Heart Failure

1   Introduction

1.1.      Aim

The purpose of this document is to scope and review heart failure services for Richmond patients. It aims to understand current clinical practice and referral routes for heart failure services. It sets out the local needs, costs, and makes the case for change for improving heart failure services for Richmond patients. The latest guidance, evidence, and best practice have been referenced and incorporated. Recommendations have been put forward to develop cost effective, equitable, and accessible high quality services for our patients.

1.2.      Who is this for?

A cardiology pathway steering stakeholder group was set up to lead the review with a smaller project working group to identify, understand and map existing services, identify gaps in service provision, identify patient need, define best practice and drive quality and cost efficiencies through service redesign. Both groups were multi-disciplinary, comprising of clinicians from primary and secondary care, commissioners, and public health professionals. The project has been led, coordinated and supported by the Public Health department, with a dedicated public health lead working full time on the pathway review and redesign work.  

The steering group met monthly over a 10 month period who delivered a final presentation at the Clinical Advisory Group on 4^th March 2014. A smaller project team was set up to undertake the work and met fortnightly. See Appendix 1 for the membership list for the projects team and steering group.

2    Background

2.1.      Case for change

Heart failure (HF) is a complex clinical syndrome in which the heart’s ability to pump blood around the body is reduced. It is caused by structural or functional abnormalities of the heart. Some patients have heart failure due to left ventricular systolic dysfunction (LVSD), which is associated with a reduced left ventricular ejection fraction. Others have heart failure with a preserved ejection fraction (HFPEF). Most of the evidence on treatment is for heart failure due to LVSD.

The most common cause of HF in the UK is CHD, as well as a number of patients having previous myocardial infarction (MI), hypertension and atrial fibrillation (AF)[1].

It has been estimated that approximately 900,000 people in the UK have HF[2]. Almost as many people have damaged hearts but, as yet, no symptoms of HF. Both the incidence and prevalence of HF increase steeply with age, with the average age at first diagnosis being 76 years.

Up to 50% of patients die suddenly and unpredictably at any stage during the course of the disease, although the increasing use of automated implantable defibrillators will impact on these figures[3]. Unfortunately, the outcomes for HF patients have been held in comparison with the most aggressive types of cancers; however good management of HF can improve survival rates and reduce hospital admissions due to HF[4].

The prevalence of HF is expected to rise in the future as a result of an ageing population, improved survival of people with ischaemic heart disease and more effective treatments for heart failure. In Richmond, intelligence data has shown that GP observed HF and HFLVD had been on the decline since 2009-2013; however, Richmond has an increasingly large ageing population and age is a key factor with HF prevalence.

Patients with chronic HF often experience a poor quality of life; symptoms include breathlessness, fatigue and ankle swelling and over one third of patients experience severe and prolonged depressive illness. HF has a poor prognosis: 30–40% of patients diagnosed with HF die within 1 year; after which, thereafter the mortality reduces to less than 10% every consecutive year. For both patients and their carers HF can be a financial burden and have adverse effects on their quality of life.

Effective multidisciplinary specialist services for people with chronic HF can have a positive effect on patients’ life expectancy and quality of life, evidence suggests they can help to reduce recurrent hospital stays by 30–50%.

2.2.      Initial presentation with signs and symptoms of heart failure (HF)

Table 2.1 List of signs and symptoms a clinician should consider for suspected HF

Source: Greater Manchester and Cheshire Cardiac and Stroke Network Primary Care Pathways

 

 

Once HF is suspected, the GP (or clinician) should primarily refer the patient for a serum natriuretic peptide (BNP) test as recommended by NICE. BNP levels can help exclude the diagnosis; if the BNP levels are higher than the recommended level, refer the patient for a specialist assessment and an ECHO. If the patient has had a previous myocardial infarction (MI) and HF is suspected, urgently refer the patient for an ECHO and a specialist assessment within two weeks^[5].

                           Figure 2.2  Guidance for diagnostics that should be conducted at initial presentation for suspected HF patients.

 

 Source: Adapted from NICE Chronic Heart Failure, 2010

 

The New York Heart Association (NYHA) can also be used to determine the function classification to determine the level of HF in a patient. There are four types of classifications shown in the table below.

Table 2.2    The New York Heart Failure Heart Association function classification for heart failure.

