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C ARE AND E DUCATION R ESEARCH G ROUP

C ARE AND E DUCATION R ESEARCH G ROUP. Keeping CR on the agenda Bob Lewin Professor of Rehabilitation RJPL1@york.ac.uk. Some terms Minimum dataset (MDS) – the information – that is collected by everyone in the audit – can be built into any database system – eg. Tomcat.

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C ARE AND E DUCATION R ESEARCH G ROUP

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  1. CAREAND EDUCATION RESEARCH GROUP Keeping CR on the agenda Bob Lewin Professor of Rehabilitation RJPL1@york.ac.uk

  2. Some terms Minimum dataset (MDS) – the information – that is collected by everyone in the audit – can be built into any database system – eg. Tomcat. CCAD – Central Cardiac Audit Datasets – the collection of UK audits for CARDIAC specialties - MI, Surgery, Stents, ICDs, Arrhythmia nursing (coming soon) and Cardiac Rehabilitation - The NACR Database – Lotus notes database that is used to send the data up to CCAD who store the information Benchmarking – comparing your results with other programmes Process Benchmarking – comparing how the outcomes of CR are effected by the different processes the patient has experienced Audit – reporting what is achieved by each programme, where needs are not being met (locality, gender, ethnicity, social class etc)

  3. Principles of the NACR • no unfair ‘league tables’ – improvement scores not raw outcomes • record resources (staff) available to each programme to make fair comparisons as show how results depend on resources • include local indices of deprivation and other health indices to ensure fair comparisons • benchmarking confidential to each programme • developed by CR for CR – it’s going to be as good as YOU make it

  4. Minimum Dataset Literature search, international consultation, possible questionnaires tried out by a panel of 100 patients and clinician from 10 CR programmes focus groups to select best measures, dissemination to experts, professional bodies and the clinical community for comment. Download papers, dataset, definitions and the questionnaires from www.cardiacrehabilitation.org.uk/datasets

  5. BHF/BACR/CCAD Lotus Database Built in ‘buttons’ for commonly requested reports All your data can be exported to Excel at any time for your own purposes Many users can unite secondary and community care Template letters or design your own Lots of free text ‘comments boxes’ for you to record notes – add as much information as you want. 30 ‘spare fields’ for you to enter any other data you want or need to collect – e.g. repeat exercise tests, dietary assessment, etc. Lists anxious and depressed patients automatically etc etc etc And it is free courtesy of the BHF

  6. CCAD CR programme staff enter data Cardiac Rehab Patients fill in questionnaires 3 times, before, after CR and at 12 months Annual Audit Reports to DH, HCC, BHF, Public, Patients BHF York

  7. We need every CR programme to join Planed to recruit 45 per quarter so that recruitment is complete end 2007 projected figure by end of 2nd quarter 2006 was 130 actual no. with software committed to take part is 210 Number linked electronically 101

  8. Annual National Audit Reports to HCC, BHF, Public, Patients. BHF York Not connected, Or, less than 12 months (April-March) data AND ANNUAL staffing questionnaire for everyone Annual / online / paper survey with Alton

  9. Annual / online / paper survey HCC – will use this data to assess trusts IF you complete the paper survey and join the NACR

  10. You’re never alone with the NACR! BHF York BHF REGIONAL CRCs CCAD HELPLINE CARDIAC NETWORK Lee, Margaret Smart group - nacr-users@smartgroups.com You Other Users

  11. People BHF York(all part-time) Project Manager – Corinna Petre Data Manager / analysis - Simon Coulton Data Quality officer – Jo Orchard Secretarial / Admin – Roz Thompson Statistician – to be appointed BHF regional Cardiac Rehabilitation Coordinators Shirley Hall, Dianne Card, Steph Dilnot, Step Lillie, Elaine Tanner Cardiac Network Lee Panter, Margaret Leid CCAD Help Desk at CCAD for your IT people

  12. Organisations involved BHF - champion, financial sponsor BACR – part of core requirement for a CR programme? DH Heart Team – Roger Boyle has put resource in Cardiac Networks – Lee, Margaret Health & Social Care Information Systems - mother organisation forCCAD, HES and other NHS and social datasets HCC – will use our data to assess trusts IF you complete the paper survey and join the NACR

