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    Cardiac Rehabilitation Capacity Tools Cardiac Rehabilitation Capacity Tools Document Transcript

    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitation Need and Capacity for Cardiac RehabilitationAuthors: Nigel Monaghan, Deputy Director of Health and Social Care QualityDate: 15/10/08 Version: 1aStatus: FinalIntended Audience: Cardiac Networks, LHB’s, TrustsPurpose and Summary of Document:This paper summarises advice from the NPHS on translation of information on needinto capacity in line with NICE Commissioning Guidance on Cardiac RehabilitationPublication/Distribution: • Cardiac Networks • Publication in NPHS HSCQ Document Database • Link from NPHS e-Bulletin • Link from Stakeholder e-NewsletterAuthor: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 1 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitation1 BackgroundOn 29th February a letter was sent from the Welsh Assembly to LHB Chief Executivesinforming them of the need for local “cost and clinically effective cardiac rehabilitationservices” as part of “an integral part of the package of care for people at risk of or who havecardiac disease”. The letter went on to request “each LHB in each of the 3 regions, workingtogether through the Cardiac Network, must assess current cardiac rehabilitation provisionagainst the requirements of the NSF Standards and submit a Network level action plan for thedelivery of the NSF Standards to the relevant Regional Office by 31 December 2008.”In addition to supporting the action plans the letter covered spending plans associated withexisting projects funded by the Inequalities in Health Fund or the Big Lottery Fund, and theneed for joint working with Stop Smoking Wales and the National Exercise Referral Scheme.£2 million of the 2008-09 LHB discretionary allocation was ring-fenced for these servicesmatching existing Inequalities in Health and Big Lottery funding which had come to an end .The letter indicated that a data collection exercise will be undertaken to ascertain the baselineinvestment in services, and any shortfall in the ring-fenced sum will be corrected during2008-09.A WAG project is seeking to develop exercise referral schemes to accept people participatingin phase 4 cardiac rehabilitation. Thus the local cardiac rehabilitation plans need toincorporate phases 1 to 4 allowing for this anticipated change.In support of the Cardiac Networks in co-ordinating these tasks the NPHS have been asked toprovide advice related to need and demand for these services.2 Evidence Base for Cardiac Rehabilitation2.1 Policy ContextCardiac rehabilitation is being promoted because it has the potential to prevent prematuredeaths. Cardiac rehabilitation whilst proven to be effective and cost-effective is not currentlyprovided across the whole of Wales to a consistent minimum standard.The Cardiac Network Co-ordinating Group submission to the Welsh Assembly Governmentproposing updates to the Wales National Service Framework for Coronary Health Disease andArrhythmias recognises the need to be more flexible in delivery of cardiac rehabilitation toreflect the needs of individual patients.1 The classification now used by NICE for cardiacrehabilitation is phase 1 – inpatient, phase 2 – early post-discharge rehabilitation, phase 3 –definitive rehabilitation service, phase 4 – long term maintenance.2Experience in Wales and elsewhere shows that even where it is offered cardiac rehabilitationis not always utilised for a range of reasons:Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 2 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitation Poor referral, take-up and attendance have been identified as problems facing cardiac rehabilitation services in the UK. There are several reasons for the lower than expected levels of participation. These include a lack of engagement (people not invited to attend cardiac rehabilitation), low levels of referral, scarcity of service provision and poor take-up due to practical reasons (for example, location and time of the session).2Across the UK cardiac rehabilitation is currently delivered in a combination of home,community and hospital settings. As a general rule in Wales and in line with Designed forLife3 the expectation is that services will be provided as locally as possible consistent withprovision of safe and effective services. There is no reason to assume that provision in a non-hospital setting should affect the outcomes of cardiac rehabilitation for suitable patientsalthough there is some evidence to suggest that patients prefer to attend local non-hospitalbased sessions and that provision of such sessions increases uptake significantly.4 A reportedreason for drop-off in attendance for hospital based cardiac rehabilitation is that patientsdislike the hospital setting and find access difficult. Applying this to cardiac rehabilitationover the longer term with increasing experience and confidence we would