Source: Adapted from Heart Failure society of America website (2014)

2.3.      Evidence based practice

        Clinical Quality standards for heart failure (HF)

There are key standards that form the current basis for diagnosis, treatment and management of HF. The National Institute of Health and Clinical Excellence (NICE) have published thirteen quality standards to reflect good clinical practice at key stages of HF diagnosis and care. This guidance includes key points that should be observed within diagnosis and treatment of heart failure that can be used as key performance indicators (KPIs)[6]:

1. People who go to their GP with symptoms of heart failure and who have had a heart attack in the past are referred urgently for assessment by a heart specialist, including an Echocardiogram within 2 weeks (KPI).
2. People who go to their GP with symptoms of heart failure but who haven’t had a heart attack in the past are offered a blood test to measure levels of substances in the blood known as serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NTproBNP]) to find out whether they should see a heart specialist (KPI).
3. People referred urgently to a heart specialist for assessment, including an Echocardiogram, because of suspected heart failure, who have either had a heart attack in the past or have high levels of serum natriuretic peptides (BNP level above 400 pg/ml [116 pmol/litre] or an NTproBNP level above 2000 pg/ml [236 pmol/litre]),, are seen by a heart specialist and have an Echocardiogram within 2 weeks of referral (KPI).
4. People referred to a heart specialist for assessment, including an Echocardiogram, because of suspected heart failure and raised levels of serum natriuretic peptides (BNP level above 400 pg/ml [116 pmol/litre] or an NTproBNP level above 2000 pg/ml [236 pmol/litre]), are seen by a heart specialist and have an Echocardiogram within 6 weeks.
5. People with chronic heart failure are offered personalised information, education, support and opportunities for discussion throughout their care so they can understand their condition and be involved in its management, if they wish.
6. People with chronic heart failure are cared for by a heart failure team and given a single person to contact from the team.
7. People with chronic heart failure due to left ventricular systolic dysfunction are offered ACE inhibitors and beta-blockers as first line treatment (KPI), and their symptoms are reviewed after each increase in dose. People who have intolerable side effects with ACE inhibitors are offered angiotensin II receptor antagonists (ARBs for short) instead of ACE inhibitors.
8. For people of African or Caribbean origin with moderate to severe heart failure offer hydralazine in combination with nitrate (KPI)
9. People with chronic heart failure are offered a supervised group exercise based rehabilitation programme that includes education and support, if it is suitable for them.
10. Department of Health (DH) National Imaging Board (2010) Cardiac Imaging. DH including a review of their drug treatment and blood tests to make sure their kidneys are working properly.
11. People admitted to hospital because of heart failure, their carer(s) and their GP are provided with a copy of their personalised management plan.
12. People admitted to hospital because of heart failure receive input from their heart failure team into their management plan.
13. People admitted to hospital for heart failure leave hospital only when their condition is stable and receive an assessment from a member of their heart failure team within 2 weeks of leaving hospital.
14. People with moderate to severe chronic heart failure and their carer(s) have access to support from a heart specialist and an end of life care (also called palliative care) service.

        Heart failure clinical pathways

The NICE chronic heart failure pathway brings together all relevant NICE guidance, quality standards, and materials to support implementation of HF management. The pathways are interactive and designed to be used online. To view the online version of this pathway visit: http://pathways.nice.org.uk/pathways/chronic-heart-failure.

 Map of Medicine (MoM) – MoM is a collection of evidence-based, practice-informed care maps, which connect all the knowledge and services around a clinical condition (www.mapofmedicine.com). The care maps can be customised to reflect local needs and practices by commissioners looking to devise new care pathways (see Appendix 2 for the MoM national care map for suspected HF.

 The South London Cardiac and Stroke Network (SLCSN) have developed their own HF pathway incorporating evidence based and best practice recommendations. The pathway has been split into sections; GP heart failure diagnosis pathway (Appendix 3). Richmond patients are part of the catchment area for the network; therefore all the GPs within this area should be following this pathway for HF patients, which would be an avenue to deliver equitable service for HF patients at primary care.

        Commissioning guidance

• Below is a list of the various publications that can be used to assist services in commissioning the most appropriate and clinically safe service for heart failure patients:
• National Institute for health and Clinical Excellence (NICE) Commissioning Guides: Services for people with chronic heart failure (October 2011).      
• Commissioning of Cardiac Services – A Resource Pack from the British Cardiovascular Society (July 2011).
• NHS Improvement. Heart Failure: A quick guide to quality commissioning across the whole pathway of care.
• NHS Improvement. End of Life care in Heart Failure: A framework for implementation.
• NHS Improvement. Continuing to Improve Cardiac Services – Health Improvement Programme National Programme Summaries 2009/10.

 

3    Local Picture

3.1.      Prevalence of heart failure in London Borough of Richmond upon Thames (LBRuT)

In Richmond, congestive HF is one of the top six conditions with the highest proportion of emergency admissions.[7] Between the ages of 45-55 HF prevalence is relatively low in males and females. From ages 55-74, there is a steady increase in HF prevalence for in both males and females. However from age 70 upwards there is a notable increase in the prevalence of HF both sexes, reaching above 800 per 10,000 in males and above 600 per 10,000 in females. With the increasing ageing population in Richmond, it is important to ensure this population are aware of and have access the necessary services to treat and effectively manage their condition, as this demonstrates the major impact on HF on the ageing population in LBRuT. Using NICE HF commissioning and benchmarking tool, the estimated annual number of people over the age of 45 in LBRuT that would be diagnosed with HF is 98; this is 0.15% of the over 45 years population.

