Hypertension in Berkshire - approaches

Dr Lise Llewellyn

Evidence and local plans

Discussion

Public Health Services for Berkshire Working together for health and wellbeing

Logic model - Impact

Risk factors : Non modifiable - age, ethnicity, family history Modifiable - not doing enough physical activity - 30% reduction being overweight or obese - x 3 - 4 having too much salt in your diet regularly drinking too much alcohol - binge cold

Consequences: mortality 20% men 24% women 50% of CHD in >30 years - BP Ischaemic and haemorrhagic stroke, myocardial infection, heart failure, chronic kidney disease, cognitive decline

Public Health Services for Berkshire Working together for health and wellbeing

Key risks attributable to DALYs

GBD (2013) indicates that the 5 main risks attributable to DALYs in South East England are:

Public Health Services for Berkshire Working together for health and wellbeing

Cardiovascular Diseases

Public Health Services for Berkshire Working together for health and wellbeing

Tobacco

Tobacco

Tobacco

Dietary

Dietary

Dietary

High BMI

High BMI

High BMI

High Systolic Blood Pressure

Low Phys. Activity

Low Phys. Activity

Low Phys. Activity

Air Pollution

Air Pollution

Air Pollution

Male Female Both

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• 48% of DALYs are attributable to dietary risks; 1,682 DALYs per 100,000 population

• High systolic BP accounts for 43% DALYs; 1,535 per 100,000

• High BMI is 29%; 1,024 DALYs per 100,000

• High Total Cholesterol is 23%; 828 DALYs per 100,000

High Systolic Blood Pressure

High Systolic Blood Pressure

High Total Cholesterol

High Total Cholesterol

High Total Cholesterol

High fasting plasma glucose

High fasting plasma glucose

High fasting plasma glucose

National profile • Prevalence

The Department of Health’s 2010 'Health Survey for England' report prevalence of hypertension in adults of 16 or older is 31.5% for men and 29% for women

Prevalence also increases with deprivation:

prevalence increased from 26% of men and 23% of women in the least deprived quintile

to 34% and 30% respectively in the most deprived quintile.

Public Health Services for Berkshire Working together for health and wellbeing

Berkshire / STP Approaches

• Primary prevention - NAO evidence • Part of treatment path • Link with digital programme – accessibility and

sustainability • NHS health checks • Local performance Appts (since 1/4/13) 41-71 % England 66% Received - 17-35% England 32% Capacity / worried well Reviewing delivery NHS health checks - targeting

Public Health Services for Berkshire Working together for health and wellbeing

Approaches continued …

• Secondary prevention

• Treatment

• Generally good – match CCG comparator performance / exceeds England average treatment measures

• Outlier stroke BP

• Improved Detection

• Ongoing

Public Health Services for Berkshire Working together for health and wellbeing

Local profiles Frimley STP prevalence:

Recorded - 12.0% in the 2014/15 QOF,

91,046 people recorded as having hypertension.

Estimated prevalence - 22.0%,

76,091 people “missing” from the GP registers in 2014/15.

England average of 13.8%.

West of Berkshire:

Recorded - 11.95% in the 2014/15 QOF

62,243 people recorded as having hypertension

Estimated prevalence - 22.2%,

53,197 people “missing” from the GP registers in 2014/15

12.69 13.2

10.62

12.39 13.01

0

2

4

6

8

10

12

14

Newbury &District CCG

North & WestReading CCG

South ReadingCCG

WokinghamCCG

England

%

Public Health Services for Berkshire Working together for health and wellbeing

STP savings • Based on PHE cost evidence • Conservative calculation of savings: best CCG performance

deliverable within 5 years not a reflection on ambition as target not estimated prevalence

East - £ 157k West - £ 84k • Change response to detection • Self care v treatment • Pharmacological – NICE guidelines Expectation on patients but with support

Public Health Services for Berkshire

Working together for health and wellbeing

Lifestyle interventions

• 10mm - 40% reduction mortality (30% - stroke)

• Weight 40%

• Exercise 30%

• Relaxation 25%

• Alcohol 30%

• Salt 25%

• Locally

Eat for Health

197 started programme with diagnosis of hypertension - 55 / 28% normal BP at end of programme - 12 weeks

Public Health Services for Berkshire Working together for health and wellbeing

Principles

• Capacity - primary care • Awareness • Self measurement equipment • Community - Slough • Pharmacies - new contract • Health settings - GP / hospitals / community • Support • Digital – patient portal • Pharmacist in practices - new and difficult

control Public Health Services for Berkshire

Working together for health and wellbeing

• All ideas welcome

Public Health Services for Berkshire Working together for health and wellbeing

End stage cardiovascular

disease –why we fail these

patients…

Dr Barbara Barrie, End of Life Lead, Thames Valley Strategic Clinical Network

Deaths from cardiovascular diseases in England -

implications for end of life care

February 2013

Annual number of cardiovascular disease deaths by disease category in England, 2004–11