expect to see a shiftof rehabilitation from the hospital except for those patients where it is assessed that risksassociated with the rehabilitation are large enough to necessitate this being provided in ahospital. Thus a shift may be indicated where there is limited hospital based rehabilitation, butsome hospital based rehabilitation will still be required for high risk individuals. Whateversetting the rehabilitation is undertaken in it is important to review participation rates,completion rates, and user satisfaction among those who complete and do not completerehabilitation alongside other outcome data.Due to the difficulties associated with conducting randomised controlled trials of differentmodels of care across most of healthcare there is only limited good quality scientific evidenceto support decisions on a particular model of care over another. This is also true for cardiacrehabilitation. Conversely cardiac rehabilitation provided in hospital, community and homesettings have all proven effective, for example home rehabilitation has been shown to providesimilar benefits to hospital based rehabilitation and some patients prefer it.2 The key issues areto ensure all patients meeting guidance on need are offered cardiac rehabilitation, and toensure uptake that they are offered a range of options which have the potential to meet theirneeds and circumstances. Given experiences across the UK these should arguably includehospital, community and home based options.2.2 NICE Commissioning Guidance on Cardiac RehabilitationOn March 20th 2008 NICE published a commissioning guide on cardiac rehabilitation (CR).The commissioning guide should be read in conjunction with the clinical guideline publishedin May 2007 MI: secondary prevention. Secondary prevention in primary and secondary carefor patients following a myocardial infarction.The prime aim of a cardiac rehabilitation programme is encouraging and supportingindividuals at risk of further events associated with cardiac disease to achieve and maintainoptimal physical and psychosocial health. This is tailored to the needs of each patient basedon a comprehensive assessment of their cardiac risks. The set of services encompass amultidisciplinary team of health professionals employed by different bodies but acting inpartnership. The NICE Commissioning Guide gives details of how to develop andAuthor: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 3 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitationcommission a high quality comprehensive cardiac rehabilitation group and emphasises theneed to provide services tailored to the needs of the patient.There are 4 sections to the commissioning guide: • Commissioning a cardiac rehabilitation service • Specifying a cardiac rehabilitation service • Ensuring Corporate and Quality Assurance • Determining local service levels for a cardiac rehabilitation service2.2.1 POTENTIAL BENEFITS OF CARDIAC REHABILITATIONThe commissioning guide lists a number of potential impacts on mortality and morbidity.These include greater survival for people with coronary heart disease who participate incomprehensive cardiac rehabilitation. There is evidence that cardiac rehabilitation reduces therisk of total and cardiac related mortality and reduces the occurrence of non-fatal MI .Evidence also suggests that cardiac rehabilitation results in improving people’s ability towork, their physical capacity and perceived quality of life In addition it indicates improvedexercise tolerance and quality of life for people with mild to moderate heart failure.Participation in comprehensive cardiac rehabilitation can enable people to become active selfmanagers of their condition, and this can assist in reducing unplanned hospital admissions. Italso reduces the need for subsequent revascularisation for those undergoing vascularprocedures.Comprehensive rehabilitation also offers an opportunity to reduce inequalities associated withheart disease. Overall providing rehabilitation offers better value for money than notproviding it.CNS are able to organise prompt and timely admission to hospital when patients symptomsdeteriorate in order to prevent adverse effects.COMMISSIONING A CARDIAC REHABILITATION SERVICEThe NICE Commissioning Guidance on Cardiac Rehabilitation indicates that cardiacrehabilitation should not be regarded as an isolated form or stage of therapy but be integratedwithin secondary prevention services. Having said that, cardiac rehabilitation services are nolonger exclusively hospital based. Emphasis is placed on helping patients become active self-managers of their condition and this can involve hospital, home and community based cardiacrehabilitation programmes, all of which are effective.NICE estimate that the cost of cardiac rehabilitation varies enormously throughout the UK,from £17 to £2186 per patient, despite it being highly cost effective at their estimate of themean cost of £550 per patient.Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 4 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationBased on their analysis of the evidence base NICE have indicated that those with the greatestpotential to benefit from cardiac rehabilitation should be the priority until such time as there iscapacity to rehabilitate all those who could benefit. NICE suggest that once trusts have aneffective system for identifying, treating and following up people who have survived an MI orwho have undergone coronary revascularisation (coronary artery bypass graft andpercutaneous coronary intervention) they should consider extending their rehabilitationservices to people admitted to hospital with stable angina, heart failure, those having cardiactransplant and those receiving implantable cardiac defibrillators. NICE CommissioningGuidance on Cardiac Rehabilitation suggests that key clinical issues in providing an effectivecomprehensive cardiac rehabilitation service are: • actively identifying all people potentially eligible for cardiac rehabilitation and encouraging them to take part in cardiac rehabilitation prior to hospital discharge • assessing an individual’s risk and need for cardiac rehabilitation and developing individualised plans to meet those needs in line with NICE clinical guideline CG48 on MI: secondary prevention and the British Association for Cardiac Rehabilitation document ‘Standards and core components for cardiac rehabilitation’. The Quality requirements within standard 6 of the NSF detail these clinical components further. • providing a quality assured service.NICE guidance does not make specific recommendations regarding patients with chronicCHD, or who had a past event.2.2.2 SPECIFYING A CARDIAC REHABILITATION SERVICEThe 29th February 2008 letter from WAG indicated concerns that access to service in Wales is“patchy”. The NICE Guidance on Cardiac Rehabilitation indicates that where cardiacrehabilitation services have been adequately resourced and where they have systematicallyidentified people and adopted a structured approach to their work, the numbers of peopletreated have increased.Thus for Wales it is proposed that the key service components of a cardiac rehabilitationservice are: • systematically identifying and actively engaging people potentially eligible for cardiac rehabilitation • developing a high-quality multidisciplinary comprehensive cardiac rehabilitation service in line with British Association for Cardiac Rehabilitation guidance.5Structures and ProcessesLocal health boards, local authorities, NHS Trusts, and the voluntary sector should agree therange and availability of services that can be drawn on for cardiac rehabilitation. For example,local authority leisure centres, church halls or other easily accessible public venues may beappropriate for cardiac rehabilitation sessions, and appropriately trained local authority staffcan play a useful role in supervising physical activity and supporting exercise referralAuthor: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 5 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitationschemes. Note that in the context of suitably trained staff there are specified skills andcompetencies for people supervising patients undertaking phase 3 and phase 4 cardiacrehabilitation. Hospital staff and facilities will be required for those patients assessed as highrisk.There is no single model of delivery of cardiac rehabilitation which can be recommendedfrom the evidence base and there is a need for many options to suit the circumstances of thepatient. Following a comprehensive assessment patients should have access to services withinthe hospital, community and home. this would be dependant on their risk assessment, personalchoice and access. From the viewpoint of patients hospital, community and home are allpossible settings). From the viewpoint of participation and maximising the health gained fromcardiac rehabilitation all of these options should ideally be offered across Wales. From theviewpoint of the taxpayer, the service should be effective and cost-effective. The vehicleoptions for delivering all of these include: • A highly detailed service specification covering all details of the service supported by details in individual patient records • A less detailed service specification indicating client groups, settings, hours of operation and outcomes supported by detailed protocols and individual patient records (which may or may not include care pathways).The Cardiac Networks are better placed than the NPHS to decide how they wish to provideadvice on service specifications and protocols.Given that there are various models of delivery in operation in Wales, that these reflect tosome degree local circumstances and that there is no good evidence to support one method ofdelivery over another the option of a less detailed service specification which operates in linewith locally appropriate and more detailed local protocols would seem to be the more flexibleapproach.Whichever