Figure 3.1  Prevalence of heart failure by age, Richmond CCG, June 2013

 Source: Richmond Public Health Analysis using SUS data and GP data extraction, June 2013

The 2013 National Heart Failure Audit results show that just under half of all the HF patients in England included in the audit had a history of ischaemic heart disease (IHD), just over half had a history of hypertension and over a quarter of these patients have had a history of both conditions[8], confirming the impact other cardiology conditions have on the development of HF.

• The medical history of heart failure patients in 2012/13

Source: National Heart Failure Audit 2012-13

 

HF is the number one disease in Richmond with the highest level of co-morbidity (see Figure 3.3). Approximately 90% patients in Richmond with HF have three or more other co-morbidities. Less than 5% of Richmond patients have HF as their only condition.

Figure 3.3   Proportion of people aged 65 and over with Heart Failure and one or more co-morbidity, Richmond CCG 2013

Source: LBRuT Public Health Intelligence (2013)

 

        Quality Outcomes Framework (QOF) Heart failure analysis for Richmond

It is estimated that a GP is likely to look after and manage 30 patients with known HF, and suspect a new diagnosis of HF in approximately 10 patients annually[9]. In June 2013, it was found that almost 50% of GP practices in Richmond have a higher prevalence of heart failure than the Richmond average (Figure 3.4).

Figure 3.4  Age and sex standardised Heart Failure rate (95% confidence intervals), by practice, Richmond CCG, June 2013

Source: Richmond Public Health Analysis using SUS data and GP data extraction, June 2013

The same data has been transformed into a funnel plot below (Figure 3.5). It shows that the prevalence of heart failure by GP surgery identified by risk stratification are within the 95% confidence interval of the mean for LBRuT, indicating that the level of HF prevalence in Richmond by GP is not statistically significant. However, it still identifies one GP with values between the second and the third degree of standard deviation, which is the same GP surgery that has its confidence interval above the average for LBRuT identified in the graph above (Figure 3.4).

Figure 3.5 Heart Failure Funnel Plot: rate in Richmond CCG, 2013

Source: Richmond Public Health Analysis using SUS data and GP extraction data

 

The QOF 2010/2011 national average prevalence for HF was approximately 0.71%; however, the estimated national average prevalence for HF is 2%. This indicates that there are a number of people across the nation that have HF and have not been diagnosed, or they have been diagnosed but have not been appropriately coded and are not on the HF register. It is already known that HF is poorly identified in primary care and its symptoms are often mistaken for respiratory conditions, such as chronic obstructive pulmonary disease (COPD)[10].

When comparing the GP observed prevalence of HF in LBRuT to the national and London average, the borough prevalence is significantly lower than the national average, and slightly lower than the London average (see Figure 3.6). There is a consistent decrease of the GP observed prevalence of HF and HFLVF (see Figure 3.7) from 2009-2013.

 

The graph below demonstrates that there is a downward trend of decreasing prevalence for GP obeserved HF patients in Richmond from 2009-2013. This value is lower than the London average and 0.3% lower prevalence than the English average. In 2009, GP observed HF prevalence was just under 0.5% (lower than the

London average of 0.5% and National average of 0.7), which steadily decreased to 0.4% in 2013.

Figure 3.6  GP observed prevalence of heart failure in LBRuT from 2009-2013

 

Source: Quality Outcomes Framework (QOF) analysis

 

Figure 3.7  GP observed prevalence of heart failure due to left ventricular dysfunction in LBRuT from 2009-2013

 

Source: Quality Outcomes Framework (QOF) analysis (2013)

 

Figure 3.8 shows the proportion of patients with HF and HFLVD on each GP list in Richmond. Over 50% of GP practices are under the Richmond average for the proportion of patients with HF and HFLVD; 14 practices are over the Richmond average and proportion of patients. One quarter of practices in Richmond have a proportion of HF and HFLVD patients higher than the London average, with one practice proportion higher than the national average.

The Twickenham and Whitton clinical network have the highest proportion of patients with HF and HFLVD, with seven GP practices over the Richmond average. This area of the borough contains large proportion of the most deprived people within Richmond. Evidence has shown a close association between social and economic deprivation and HF.

Figure 3.8  Proportion of GP list size on heart failure and heart failure due to left ventricular dysfunction registers by practice, Richmond CCG

Source: LBRuT Public Health Intelligence (2013)

 

Table 3.4 has Richmond CCG achievement results for the QOF indicators relating to heart failure.

Table 3.4  QOF achievement for Richmond CCG for 2012/13

 

The total QOF achievement result for all Richmond practices being able to produce a register of patients with HF is 0.4% (England =0.71%). This indicates that practices may not be keeping an up-to-date register of all their HF patients, which may impact on the level of care they receive, management of their condition and their overall experience of patient care.

