasty in the shorter-term and better in the long-term than angioplasty. Such a programme also increases quality of life.
Of people with simple claudication, 20-30% will come to critical ischemia. Exercise may reduce the proportion of patients who end up with amputation.
Proposed Policy statement: Claudicants will be offered a lifestyle programme by their GP including Smoking Cessation Advice and will be referred as clinically appropriate before being considered for surgery Areas of high activity and variation Value-based commissioning:
Colonoscopies / Diagnostics Colonoscopy and sigmoidoscopy are not recommended to confirm diagnosis of irritable bowel syndrome (IBS). NICE offers a separate pathway and guidance (CG61) for people with probable IBS.
Nice is developing guidance on faecal calprotectin tests to differentiate inflammatory bowel disease from irritable bowel syndrome.
NICE CG 118 recommends colonoscopic surveillance for people meeting specified criteria who have Inflammatory Bowel Disease (IBD) or adenomas. Surveillance intervals depend on specified severity criteria. Analysis of variation by
CCG: Colonscopies Benchmarking:
In 2011/12 Colonoscopy Nene CCG levels of procedure activity is statistically similar when compared to the national average, within 2 standard deviations.
In 2009/10 the level of colonoscopies was significantly low, in 2010/11 the level rose to similar to the national average. Benchmarking:
In 2011/12 1257 Colonoscopy and biopsy of lesions of colon procedures Nene CCG levels of procedure activity is statistically low when compared to the national average, 3 standard deviations from the mean.
In 2009/10 & 2010/11 Nene activity was significantly low compared to the national average. Benchmarking:
In 2011/12 710 Diagnostic endoscopic examinations of lower bowel Nene CCG level of activity is statistically high when compared to the national average, 3 standard deviations from the mean.
In 2009/10 & 2010/11 Nene activity was significantly high compared to the national average. Colonoscopies The trend data from RY Q1 2010/11 to the RY Q4 2011/12 displays an increasing trend. This would indicate that there has been consistent growth in the number of Colonoscopies being carried out. & Biopsy The trend data from RY Q1 2010/11 to the RY Q4 2011/12 displays an increasing trend. This would indicate that there has been consistent growth in the number of Colonoscopies being carried out. Diagnostic endoscopic examinations of lower bowel The trend data from RY Q1 2010/11 to the RY Q4 2011/12 displays a sudden increase during 2011/12. This would indicate that there has been growth in all four quarters of 2011/12. Variation by GP practice In view of significantly high rates of diagnostics and the rising rates of colonoscopies it is important to address variation in referrals and procedures In this area Examination of the spend and outcome analysis for gastro intestinal for Nene CCG shows that Nene is in the lower spend worse outcome sector.
Spend on gastro intestinal in 2010/11 was £71.96 per head of population for Nene which is lower than the national average of £84.08.
When measuring outcomes Nene has higher rates of premature death from gastrointestinal disease. “The right things are those activities which are of high value because they do more good than harm at reasonable cost. Doing the right things means making the right choices and that requires the right knowledge.” Sir Muir Gray Value based commissioning for elective procedures Policy Summary
Surgical treatment of asymptomatic gallstones is considered a low priority treatment and will only be
provided in line with the criteria specified below.
Surgical treatment will only be funded when one or more of the following criteria are met:
The patient is at increased risk of gallbladder cancer (indicators of this include a calcified gallbladder, presence of larger gallstones greater than 3 cm in diameter or presence of gallbladder polyps greater than 10mm in size)
The patient is awaiting transplant surgery
The patient is immunocompromised (for example post transplantation)
The patient has chronic haemolytic syndrome
The patient is at increased risk of developing complications of gallstone disease (indicators of this include the presence of gallstones greater than 2 cm in diameter, the presence of choledocholithiasis, gallstones smaller than 3 mm in diameter with a patent cystic duct or a non-functioning gallbladder)
The patient has a life expectancy of more than 20 years and the clinician considers surgery will avoid long term complications and benefit the patient clinically Proposed policy for referral for asymptomatic gall stones Adapted from Elisabeth Kübler-Ross 5 stage model
(Though more modern grief theories such as that of John Bowlby described as ‘ebb and flow of processes such as shock and numbness, yearning and searching, disorganization and despair, and reorganization’ have some attraction) DENIAL ANGER BARGAINING DEPRESSION RESOLUTION The data is wrong It does not apply to me I will get the correct
data There is nothing I can do Acceptance and action Thanks to Simon Swift of the East Midlands Quality Observatory Right Care Decision Aids At the core of Shared Decision Making is the belief that patients and their clinicians bring equally valuable input to the table when patients reach a decisions crossroads in their healthcare. Clinicians know about the options available, while patients know what they want from their treatment, based on their particular circumstances, expectations and attitudes toward risk. As part of the Shared Decision Making programme, 36 Patient Decision Aids (PDAs) are being created during 2012 and early 2013, designed to help patients understand and consider the pros and cons of possible treatment options and to encourage communication between them and their healthcare professionals. http://sdm.rightcare.nhs.uk/ Options for action Features of typical angina on clinical assessment
Estimated likelihood of CAD greater than Estimated CAD risk 10%-90%: Estimated CAD risk less than 10% Refer to rapid access chest pain clinic for further investigations.
Follow local protocols for stable angina while waiting for the results of investigations if symptoms are typical of stable angina Consider other causes of chest pain
Only consider chest X-ray if other diagnoses are suspected OR 90% Further diagnostic investigation is unnecessary - manage as angina Choose and Book referrals April 2010 to December 2011 Asymptomatic gallstones:
are usually discovered incidentally by imaging
account for the majority of gallstones (more than 80%)
become problematic in about:
1-4% of patients within a year
10% of patients within 10 years
20% of patients within 20 years
most patients will experience symptoms of biliary colic before developing complications
the longer the gallstones remain quiescent, the less likely the patient is to develop complications
This information was drawn from the following reference:
 Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease. Lancet 2006; 368: 230-9. Prophylactic cholecystectomy is not recommended in patients with asymptomatic gallstones as the risks of surgical intervention outweigh the perceived benefits [8,9].
2. Choosing wisely campaign is the list we need to look at next :
mostly are investigations . Analysis of variation by
CCG: Asymptomatic Gallstones Benchmarking:
In 2011/12 surgery for asymptomatic gallstones procedures Nene CCG level of activity is statistically low compared to the national average, 2 standard deviations from the mean.
In 2009/10 & 2010/11 Nene activity was significantly low compared to the national average. Trend:
The trend data from RY Q1 2010/11 to the RY Q4 2011/12 displays an upward direction of travel. This would indicate that there has been consistent growth in the number of procedures. Asymptomatic Gallstones Variation by GP practice In view of rising rates . Referrals and procedures need to be addressed as lack of evidence.