combination of service specification/protocol/care pathway option is chosen itneeds to cover: • the target groups currently served • the expected number of patients based on discharge data for the target groups (this should take into account how quickly any changes in service provision are likely to take place) • ease of access, service settings and hours of operation (commissioners should engage with service users and other relevant individuals and organisations locally and consider need for home, community and hospital based elements) • outcomes expected in terms of targets for clients offered cardiac rehabilitation, waiting times and number of clients waiting for access to cardiac rehabilitation, targets for clients choosing to participate in cardiac rehabilitation, targets for clients completing rehabilitation by phase, clinical outcomes expected and service user satisfaction with services; these will for the basis of service monitoring criteriaAuthor: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 6 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitation • information, quality assurance and audit requirements, including IT support and infrastructure for all settings and phases • the required competencies of and training for, staff responsible for providing the service for all settings and phases • detailed information on service locations, hours of operation and contact details for all settings and phases • detail on the scope of the programme - balance of dietary, exercise, education, psychological and social etc and difference for different groups of patients – for all settings and phases • detail on how programme options are offered to patients and how programmes are tailored to each patient’s need • detail on number and length of sessions for each element of the programme • care and referral pathways for the individual can be described from the detail outlined above • protocols, equipment and training for the management of predictable medical emergencies appropriate to the hospital, community or home setting • planned service improvement, including redesign, quality, equitable access, and referral-to-treatment timesAppendix 1 proposes a minimum content for service specifications in Wales. It is structuredso that local data can be entered and local estimates of proportion of cases suitable for eachsetting for rehabilitation by phase can be entered.Appendix 2 proposes minimum content for protocols which it is suggested should be settingand phase specific. If a decision is taken to have a single highly detailed service specificationrather than a less detailed service specification indicating client groups, settings, hours ofoperation and outcomes supported by detailed protocols and individual patient records then itis suggested that the content in appendix 2 should also be included in the local protocol.Appendix 3 is attached as a tool to assist local planning for provision of cardiac rehabilitationin hospital, domiciliary and community settings. It is structured to allow local data onexpected hospital discharges to be combined with estimates to calculate capacity needed byphase of cardiac rehabilitation and by setting for each clinical indication. Factors affectingthese estimates include risk assessment for rehabilitation in different settings, preferringrehabilitation in particular settings and proportions of those commencing completing eachphase. NPHS has produced similar excel spreadsheets for each health community in Wales.2.2.3 ENSURING CORPORATE AND QUALITY ASSURANCEThe NICE Commissioning Guidance on Cardiac Rehabilitation suggests that commissionersneed to ensure they consider both the clinical and economic viability of the service, and anyrelated services, and take into account patient’s and carer’s views and those of otherAuthor: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 7 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitationstakeholders when planning these services. It also suggests that a clear specification is thestarting point for monitoring and assuring quality in the service contract.The NICE Commissioning Guide for Cardiac Rehabilitation lists the features of a cardiacrehabilitation service needs to ensure corporate and quality assurance and for local qualityassurance they suggest the following: • Equipment: testing and calibration of exercise and monitoring equipment. • Health, safety and security: infection control, waste management, confidentiality procedures, legislative requirements. • Staff competencies: individual and team baseline requirements, monitoring and performance. See Implementation advice for NICE clinical guideline CG48 on MI: secondary prevention for recommendations on assessing training needs. • Accreditation requirements: for some or all elements of the service, the premises and/or staff. • Clinical quality criteria: appropriateness of referral, consenting procedures, clinical protocols. • Information requirements, including