3.2.      Emergency admissions for heart failure in LBRuT

In 2011/12, the South East Public Health Observatory (SEPHO) reported that the emergency admission rate for all HF patients in LBRuT was 54.8 per 100,000 (see Figure 3.9). This is lower than England (60.7 per 100,000) and significantly lower than London (80.3 per 100,000). Male HF emergency admission rates were significantly higher than female HF emergency admission rates in Richmond (males= 76.9, females= 35.9); indicating that the proportion of males in Richmond with HF is over double the amount of females within the borough. The higher emergency admission rates for males with HF could be an indication that current management initiatives for HF patients in Richmond (especially males) within primary care and the community are not adequately matching the patient need.

Figure 3.9  Heart Failure emergency admission rates (DSRs) in Richmond, London and England by sex, for all ages (2011/12)

 

Source: SEPHO, Cardiovascular Disease Health Profile- Richmond upon Thames, 2011/12

 

The SEPHO CVD profile for LBRuT (2011) also identified that people who lived in the most deprived areas of Richmond that were admitted on an emergency basis for HF was 1.7 times greater than that of those living in the least deprived areas of LBRuT. However, Richmond has less than 1% of its total population in the most deprived quintile, and 46.4% in the least deprived quintile.

 

Public Health Intelligence (PHI) analysis of SUS data has shown that there has been a decrease in the total number of HF patients being admitted under emergency conditions from 2009-2013, although there was a slight increase in numbers in 2010/11. Also, the total number of admissions has decreased since 2009: however, 2010-2012 there was a marked increase in the total number of admissions.

Table 3.5  Heart Failure Emergency Admission Rates (DSRs), for all ages

Source: Richmond Public Health Analysis using SUS data

 

3.3.      End of Life Care

HF patients usually die in secondary care (hospitals) rather than their usual place of residence; HF accounts for 2% of all NHS inpatient bed-days and 5% of all emergency medical admissions to hospital. Readmissions for HF patients are common; approximately 1 in 4 patients are readmitted within 3 months[11]. Hospital admissions because of HF are projected to rise by 50% over the next 25 years – largely as a result of the ageing population[12].

According to the SEPHO CVD profile 2012, 91.6% of deaths from heart failure occurred in the usual place of residence in LBRuT, which is a higher proportion than London (51.3%) and England (58.5%)[13].

Figure 3.10  Proportion of deaths from heart failure that occur at home or usual place of residence (2007-2011)

Source: SEPHO CVD profile 2012

 

However, the SUS data (the activity data that acute providers submit to the CCGs) show that the majority of HF deaths occur in acute hospitals, and not in their usual place of residence. This pattern has been observed year after year; however the overall deaths due to HF have reduced by approximately half since 2009 to 2012.

Table 3.6  Place of death for HF Richmond patients 2009-12

Source: Public Health Mortality File, 2013

 

As part of the National End of Life Care Programme, the NHS recommends a framework for implementation to provide the best care for patients at the end stages of their life[14]. Patients palliative care needs should be identified as soon as possible whist having access to healthcare professionals within a HF team who have the skills in palliative care[15].

3.4.      Modelled estimate of Heart Failure prevalence, diagnosis and assessment

In 2011, the National Institute for Health and Care Excellence (NICE) published a commissioning and benchmarking tool chronic heart failure. Below is the adapted table estimating the prevalence and incidence for HF for LBRuT residents. The NICE model estimates the total (diagnosed and undiagnosed) number of people over the age of 45 that should have HF in Richmond. The modelled estimate for prevalence of HF in LBRuT is slightly higher than the GP recorded prevalence for HF within the same time period (2011/12); the GP recorded prevalence has reduced further in 2012/13. However, the difference in the estimated and actual prevalence reflects the proportion of patients in the borough who are yet to be identified and diagnosed with HF. It is estimated that 0.45% of people over the age of 45 had heart failure in 2011/2012, which is approximately 294 people, with approximately 98 new cases to be discovered each year, it is important to note that the estimation model does not take into account those under 45, so there are more cases prevalent in LBRuT than calculated.

Table 3.7  NICE estimated activity and indicative benchmarking rates for heart failure in LBRuT

Source: Adapted from NICE chronic heart failure commissioning and benchmarking tool (2011)

This model demonstrates that approximately half of Richmond residents over 45 that present to their GP with suspected HF without a previous MI will have raised or high BNP levels, therefore meeting the NICE criteria to be referred onwards for an Echo. This table therefore demonstrates that a potential savings that could be made from approximately 70 Echo referrals for suspected HF without previous MI if BNPs were conducted first.

NICE has also produced a model to estimate metrics relating to end of life due to HF.

Table 3.8  NICE estimated activity and indicative benchmarking rates for metrics associated with HF end of life.

 

NICE estimates that 51 people will die each year due to HF. This is 25% of the overall estimated number of HF hospital admissions per year. With the annual estimated increase of prevalence of HF in LBRuT due to the annual incidence, this is likely to increase the number of deaths each year attributed to HF.

