Download Example of a LES to reduce cardiology admissions

Central Manchester Commissioning Group Manchester PCT
LOCAL ENHANCED SERVICE (LES) FOR MANAGEMENT OF LEFT VENTRICULAR
SYSTOLIC DYSFUNCTION (LVSD)
INTRODUCTION
Introduction
In his preface to the 2003 NICE guidance for Chronic Heart failure, Dr Roger Boyle
anticipates ‘better outcomes for patients and their families, and more cost-effective
use of staff, resources, beds, and medicines in the local health economy’. In addition
may be added better job satisfaction for those who work in primary care teams.
This Local Enhanced Service recognises these facts and seeks to provide high quality
comprehensive care to patients within their familiar primary care setting.
Key elements of this enhanced service are: Optimising medication
 Regular monitoring
 Patient education to enable better self-management
 Rapid access to clinical advice as and when required.
Left Ventricular Dysfunction is used synonymously with Left Ventricular Systolic
Dysfunction since Diastolic dysfunction is less clearly defined and interventions less
robustly investigated.
Background
The prevalence of LVSD according to the QuOF is 0.4% in Central Manchester. This is
about the same as the UK and a little higher than Manchester as a whole. The Heart
of England Screening study (1), found over 2% of patients aged over 45 yrs (3% of
men and 1.7% of women) had definite heart failure. There was probable heart failure
in another 1% of patients. The prevalence of LVSD increases with age from 1% under
65yrs, to 7% in 75-84 years and 15% 85+. So there are about 800 patients with LVD in
Central Manchester.
Hillingdon Study(2) of new heart failure cases from a Primary care population of
151,000 found crude incidence of 1·3 cases/1000/year for 25+ years. Incidence
increased from 0·02 cases/1000/year in 25–34 years to 11·6 in over 85’s. The male to
female age-adjusted incidence ratio is 1·75. The median age at presentation 76
years. So there are about 200 new cases diagnosed in Central Manchester each year.
Each practice will, on average, have 5 new patients each year.
There are many guidelines which have been published in recent years and these
resources as shown below (3,4,5).
There is good evidence that with more intensive and consistent care mortality and
wellbeing can be improved and hospital admissions reduced. In particular better
patient education, closer follow-up, and easier access to advice and early
interventions can improve those outcomes by as much as 20% (6,7).
Aims
To improve the quality of care provided to patient with LVSD
To improve the well being of patients with LVSD
To improve the satisfaction with their care of people with LVSD
To reduce hospital admissions of people with LVSD
This specification is limited to provision for the practice’s registered patients only. It
is proposed that this will be extended in future to cover patients belonging to other
practices.
This Enhanced Service is available to GMS/PMS services to patients registered with
Central Manchester (Commissioning Group) Practices.
The LES is subject to change either through changing clinical guidelines or changes to
the GMS contract. The PCT will give notice of change of three months to LES
practices.
The period of the LES will be concurrent with the PCT financial year with renewal
being made on the 1st of April each year. Practices who commence the LES part way
through the year will have agreement up to the 31st March.
PRIOR TO COMMENCING THE LES
Practices will submit a proposal to the PCT in a format provided to them. They will
have to provide assurance or be assessed against the following criteria.
 The practice has a register of patients with LVSD (QOF) which has been
validated by the audit which was part of the PBC LES 07/08, including: Name,
DoB, NHS number, implied ethnicity (as per QOF recording), date of diagnosis
and abnormal echocardiogram
 All healthcare professionals leading the delivery the LES within the practice (a
GP and possibly a nurse) have successfully completed the PCT/CMMC LVSD
training programme.
 The practice has the appropriate systems in place for enhanced management
of LVSD patients, in particular access to early advice.
 Practices will have in place the appropriate recording systems to enable them
to submit detailed and auditable activity reports to the PCT. Namely:




Record of educational process, see appendix 1.
Record of medication and titration
Method of access to advice
Number of admission
 Practices will undertake Significant Event Analysis for each hospital admission
and improve systems accordingly.
 Practices will undertake an audit of care each year.
 Practices will undertake a patient wellbeing/satisfaction survey
Practices will be accredited by the PBC executive board to undertake the LES if they
satisfy these criteria. Practices will not be reimbursed if the appropriate information
is not provided.
CLINICAL CARE
All practices are expected to provide essential services relating to LVSD. These are
detailed within the GMS contract.
The LES has two levels of care for
1. New patients
2. Existing patients
New Patients (diagnosed < 1 year)
All newly diagnosed patients should receive an initial cardiologist’s assessment to
identify whether the patient needs further preventive intervention
(angioplasty/CABG/pacing/Defibrillator). Once this is done the patients will return to
Primary Care. The aims of management are to:
1. Optimise medical treatment (up-titrating drugs)
2. Patient education about the condition, lifestyle and self monitoring
3. Develop systems for early advice and intervention to prevent admission
It is envisaged that patients will see the GP and nurse on several occasions,
particularly soon after the diagnosis, to achieve these aims. (see appendix 1 for
details)
Existing Patients (diagnosed > 1 year)
These patients will receive regular monitoring and supervision to ensure that:
1. They are on the maximum tolerated medical treatment
2. They have an understanding of the condition, lifestyle interventions and how
to self-monitor
3. They know how and when to adjust their treatment or access advice to help
prevent admissions
It is envisage that these patients will be proactively monitored at least six monthly
and more frequently if necessary. (see appendix 1 for details)
FINANCES
The fee structure has been developed using an average cost method, including an
overhead and profit assumption, based upon the expected resource required for a)
New Patients and b) Existing Patients.
The fee for each New Patient (diagnosed < 1 year) will be £278
The fee for each Existing Patient (diagnosed>1 year) will be £52
An ‘average’ practice with 5 new and 25 existing patients will receive
QUARTERLY REPORT
The practice will submit a Quarterly Report. It will contain the following information:
1. Number of New Patients
2. Number of Existing Patients
3. Number of hospital admissions
4. Outcome of Significant Event Analysis of each hospital admission
5. Changes enacted as a result of the SEAs
YEARLY REPORT
The yearly report will be an aggregate of the quarterly reports. In addition it will
include the finding of a patient’s survey of satisfaction and well-being.
The Report may be checked by the PCT, who retain the right to confirm the accuracy
of information submitted.
Submission Dates
15th July
15th October
15th January
15th April
(Quarterly)
(Quarterly)
(Quarterly)
(Yearly)
Submissions will be made electronically to [email protected]
SUPPORT FOR PRACTICES
Support will be provided by Dr Ivan Benett, GPSI Cardiology.
Appendix 1. Details of enhanced service
Proposed service outline