both patient-specific information (NHS number, referring GP, provision of high-quality information to patients/carers) and service- specific information (referral-to-treatment times, workload trends, number of complaints). Clinical governance arrangements, including incident reporting. • Audit arrangements: frequency of reporting, reporting route and format, and dissemination mechanisms; this should include auditing the proportion of eligible patients requiring cardiac rehabilitation who are provided with care, and monitoring of patient outcomes and complications. (See audit criteria for NICE clinical guideline CG48 on MI: secondary prevention, which includes recommendations to link with the national audit of cardiac rehabilitation which is also recommended within the Welsh Cardiac NSF). • Service and performance targets, including estimated activity levels and case mix, waiting and referral-to-treatment times (ensuring that patients and carers do not experience unnecessary delays), complaints procedures. • Patient outcomes: reduced risk of further cardiac problems, improved quality of life, reduction in hospital admissions, improved return to work rates, reduced blood pressure and cholesterol levels, improved patient knowledge and psychosocial well- being and reporting these outcomes to the ‘National audit of cardiac rehabilitation’ (see Appendix 3 for rationale). • Patient satisfaction: patient and carer perspective and perception of service provision, complaints. • Achieving targets associated with equalities legislationAuthor: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 8 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitation • The process for reviewing the service with stakeholders, including decisions on changes necessary to improve or to decommission the service.3 Potential Need and Demand - Determining Local Service Levels for a Cardiac Rehabilitation ServiceNICE used data to estimate that the standard benchmark rate for a cardiac rehabilitationservice for all the conditions/procedures listed in the is 0.20%, or 200 per 100,000, populationper year. The estimates used in these calculations of the benchmark for cardiac rehabilitationare provided by the topic-specific advisory group; they are based on best practice and are theproportions that could be achieved given optimal service design. Some clinicians haveexpressed concern that these numbers do not reflect the position in Wales.The NICE assumptions used in estimating a population benchmark rate for new referrals intoa cardiac rehabilitation service were based on the following sources of information:- • ‘Hospital episode statistics’ and general practice data to establish the proportion of the population discharged alive per year following an acute admission for a myocardial infarction (MI) or heart failure; and after admission for revascularisation, heart transplant or implantable cardiac defibrillators; and the proportion of the population identified in the community with angina per year • published research on cardiac rehabilitation • expert clinical opinion of the topic-specific advisory group, based on experience in clinical practice and literature reviewTable 1 Assumptions used in the population benchmark for cardiac rehabilitation based on 2006/7 hospitalactivity data and expert clinical opinion Percentage of Percentage of Percentage Combination of Percentage population discharged (optimal) of referral and (optimal) of discharged population population optimal take-up dischargedDiagnosis/procedure alive in suitable for suitable for (percent) – that population who 2006/07 cardiac referral who take is, attendance take up cardiac rehabilitation up cardiac rehabilitation based referral rehabilitation on 2006/7 dataMyocardial infarction 0.12 85 80 68 0.082Percutaneous 0.02 100 85 85 0.017coronary interventionCoronary artery 0.04 100 85 85 0.034bypass graftHeart failure 0.07 75 70 53 0.037Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 9 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationImplant of a cardiac 0.004 100 85 85 0.0034defibrillatorTable 2 NICE commissioning guidance estimates of percentage of whole populationtaking up cardiac rehabilitation Year 2007 Percentage of whole population requiring rehabilitation for Coronary Percutaneous Artery Myocardia Coronary Bypass Heart Implant of l Infarction Intervention Graft Failure Defibrillator 0.082 0.017 0.034 0.037 0.0034 Area Wales 2979975 2444 507 1013 1103 101 Isle of Anglesey 69003 57 12 23 26 2 Gwynedd 118374 97 20 40 44 4 Conwy 111709 92 19 38 41 4 Denbighshire 97009 80 16 33 36 3 Flintshire 150537 123 26 51 56 5 Wrexham 131911 108 22 45 49 4 Powys 131963 108 22 45 49 4 Ceredigion 77777 64 13 26 29 3 Pembrokeshire 117921 97 20 40 44 4 Carmarthenshire 179539 147 31 61 66 6 Swansea 228086 187 39 78 84 8 Neath Port Talbot 137376 113 23 47 51 5 Bridgend 133917 110 23 46 50 5 The Vale of Glamorgan 124017 102 21 42 46 4 Cardiff 321000 263 55 109 119 11 