3.5.      National Heart Failure Audit 2012/13

The National Heart Failure Audit (NHFA) was established in 2007 to monitor the care and treatment of patients in England and Wales with acute heart failure. The audit reports on all patients discharged from hospital with a primary diagnosis of heart failure, publishing analysis on patient outcomes and clinical practice. The audit findings are a good indicator to use to measure the implementation of contemporary guidelines for the clinical management of HF from NICE and the European Society of Cardiology Heart Failure Association (ESC HFA)[16].

In the 2012-13 NHFA report, the data analysed demonstrated that more men than women in every age group, except for 85 years and over, more men were admitted for HF than women (see Figure 3.11 below).

Figure 3.11  Number of males and females in England and Wales with HF according to age

 

Source: National Heart Failure Audit (2012-13)

 

Figure 3.12 shows the average age of admission for HF relative to the individual’s position on the index of multiple deprivation. The data shows that the mean age of admission for people in the most deprived quintile (score number 5) was approximately 74 years, whilst patients in the least deprived quintile (score number 1) average was age approximately 79. There is an approximate difference of 5 years between the mean admission of the most deprived and least deprived. This indicates that patients with HF and are in the ‘most deprived’ quintile are more likely to present in hospital at an earlier age than their ‘least deprived’ counterparts.

Figure 3.12  Mean age of admission for HF relative to the individual’s position on the index of multiple deprivation (2012/13)

Source: National Heart Failure Audit (2012-13)

 

Table 3.9 (below) shows a higher percentage of patients under 75 had their cardiology and HF nurse follow-up organised, whilst less than half of over 75 year olds had a proper cardiology appointment arranged and just over 50% had a pre-arranged nurse specialist follow-up. This shows that HF patients of all ages are not being provided with the access to the necessary services required to follow-up their condition at the point of discharge. It also highlights that the elderly have a higher chance of not having adequate follow-up appointments with cardiology, and/or a HF nurse specialist. Since Richmond has a growing ageing population with the majority of HF patients being elderly, it is important to ensure that these patients have the necessary follow-up care they need and the services within primary care are adequate and accessible.

• Referral to follow-up services by age

Source: National Heart Failure Audit 2012-13

4    Local Services

4.1.      Services based in the community (primary care)

        General Practitioners (GP)

For patients with suspected HF and no previous episode of Myocardial Infarction (MI), best practice would be to measure the individual’s BNP or NTproBNP[17]. Within Richmond, it is a challenge to ascertain if this is being done for all patients that fall under this category; however NICE has recommended this measurement be monitored as a key performance indicator (KPI). Further ‘soft-intelligence’ suggests that BNP tests are not being done consistently before conducting an Echo as recommended.

 

Conducting Echo’s for suspected HF patients before the patient has a BNP test is not the most effective of clinically appropriate method of getting a more affirmative diagnosis, as only 20-25% of patients referred for an Echo before a BNP will have a positive diagnosis for HF[18]. Therefore, it is evident that a more effective suspected HF GP pathway can be applied in Richmond which will provide a more accurate diagnosis, be more efficient for the patient and GP and could provide cost savings to the CCG through the reduction of inappropriate Echo referrals.

 

        GP Cardiology Services and Provision in Richmond Questionnaire (LPIS) 2013

GPs comments about HF patients and current HF services:

• Richmond should have a community HF Nurse Specialist
• There should be and integrated HF pathway across both acute Trusts (assume the trusts they are referring to are secondary and tertiary trusts).
• For suspected HF patients, we would work the patient up initially (BNP), and then refer for echo (TMH) and then treat (this response is from only one GP practice).
• Interested in an incentivised scheme for follow up for HF patients.

 

From the GP questionnaire, it was evident that GPs would like more support around the management of HF patients in different ways including having a HF nurse within the community, as GPs made reference to the benefit of HF community nurse at WMUH. It is also clear that some GPs are following NICE recommendations for suspected HF patients by referring them for a BNP before referring them for an Echo; however, it is not clear exactly how many GPs are doing this due to the observed difference in practice between GPs. It is necessary therefore to create an equitable service for HF and suspected HF patients by having an agreed universal HF primary care pathway.

        Imperial College Hospital Trust (ICHT) community service hosted at Teddington Memorial Hospital (TMH):

GPs that refer suspected HF patients to TMH are required to refer them to general cardiology as per the patient profile specification from ICHT (appendix 4). The diagnostic tests that will be carried out these patients are an ECG and an Echo; however this is not a MUST and we are currently unaware of the criteria used to make the decision of having these tests. The patient will be seen by a consultant cardiologist who may then request for an ECG or Echo. After review, a treatment plan will be decided and the patient will be referred back to the GP if the results are within normal limits. For abnormal or questionable results, patients are referred to ICHT for further investigation and treatment is necessary. It is not absolutely clear if this procedure followed consistently for all its patients. In order to ascertain that this is consistently happening, a patient notes audit could be conducted. This can help identify best practice and weaknesses in the current pathway (if any).