Population dynamics will increase need

From pyramid to coffin

Anticipated 46% increase in HF prevalence by 2030 AHA Heart Disease and Stroke Statistics—2016 Update

CVD – mortality market share

Cardiovascular disease - leading cause of death in England, resulting in 158,500 deaths 34% of all deaths Cancer responsible For 23% of all deaths

34%

23%

Atlas of Risk (NHS 2009)

Service factors

• Poor end-of-life

planning

• Treatment focus

• Poor palliative /

supportive care

access

• Low coverage in

diverse settings

e.g. acute medicine /

nursing homes

• Cancer bias

Barriers to equitable and accessible heart failure

palliative care

Clinician Factors

• Palliative v.

general medicine /

cardiology tension

• Technophobia

• Reluctance to

address end of

life issues

• Inadequate

assessment skills

• Fear of defeat

Patient factors

•Disempowered

• Unexplored /

unrealistic goals

•Stoicism

• Reluctance to

accept impending

death

• Social isolation /

poverty

Disease factors

• Need for dual

treatment /

palliative

approaches

• Comorbidities:

cognitive impairment

• Lack of

predictability

Modified from Goodlin SJ JACC, 2009, 54:386-96

The heart failure disease trajectory

Every HF patient’s trajectory is unique

Gott M et al. Palliat Med 2007; 21: 95-9

Fifty shades of dying

End of life symptomatic spectrum in heart failure

Prevalence of refractory symptoms

Dyspnoea 60-88%

Fatigue 69-82%

Pain 63-80%

Nausea 17-48%

Anxiety 49%

Depression 9-36%

Confusion 18-32%

Solano JP et al. J Pain Symp Manag, 31: 58, 2006

HF care – a protocol driven paradigm

Challenges to initiating PC

• The culture of HF care favours a medical

model and is treatment focussed.

• Evidence based intervention is often

the default position.

• Patients’ preferences may be unexplored

or they may be disempowered by technicalities or lack capacity.

• A structure of sub-speciality silo working.

• There is a reluctance to discuss prognosis in the face of uncertainty.

Spencer Tunick

Implantable cardioverter defibrillators

(ICDs): unintended consequences?

ICDs are implanted for the primary or secondary prevention of SCD in patients who have had a life-threatening ventricular arrhythmia or at risk of developing such arrhythmias,

but – patients about to die with end-stage HF or an unrelated terminal illness often exhibit metabolic and biochemical derangement and complex agonal arrhythmias that could trigger multiple ICD discharges.

Rates of implantation of defibrillators

High Energy Implant Rate trend per million population in England: ICD vs CRT‐D

Thames Valley

‘Ironic technology’

“I have an ICD and a pacemaker. It’s prolonged my life a little bit. But the longer it prolongs my life, the more things happen to me that it can’t correct. So the question is, do you want to have those effects, or do you want to end it all?” —86 year old man.

.

Elements of palliative care for heart failure

Patient

End of life care

Family/ informal carer

Heart failure professional

Spiritual care

Rehabilitation

Symptom control

Psychological support

Information

Family / bereavement care

Advance care planning Primary care

Secondary / emergency care

General palliative care

Specialist palliative care

Social support

ESC HFA workshop, Copenhagen, Nov 2007

Optimising device therapy

Who should co-ordinate end of life care?

• GP

• Community matrons / case managers

• District / heart failure nurses

• Community specialist palliative care

• Hospital specialists

– Palliative care

– Cardiology

– Other specialties

About 90% of the last year of life is spent at home 59% of deaths take place in hospital

MDT working and good patient navigation essential

HF: Early integration of palliative care

Courtesy of Deborah Meyers MD, Texas Heart Institute

Meyers DE, Goodlin SJ. Can J Cardiol 32:1148-56, 2016

Amber Care Bundle

• Gap between health and

dying with uncertain outcome

• May recover or deteriorate

• DNACPR

• Devices

• Ceiling of Care

• Communication

– Situation

– Choices – PPC / PPD

– Advance care planning

May 2014

Driving the provision of

palliative care for heart failure

• Raise awareness – make it mainstream

• Develop better approaches to prognostication

but undertake needs assessment early

• Improve disease specific symptom management

• Build a robust evidence base

• Form effective multidisciplinary models of collaborative practice across provider systems

Caring Together Task Force

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