Register & usual care
Patients diagnosed with LVSD should be READ coded as ‘G58’. This will enter them
on the register of patients. In addition practices should ensure that an
echocardiogram has been performed to confirm the diagnosis, and that an ACEI or
ARB has been introduced to maximum tolerable doses (unless there is a
contraindication). (see QuOF). All patients should be seen by a cardiologist initially to
assess the need for angiography or ICD implantation unless either is felt to be
clinically inappropriate. Care will then revert to the practice.

Care for patients at an enhanced level in Primary care
 Regular Review & Monitoring
All patients will have at least a six monthly review. New Patients will be seen more
frequently. This will include a review of life-style choices, medication, understanding
of the condition, satisfaction with the service, weight and electrolyte measurement
 Education of Patients
All patients will receive education about the nature of heart failure, life-style choices,
the medications and their side effects, and what to do to monitor their own well
being. In particular, new patients will be taken through a structured programme,
usually by a trained practice nurse.
Life style options
Exercise and rehabilitation
Smoking
Alcohol
Sexual Activity
Vaccination
Air Travel
Driving Regulations
 Individual management plan
Medical management should include diuretics, ACEI/ARBs, Beta-blockers, and
spironolactone. Consider digoxin if symptoms still with maximum doses of other
drugs or if in Atrial Fibrillation. Consider Isosorbide and Hydrallazine in patients of
African descent. Dose adjustments will require more regular review and electrolyte
monitoring, in particular when introducing ACEI/ARB and spironolactone and
uptitrating betablockers. There should be optimal management of the underlying
condition as well.
Patients should know how to monitor their condition by regular weighing, and who
to contact at the surgery for urgent advice.
 Professional Links
The practice should form links with the local secondary care heart failure team, in
particular the heart failure nurse and consultant. Links with other practices providing
this service should also be made to enable an exchange of ideas and discussion of
difficult cases.
 Referrals Thresholds
Patients should be referred back to the consultant if:
1. Ejection Fraction < 35% but no worse than Class III of the NYHA functional
classification
2. If there is valvular disease, congenital heart disease, pregnancy, obstructive
cardiomyopathy, or suspicion of rare muscle fibre conditions.
3. Heart Failure that does not respond to standard treatment, or where the
diagnosis is in doubt, or where there is an acute relapse such that
management can no longer take place in the home setting
 Record Keeping
Record keeping should be at the usual high standard. In particular they should be
contemporaneous and include the following:
 Weight
 New physical signs and symptoms
 BP & pulse rate
 Medication and record of side effects
 Electrolytes
 Patient education
 Training
Lead clinicians from the practice must attend the training sessions run by the PCT (in
conjunction with secondary care) before accreditation for the enhanced service, and
at least yearly thereafter.
 Audit
Once a year an audit of care will be undertaken. The audit tool will be circulated in
due course.
 Significant Event Analysis
If untoward events occur, such as hospital admissions, deaths, or other events or
near misses, then a formal SEA will be conducted. Lessons learnt and action taken
will be reported to the PCT
 Research
Practices will be encouraged to take part in local research activities in LVSD.
 Patient Satisfaction
Every year a patient satisfaction survey and wellbeing questionnaire will be
administered to the patients with LVSD. Lessons learnt and action plan will be
reported to the PCT
References
1. Prevalence of left-ventricular systolic dysfunction and heart failure in the
Echocardiographic Heart of England Screening Study: a population based study.
Davies MK, Hobbs FDR, Davis RC et al. Lancet 2001;358:439-44
2. Incidence and aetiology of heart failure; a population-based study
M.R. Cowie, D.A. Wood, A.J.S. Coats, S.G. et al. Eu Heart Journal 1998;20:421-428
3. Chronic heart failure: management of CHF in adults in primary and secondary
care. NICE clinical guideline 5. www.nice.org.uk
4. Management of chronic heart failure: A national guideline. SIGN guideline 95.
www.sign.ac.uk/pdf/sign95/pdf
5. Guideline Update for the diagnosis and management of chronic heart failure in the
adult. ACC/AHA 2005. www.acc.org
6. Nurse interventions - RCT of specialist nurse intervention in heart failure. Blue L et al BMJ
2001;323:715-718
7. Telemonitoring or structured telephone support programmes for patients with chronic
heart failure: systematic review and meta-analysis. Clark R et.al. BMJ 2007;334:942