Aside from this, the current pathway used at TMH community cardiology service for suspected HF patients is not in line with NICE guidance for HF, as the pathway does not include that a BNP test should be done before the request of an Echo (NICE provides the criteria at which stage of the investigation a patient should have an Echo). Echo’s being conducted at TMH without a prior BNP test is further reflected in the amount spent at TMH for Echo’s in 2012/13 which is approximately over £50,000.

        Queen Mary’s Hospital Roehampton (QMR):

QMH only hosts rapid access diagnostic clinics for suspected HF patients (see Appendix 5 for pathway) and no services for follow-ups or HF management. At QMR, the following diagnostics are available at the HF clinic:

• Blood Tests – FBC, U&Es, Lipid Profile & BNP
• X Ray
• Echo
• ECG

There is a SGH community heart failure nurse who comes weekly to QMH but this service is not related to the QMH cardiology service

4.2.      Heart Failure services based within secondary care

        Kingston Hospital (KHT)

KHT has a one-stop HF clinic with an Echo conducted prior to the outpatient appointment. This service is available once a week and appointments for this service are provided via the ‘choose and book’ service. It is unclear whether the clinic requires that a BNP test be conducted before Echo’s are performed as recommended by NICE.

 

        St. George’s Hospital (SGH)

The one-stop HF diagnostic clinic accepts local and tertiary referrals and acts as a triage point to direct patient to the most appropriate treatment strategies:

• Medical therapy: Community based and delivered via a network of heart failure specialist nurses across the local and southern counties CCGs.
• Electrophysiological intervention: CRT, CRT-D, Atrial fibrillation, ventricular tachycardia and AV node ablation
• Revascularisation: Minimally invasive off-pump bypass surgery, High risk percutaneous coronary intervention (PCI)
• Patient with valvular disease: Valve surgery, Percutaneous valve replacement programme (TAVI)

All patients referred to the HF clinic would have the following within a single session:

• Bloods including NTproBNP
• ECG
• Echo
• Chest X-Ray (where necessary)
• Spirometry (where necessary)
• Consultant Assessment and long-term management plan
  • Additional investigations such as angiography, myocardial perfusion scanning and cardiac MRI arranged where necessary

 

SGH have also commissioned GE Healthcare Finnamore to support the HF team at SGH to develop a whole systems integrated care pathway for HF. They are looking to give SGH an audit and 5 clinical measures which will help them to illustrate a map of variability and then develop an integrated consistent community based HF service to address this. They intend to identify unmet need for telemetry. The aim is to reduce clinical variation by implementing evidence based care measures at various steps along the pathway to inform improvements towards achieving best practice

        West Middlesex University Hospital (WMUH):

WMUH HF service is a joint venture between cardiology and care of the elderly in order to provide some community HF and post hospital discharge support for HF patients.

Data supplied by WMUH demonstrated that WMUH saw 1,463 HF patients in secondary care in 2011/12; a proportion of these patients were from LBRuT, however the exact figure has not been confirmed). This data indicates that quite a few HF patients within our locality are treated by secondary care services rather than primary care services within the community.

        Tele health heart failure pilot

Telemonitoring is a relatively cost effective service to help monitor patients and any changes in their condition once they are discharged from hospital. Evidence from a pilot conducted at WMUH by Dr. Callum Chapman demonstrated that telemonitoring for HF patients showed a decrease in A&E attendances. Although patients are still being seen in clinic, it is less frequent and there has been a decrease in non-elective procedures relating to HF. Richmond CCG in partnership with WMUH and Hounslow CCG has commissioned a pilot telemonitoring service for its HF patients (currently funding 10 patients, costing £3,770). This service has been commissioned by Richmond CCG to be delivered by WMUH from 1 October 2013- 1 April 2014. Currently, no data analysis for LBRuT patients has been provided yet.

        Imperial College Healthcare NHS Trust (ICHT):

ICHT has a HF speciality clinic as well and a HF nursing team that also supports the ambulatory service.

        Royal Brompton and Harefield NHS foundation Trust (RBH):

RBH has a rapid access HF clinic where patients can be seen by either a consultant or a HF nurse specialist to discuss the results and further action, in any.

The following diagnostics are available at this clinic with tests results available on the same day:

• BNP
• Echo
• chest X-ray
• full blood screening
• ECG
• Assessment of severity of heart failure
• Risk stratification and patient prognosis

4.3.      Heart Failure service mapping

The Table 4.10 below shows the heart failure services available to Richmond residents from the key providers. The tertiary acute providers (ICHT, SGH and RBH) all have access to more than one HF nurse, a range of diagnostic services available and the expertise to perform invasive or surgical procedures for HF. Both community cardiology services (TMH and QMR) do not have access to a HF nurse, and do not have a comprehensive HF clinic service, which will easily result in patients being referred onto another provider for more comprehensive services. This means that the community cardiology services accessed by LBRuT residents are not able to provide the necessary community services that HF patients will require.