Rhondda, Cynon, Taf 233734 192 40 79 86 8 Merthyr Tydfil 55619 46 9 19 21 2 Caerphilly 171824 141 29 58 64 6 Blaenau Gwent 69170 57 12 24 26 2 Torfaen 91086 75 15 31 34 3 Monmouthshire 88200 72 15 30 33 3 Newport 140203 115 24 48 52 5Calculated using NICE Commissioning Guidance for Cardiac Rehabilitation and the Mid-Year Population Estimates (2001 onwards), bylocal authority from Statistical Directorate, Welsh Assembly GovernmentSome concern has been expressed that these estimates based on NICE guidance may not beapplicable for Wales. To address these concerns hospital discharge data for Wales has alsobeen analysed and presented.For a complete picture on hospital discharges alive for the procedures and diagnoses whichNICE Commissioning Guidance recommends Cardiac Rehabilitation Appendix 4 providesdata on the number of individuals discharged alive in each of the years from 2002 to 2006 atLHB, old Trust and new Trust levels. All Wales trends in diagnoses are not consistentlyreflected in 2006 data at LHB and Trust level. However at all Wales level there is a tendencyto decrease in myocardial infarction in more recent years whereas there is an increased trendfor provision of a range of cardiac procedures.Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 10 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationGiven these trends the most recent data is presented in Tables 3 and 4. Table 3 provides LHBdata on the number of individuals discharged alive in 2006 for each of the procedures listed intable 1. Note that in tables 3 and 4 the data on revascularisation includes that for coronaryartery bypass grafts, for percutaneous coronary angioplasty and for stent placement combined.Table 3 Discharges Alive for Selected Cardiac Diagnoses and Interventions by LHB Myocardial Infarction Revascularisation Heart Failure Transplant Defibrillator Isle of Anglesey 96 140 239 0* 6 Gwynedd 179 198 444 0* 8 Conwy 257 255 494 0* 0 Denbighshire 183 166 403 0* 8 Flintshire 226 317 540 0* 17 Wrexham 205 221 457 0* 18 Powys 179 227 613 0* 0 Ceredigion 88 117^ 245 0* 0 Pembrokeshire 232 158^ 457 0* 0 Carmarthenshire 269 275 758 0* 0 Swansea 229 384^ 907 0* 0 Neath Port Talbot 249 284^ 678 0* 0 Bridgend 252 257^ 637 0* 0 Vale of Glamorgan 116 200 339 0* 0 Cardiff 227 484 807 0* 0 Rhondda Cynon Taff 353 257 754 0* 6 Merthyr Tydfil 103 88 202 0* 0 Caerphilly 287 270 543 0* 0 Blaenau Gwent 124 70 363 0* 0 Torfaen 154 120 326 0* 0 Monmouthshire 157 103 320 0* 0 Newport 249 190 395 0* 0 * data still being analysed, number and Wales very low and typically 0 for most LHBs ^plus an additional 0-4 stent placementsTable 4 provides similar data for the new Welsh Trusts. More detailed breakdown by oldWelsh Trust is presented in Appendix 4.Table 4 Discharges Alive for Selected Cardiac Diagnoses and Interventions by Trust Myocardial Revascularisatio Stable Heart Infarction n Angina Failure Transplant Defibrillator ABM 287 1543 ? 640 0 68 Cardiff and Vale 0 0 ? 0 ?* 0 Cwm Taf 0 0 ? 0 0 0 Gwent Healthcare 0 0 ? 0 0 0 Hywel Dda 0 0 ? 0 0 0 North Wales 0 0 ? 0 0 0 North West Wales 0 0 ? 0 0 0 Powys Teaching LHB 0 0 ? 0 0 0 All English Providers 0 0 ? 0 ?* 0Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 11 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitation Velindre 0 0 0 0 0 0It should be noted that stable angina is not included in any of these tables or in the estimaterates in the NICE commissioning guidance. Although data on all angina codes is collected andwithin the codes used there is a specific diagnosis of unstable angina, it cannot be concludedthat all patients with angina codes other than those for unstable angina have stable angina. It islikely that there may be a mix of stable and unstable angina cases among these codes. Thediagnostic codes for angina are:INC 10 Code 120 Angina pectoris I20.0 Unstable angina • Angina: o crescendo o de novo effort o worsening effort • Intermediate coronary syndrome • Preinfarction syndromeI20.1 Angina pectoris with documented spasm • Angina: o angiospastic o Prinzmetal o spasm-induced o variantI20.8 Other forms of angina pectoris • Angina of effort • StenocardiaI20.9 Angina pectoris, unspecified • Angina: o NOS o cardiac • Anginal syndrome • Ischaemic chest pain .The identification of all patients admitted to hospital (not just those admitted with cardiacindication) with stable angina is a challenge and could be a useful audit topic.Similarly NICE do not provide an estimate of the number of individuals receiving heart andlung or heart only transplants who are in another group for which rehabilitation isrecommended when capacity allows. In Wales there are less than 5 transplants in a typicalyear. Thus the LHBs will normally have 0 cases per annum and the additional burden on anindividual Trust service from cardiac transplants will also be small.Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 12 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitation4 Capacity of Existing ServicesThe NPHS does not have access to data describing the current cardiac rehabilitation servicesin place in Wales. The Cardiac networks are in the process of auditing existing provision. Thisaudit should facilitate a gap analysis identifying development needs for individual services.The description of the number of cases per Trust and Per LHB summarised in Section 3 anduse of the tool attached as Appendix Z should assist local discussion regarding the demandsupon local rehabilitation services, the capacity which can be provided by local services andany opportunity to expand beyond the initial priority groups of those who have had MI or whohave undergone coronary revascularisation recommended by NICE.NPHS are exploring the possibility of making this tool available to LHBs and Trusts in apartially completed spreadsheet format.5 References1. Cardiac Network Co-ordinating Group (2007). Tackling Coronary Heart Disease and Arrhythmias in Wales – Update of the original Coronary Health Disease National Service Framework for Wales http://howis.wales.nhs.uk/sites3/Documents/338/Updated%20CHD%20NSF%20Final %20Submission%20to%20WAG%20March%202007%20%283%29.pdf (accessed 29/08/2008)2. NICE (2007) Specifying a cardiac rehabilitation service. http://www.nice.org.uk/usingguidance/commissioningguides/cardiacrehabilitationservi ce/SpecifyingCardiacRehabilitationService.jsp?textonly=false (accessed 29/08/2008)3. National Assembly for Wales (2005). Designed for Life - creating world-class health and social care for Wales in the 21st century http://www.wales.nhs.uk/documents/designed-for-life-e.pdf (accessed 29/08/2008)4. Harris N (2007). Cardiac Rehabilitation in Westminster http://www.selcardiacnetwork.nhs.uk/files/NigelHarris.pdf (accessed 29/08/2008)5. British Association for Cardiac Rehabilitation (2007). Standards and Core Components for Cardiac Rehabilitation http://www.bcs.com/documents/affiliates/bacr/ BACR%20Standards%202007.pdf (accessed 29/08/2008)Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 13 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationAppendix 1Suggested Minimum Content for Service SpecificationService Specification for Cardiac Rehabilitation 1 BackgroundThe prime aim of a cardiac rehabilitation programme is to provide a set of services tailored tothe needs of each patient based on a comprehensive assessment of their cardiac risks.Cardiac rehabilitation associated with admission to hospital has four main phases: phase 1 –inpatient, phase 2 – early post-discharge discharge, phase 3 – definitive rehabilitation service,phase 4 – long term maintenance. This specification relates to cardiac rehabilitation across all4 phases and encompasses a comprehensive programme as outlined in national guidelines(BACR) of assessment, risk stratification, goal setting, health education, structured exerciseprogrammes, psychological assessment, support and review.Cardiac rehabilitation provided in an effective and efficient way is a cost-effectiveintervention. The cost effectiveness is dependent upon putting in place effective systems foridentifying, treating and following up clients. 2 Client GroupsWhere capacity is an issue NICE have proposed that people who have survived an MI or whohave undergone coronary revascularisation (coronary artery bypass graft and percutaneouscoronary intervention) are those who gain the greatest benefit. They advice that when there issufficient capacity locally rehabilitation services should also cover those people admitted tohospital with stable angina, heart failure, those having cardiac transplant and those receivingimplantable cardiac defibrillators.In [name of health community] each year approximately [number of] people are dischargedfrom hospital as follows: Need for Cardiac Rehabilitation Estimated DischargesDiagnosis/procedure Alive Per AnnumMyocardial infarctionPercutaneous coronary interventionCoronary artery bypass graftHeart failureImplant of a cardiac defibrillatorAuthor: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 14 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationLocally cardiac rehabilitation should be offered to those who have survived an MI or whohave undergone coronary revascularisation (coronary artery bypass graft and percutaneouscoronary intervention) [add or delete from the following list according to local capacity:those people admitted to hospital with stable angina, heart failure, those having cardiactransplant and those receiving implantable cardiac defibrillators.] 