  13. The audit will provide you with • automatic reporting of NSF targets & many other reports about your programme • evidence about what you achieve as a health gain for your local population • evidence to inform local planners as to the adequacy of CR provision in your patch • an understanding of how well funded you are compared to the national norms • the ability to compare what your programme achieves with the national averages on a range of outcomes – national benchmarking

  14. Descriptive overview of patients on the database

  15. Rehab Processes across 4 ‘stages’

  16. NSF targets measured at 12 weeks…

  17. those who attend – Quality of life indicators…

  18. Of those who do attend – anxiety and depression…

  19. Descriptives of CR programme - logistic regression modelling assessing factors associated with success. – (inc. disability, age, programme staffing level etc. CR-MDS Weighted comparison of uptake for cardiac events (acute MI, PTCA, CABG) stratified by Acute Trust, PCT, SHA, age, gender, ethnicity. Additional PCT, Acute Trust & SHA factors - regression modelling assessing external factors associated with uptake HES Quality & Service Delivery Additional demographic factors, social deprivation and health indices factors added to regression model to explore factors associated with success. ONS Analysis

  20. By 2002 85% of MI and revasc patients will be offered cardiac rehabilitation After that all except unstable angina patients should receive CR. Best guestimate 25-30% of patients getting CR in 2005-6.

  21. Problems under treatment inequalities – women, poor, ethnic minorities, depressed, smokers, elderly, all believed to be under-represented, postcode lottery failure to invite all indicated in NSF – angina, heart failure, ICD, arrhythmia dropout – varies widely from programme to programme staffing – from single-handed, part-time, coordinator for 600 patients to a full multi-disciplinary team. Only 50% of programmes have an identifiable budget. poor outcomes?- pragmatic’ RCT by Robert West

  22. Can Cardiac rehabilitation survive? 2000/2001 £31m for revascularisation 2002/2003 £161m. 400% increase Probably 2-5% reduction in mortality from CABG vs. medical treatment No increase in funding of CR apart from BHF Lottery £4m Evidence based Healthcare not costed in ‘payment per treatment’ Been rejected by GPs as a QOF target. In the new age of ‘self-management’ and ‘Chronic Disease Management’ why have we not seen a single mention of CR in Government literature? Using NSF criteria for those expected to benefit, guesstimated shortfall of 330,000 patients a year

  23. How do others get funding? CentralCardiacAuditDatabase NationalPacemaker &ICD Database Regional variations in ICDimplantation rate.Only health authorities shown in orange reach the new implant rate required by N.I.C.E. guidelines.

  24. NACRed or wot? The good news is… The technology works and is helping programmes all over the country organise and communicate better information sharing between trusts and across primary/secondary care may be about to become very simple making the project even more effective around 50% of UK programmes have already committed there is solid support from major stakeholders, BHF, DH, HCC NICE guidance on MI and secondary prevention strongly supports CR, indeed treats it as obvious that all patients including heart failure patients should take part

  25. Amanda Hutchinson – Healthcare Commission “I was involved in a large project about the National Service Framework and I became increasingly passionate about the importance of cardiac rehabilitation. We identified that it was one of the standards where less progress had been made despite the enormous commitment of staff and the effort that was being made to try and make it work given the historic lack of priority that cardiac rehabilitation services have been given. … patients were extremely positive about this as a service and it was something that was valued by everyone we spoke to and surveyed. A key finding was that only 16% of Trusts were able to provide the data we required ... This is why the audit database is so important, because without the data, it is extremely difficult to make a case for service improvement and why the audit is such an exciting prospect.”

  26. Change the future COULD be the beginning of the best period yet for CR – BUT it could also be the beginning of the end - replaced by leaflet bearing lay health trainers in primary care. We have powerful friends but NO active champions – we are going to have to DO IT OURSELVES working with charities (BHF), patients, the media and politicians. Proposal - we should join together in a sustained 5 year campaign using NACRed to draw attention to the unmet need. We should show what we can achieve and how much more we could achieve if we were all adequately funded. And we must all do it all together – have a moan, whinge all you want complain about the extra work - but do it – join NACR today and change the future. WE WILL WIN!

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