• List of heart failure clinics and heart failure nurses by key providers

 

4.4.      Proposed service arrangements by neighbouring CCGs

        Hounslow CCG

Hounslow CCG is in process of commissioning WMUH to provide a community HF. The service aims to improve the management of patients with chronic HF and to reduce hospital admissions and readmissions. The service will liaise with secondary care hospital teams to enable earlier discharge and provide patients with home visits and telephone support.

Hounslow Community Cardiac Services have identified a gap in the heart failure service for their patients and have indicated the need for a HF nurse within the Hounslow community. A number of NHS Richmond patients are currently referred to and make individual choices to use the secondary care cardiology services at WMUH, suggesting that a proportion of Richmond residents make up the total number of heart failure patients presenting at WMUH for secondary care. Therefore, any proposal to the service change is necessary for NHS Richmond to be a part of and ensure that the best and most appropriate service is available to Richmond patients.

LBRuT patients access HF services at WMUH, and WMUH estimate that LBRuT patients are approximately 25% of their total caseload. For this reason, Hounslow CCG with WMUH have informed Richmond CCG of their plans improve their HF services. However, Richmond is currently not in a position to change/commission new services until the cardiology review has been completed and consulted on.

4.5.      Medicines management

The pharmacological management of patients should be in line with current NICE clinical guidelines for chronic heart failure (NICE CG108, August 2010)[19].  This includes recommendations on the use of diuretics, calcium channel blockers, amiodarone, anticoagulants, aspirin and inotropic agents for patients with heart failure (both LVSD and HFPEF) as well as the use of angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor agonists (A2RA), beta-blockers, aldosterone agonists, hydralyzine (with nitrates), digoxin and ivabradine (NICE TA267, November 2012) for patients with heart failure due to LVSD specifically.

The local formulary should be followed and there are additional prescribing guidelines which have been produced by the South London Cardiac and Stroke Network to support the prescribing of ACE inhibitors, A2RAs, beta-blockers and diuretics in patient with heart failure due to LVSD, these are available on the Richmond CCG intranet (https://gpportal.richmondccg.nhs.uk/Functions/MedicinesManagement/SitePages/Cardiovascular%20System.aspx)

4.6.      Activity and financial costs

In the financial year 202/13, there was a significant drop in the number of GP emergency referrals for HF (44 patients) in comparison to the previous three years, in which the referral numbers for the previous years were stable.

Richmond Public Health Intelligence (PHI) have utilised the activity data from SUS, the agreed tariff for first appointments and follow-up appointments and the MFF factor to calculate the estimated costs of the reported activity by providers for the treatment of Richmond patients for HF. In 20102/13 the costs associated with HF admissions was £148,670, which is approximately £100,000 less than it was in 2009/10. There has been a reduction of GP observed HF and HFLVD within the same time frame; however, it is not certain that the reduction alone exclusively mitigates the reason for the steep reduction in HF admission costs. The table below includes all the providers in London that Richmond LBRuT patients have utilised for the treatment and management of HF.

• HF admission type and associated costs

Source: Richmond Public Health Intelligence using SUS data 2012/13

 

In 2012/13, 0-1 day length of stay for HF patients was £4,349. This cost also reduced by over half the amount of the cost in 2009 (£10,801). Year after year it appears that the majority of the HF patients requiring secondary care consistently present themselves at A&E. In 20012/13 all of the HF patients recorded as having 0-1 day length of stay all presented at A&E.

 

• HF admissions – Length of stay and associated costs

Source: Richmond Public Health Intelligence using SUS data 2012/13

 

It would appear that the prevalence and treatment costs for HF in Richmond are decreasing. However, this should not normally be the case, with the increasing ageing population and increasing prevalence of co-morbidities. It would appear that there may be issues around the coding of HF when patients present at secondary care.

4.7.      Current challenges facing the service

• Variation in services and diagnostics available or offered by the GP
• Differing referral criteria for patients referred on to secondary care
• Cultural referral patterns amongst GPs
• GPs not having the necessary equipment to undertake initial tests before referring patients to secondary care for cardiology outpatient appointments and tests.
• Community nurses feel under skilled in heart failure and would like a resource that supports them for education. They feel a HF nurse that also has an interest in End of Life Care, AF, and COPD would be useful.
• There are shortages in key groups of staff vital to the management of heart failure in the community including rehabilitation services, e.g. HF nurse, OTs, etc.
• HF patients are currently excluded from accessing community based cardiac rehabilitation services within LBRuT.

5    Recommendations

1. Educational sessions for GPs and healthcare professionals

Provide educational HF session for GPs and other healthcare professionals in the community to promote shared learning, common assessment and referral patterns. This type of working will enable the most clinically appropriate way to manage patients in the community and to prevent unplanned emergency admissions and re-admissions.

2. GPs should have an agreed nominated list of providers for diagnostics

There should be standardisation across services patients can access to create the opportunity for equity in service provision.

3. Review pilot results from WMUH community-based heart failure telehealth service

This review should contain key findings and assess suitability for commissioning this service in the long-term.

