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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