^The Treatment Gap - Primary Healthprimaryhealth.org.nz/3ctreatmentgap.pdfCVD Management ^The...
Transcript of ^The Treatment Gap - Primary Healthprimaryhealth.org.nz/3ctreatmentgap.pdfCVD Management ^The...
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CVD Management“The Treatment Gap”
Dr Allan Moffitt & Pauline Sanders-Telfer
(on behalf of Metro-Auckland Clinical Governance Forum)
15 November 2017
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What we will cover
Metro-Auckland Clinical Indicators (CVD, Diabetes)• History & context • Agreed indicators • Why these – treatment gap!• Definition & data issues• Regional adherence reports• Performance – how are we doing?• Focus on improving management
– SLMF; LDT (Modified DIP); Diabetes SLA Team
• Enablers• Lessons Learnt
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Outcomes & Quality Framework
• Started in 2014 - implemented 2015
• Borrowed on prior work (MHN, AH+, ProCare)
• Focus on reducing inequalities
• As chair of MACGF at the time
• Agreement in principle to indicator set
• Initial false start
• Took quite a while to implement
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Closing the Equity Gap
Life Expectancy: What is contributing to the gaps in equity. CMDHB 2005 [Source: G. Jackson, CMDHB, Public Health Team, CMDHB 2005]• Smoking• CVD• Diabetes
0.5 0.6
1.6 1.9
2.10.5
1.5
0.3
0.7
0.7
3.9
1.5
-
2
4
6
8
10
12
Maaori Pacific
LE
ga
p (
ye
ars
)
Remainder
Diabetes
Cancer (non-lung)
Smoking-related
lung disease
Cardiovascular
disease
Infant mortality
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CVDRA Clinical Performance – Dec. 2012 to Jun. 2014
0
25
50
75
100
125
Nu
m. o
f p
ract
ice
s
PerformanceDec-12 Jun-13 Dec-13 Jun-14
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CVDRA where are we now?
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The Treatment Gap
• Initial data suggested that we did reasonably well on anyone indicator
• But bundled together there was a much bigger gap from ideal
Secondary Prevention
• 40-50 % gap for Triple Therapy in secondary prevention
Primary Prevention
• 60-57 % gap for Dual Rx (BP lowering and Statin)
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PHO variation:Triple therapy
Slide courtesy of Dr Andrew Kerr
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Statin initial prescribing, dispensing and long-term maintenance after ACS admission (n = 1846) ANZACS-QI 11
Slide Courtesy of Dr Andrew Kerr
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NRA Regional Adherence Reports
• Data from TestSafe – the DHBs health summary portal including laboratory results and dispensing data.
• Used Predict to i.d. Prior CVD ‘tick’ in Predict
• Encrypted so cannot use for improvement
• Data issues
• However useful way of presenting outliers and those to target for best impact!
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CVD Primary Prevention medication -Individual practice variation : Funnel plots
70% is MACGF target.Cardiac Network target is increase by 5%.
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Funnel plots – use dispensing data
Secondary prevention for known CVD (where ticked)
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CVD Prevention medication - Individual Practice variation :Outlier practices
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The Indicators
• Diabetes
– Glycaemic Control (HbA1c <64 mmol/mol)
– ACE inhibitor for those with Microalbuminuria
– Blood pressure control (BP <140 mmHg systolic)
• Cardiovascular Disease
– Secondary Prevention – Triple Rx for known CVD
– Primary Prevention – Dual Rx (BP & Statin) for those with 5yr CVD Risk >20%
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Secondary Prevention - MACGF
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2* Prevention Ethnic Variation
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Individual Practice variation 2*
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Primary Prevention & Dual Rx
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Ethnic Variation 1* Prevention
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Data issues
• Disease Coding cf. Predict
• Prescribing cf. Dispensing
• Upper Age limits
• Laboratory coding changes e.g. HbA1c
• Took a long time to get standardisation to compare ‘like with like’
• Now regular quarterly reporting – collated by A-WDHB Planning, Funding & Outcomes team.
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Nursing Management
Nurse Led Care & Nurse Led Clinics
Supportive team environment
Virtual Clinics
CVD/DM courses
Structured process
Understanding and analysing data
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Current DHB Funding Enablers
Diabetes ManagementPlanned Proactive Care Model
Diabetes Care Improvement Packages• Outcomes based and volumes based
CVD ManagementPlanned Proactive Care Model
Volumes based
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Future DHB Funding Enablers
CVD Management
Focus on Management vs Screening alone
Equity focus
SLM ProgrammeDM Management
Volumes and outcomes based
SLM Programme
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PHC Enablers
CVD & DM Management• Transparency across the system
• Data availability and analysis
• Quality Improvement – Safety in Practice CVD Bundle
• Models of Care
• SMO and NS availability
• Technology
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Learnings
• Keeping the patient/family in the centre• No blame/shame environment• Transparency across the system• Data Sharing agreement• Data definitions• IT capability – PHO / DHB• Consistent PMS Coding• Data analysis at practice level
What does it mean? What difference can I make?
• Collaborative environment
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Learnings
“Let not the perfect, be the enemy of the good”