4. All NICE recommended diagnostics should be completed before patients are referred to a heart failure specialist
5. Patients with stable heart failure should have patient review every 6 months at the GP Practices[20].
6. Heart failure patients should be included in the eligibility criteria and referred to cardiac rehabilitation service as recommended by NICE[21]
7. Richmond CCG should be encouraged to adopt the NICE recommended key performance indicators (KPIs) for GPs to enable evaluation of the HF pathway within primary care:

• People with symptoms of heart failure and who have had a heart attack in the past are referred urgently for assessment by a heart specialist, including an Echocardiogram within 2 weeks (KPI).
• People with symptoms of heart failure but who haven’t had a heart attack in the past are offered a BNP or NTproBNP to find out whether they should see a heart specialist (KPI).
• People referred urgently to a heart specialist for assessment, including an Echo, who have either had a heart attack in the past or have high levels of serum natriuretic peptides are seen by a heart specialist and have an Echocardiogram within 2 weeks of referral (KPI).
• People with chronic heart failure due to left ventricular systolic dysfunction are offered ACE inhibitors and beta-blockers as first line treatment (KPI), and their symptoms are reviewed after each increase in dose. People who have intolerable side effects with ACE inhibitors are offered angiotensin II receptor antagonists (ARBs for short) instead of ACE inhibitors.
  • For people of African or Caribbean origin with moderate to severe heart failure offer hydralazine in combination with nitrate (KPI)
    8. Explore developing preventative initiatives, early identification and management tools for males with HF

Men in Richmond have higher HF prevalence than females. Developing a tailored pathway to capture and engage male patients with risk factors, or known HF could promote improved lifestyles and/or their management of their condition and help them recognise the signs and symptoms.

9. Investigate the reason for the appearance of reduction in HF prevalence and treatment costs

 

 

 

 

6    References

[1] South London Cardiac and Stroke Network (SLCSN) (2011) Guide for commissioning a quality heart failure service. SLCSN

[2] National Institute of Health and Clinical Excellence (NICE) (2010) Chronic Heart Failure. NICE.

[3] Scottish Partnership for Palliative Care (2008) Living and dying with advance heart failure – a palliative approach. Scottish Partnership for Palliative Care

[4] National Institute for Cardiovascular Outcomes Research (NICOR) (2013) National Heart Failure Audit 2012-2013. NICOR.

[5] National Institute of Health and Clinical Excellence (NICE) (2010) Chronic Heart Failure. NICE.

[6] National Institute of Health and Clinical Excellence (NICE) (2010) Chronic Heart Failure. NICE.

[7] London Borough of Richmond Upon Thames (LBRuT) 2012. Joint Strategic Needs Assessment – Older People Needs Assessment Summary, LBRuT.

[8] National Institute for Cardiovascular Outcomes Research (NICOR) (2013) National Heart Failure Audit 2012-2013. NICOR.

[9] National Institute for Health and Clinical Excellence (NICE) (2010) Chronic Heart Failure. NICE

[10] Department of Health (DH) (2013) Cardiovascular Disease Outcomes Strategy. DH.

[11] National Institute for Health and Clinical Excellence (NICE) (2010) Chronic Heart Failure. Management of chronic heart failure in adults in primary and secondary care

[12] National Institute for Health and Clinical Excellence (NICE) (2010) Chronic Heart Failure. Management of chronic heart failure in adults in primary and secondary care

[13] SEPHO, Cardiovascular Disease Health Profile- Richmond upon Thames, 2011/12

[14] National End of Life Care Programme ( 2010) End of life care in heart failure: A framework for implementation

[15] National Institute for Healthcare and Clinical Excellence (NICE) (2010) Chronic Heart Failure. NICE

[16] British Society for Heart Failure (BSH) (2014) National Heart Failure Audit. BSH.

[17] National Institute of Health and Clinical Excellence (NICE) (2010). Chronic Heart Failure. NICE

[18] National Institute of Health and Clinical Excellence (NICE) (2010). Chronic Heart Failure. NICE

[19] National Institute of Health and Clinical Excellence (NICE) (2010). Chronic Heart Failure. NICE

[20] National Institute of Health and Clinical Excellence (NICE) (2010). Chronic Heart Failure. NICE

[21] National Institute of Health and Clinical Excellence (NICE) (2010). Chronic Heart Failure. NICE

 

Document Information

Published: March 2014

For review: March 2017

Topic lead: Leona Patel, Public Health Lead

Appendices

Appendix 1.   Membership of Cardiology Pathway Steering and Working group

Steering Group

 

Working Group

 Appendix 2.   Map of Medicine care pathway for suspected Heart Failure

 

 Appendix 3.  South London Cardiac and Stroke Network – GP heart failure diagnosis pathway

 

 

• Patient referral profile for Richmond community cardiology services at Teddington Memorial Hospital (TMH) by Imperial College Healthcare Trust (ICHT)
• Queen Mary’s Hospital, Roehampton Suspected Heart Failure pathway