3 Access – Settings and Hours of OperationThe evidence based for cardiac rehabilitation is strongest for those who have been recentlyadmitted to hospital and this is the basis of the NICE guidance. This all patients admitted tohospital for conditions included in the client group section should be offered cardiacrehabilitation.There is some evidence that offering rehabilitation in domicilary and community settings iseffective and is preferred by many patients. Setting of rehabilitation is more commonly anissue for patients than hours of the service or language issues therefore all patients who arerisk stratified as able to participate in rehabilitation outside a hospital setting should be offereddomiciliary or community based rehabilitation in the latter phases.Rehabilitation services should operate [according to hours agreed locally]. Data frompatient surveys should be collected to inform decisions regarding future hours of operation. 4 Quality AssuranceComprehensive routine data collection is the bedrock upon which a quality assured service isbuilt. As different models of delivery of care may be in place in different settings it isimportant that for all phases and settings of cardiac rehabilitation that Protocols are developedand used to construct a range of patient care pathways. Data collected as protocols arefollowed will form the patient record and will usefully inform audit, and performancemanagement.Performance management data will examine the participation rates and completion rates forcardiac rehabilitation by setting and by phase. This data will also contribute to the NACR.Service users views will be collected by setting and by phase. This work to be conducted asadvised by the all Wales cardiac rehabilitation working group (AWCRWG).In addition to the NACR local audit will be undertaken to target areas or service user concernand settings and phases where completion rates are poorest. The audits should be conductedas closely as possible to standards promoted by the AWCRWG and findings be reported backto the AWCRWG.Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 15 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationAn annual report will draw on performance management findings, service users views andchanges made as a result of audit. 5 Performance IndicatorsThe objective of cardiac rehabilitation is encouraging and supporting individuals at risk offurther events associated with cardiac disease to achieve and maintain optimal physical andpsychosocial health.In the long term an ultimate objective is to enable individuals to live longer and live morecomplete lives than they would without cardiac rehabilitation. Thus potential outcomemeasures could include mortality and quality of life indicators. However these are indicatorswhich take time to effect even a small change in at population level of statistical significance.In the shorter term there are clinical indicators which may change as a result of participationin rehabilitation. These include reaching CHD risk targets, medication and psychologicalaspects. It is possible that future studies or audits may show benefits of one model ofrehabilitation over other models where delivery is equally good but the actual model is better.In the shorter term still and as part of the evaluation of the management and delivery isnecessary to ensure that any comparisons of outcomes of models are grounded on similarlevels of participation in cardiac rehabilitation.Many clinical targets for cardiac rehabilitation (such as BMI changes or regular participationin exercise) are set at individual level.There is debate as to whether an intended objective is for individuals to be ready to move toindependent and regular exercise. The commissioners of services are unlikely to viewparticipation in phase 4 Cardiac Rehabilitation as the end of the patient journey. Most if notall of them will expect patients to move from phase 4 into mainstream community or homebased activity as the end point. Therefore this transition from completion of phase 4 into thecommunity is likely to be an outcome of interest.Certainly the satisfaction of users with a service may be a reason for participation or droppingout. This too is a key indicator of the quality of a patient centred service of interest for boththose completing and those not completing expected programmes of rehabilitation.As different models of care may be in place it is important to define the indicators on whichthe range of models may be compared and the data collected will need to separate differencesdue to the models of rehabilitation from how well they are managed and delivered. Thus thepotential framework within which performance indicators could be identified by the cardiacnetworks include:Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 16 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitation Mortality and Quality of Life | Clinical Indicators (e.g, blood pressure, BMI, psychological) | Participation indicators (e.g. completion rates for phases) | Satisfaction of those completing and not completing rehabilitationAuthor: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 17 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationAppendix 2Suggested Content for Setting and Phase Specific ProtocolsProtocolsIt is assumed that protocols may be developed for a range of settings as follows:Setting Phase Phase 2 Phase 3 Phase 4 1Hospital √ √ √ √Domiciliary √ √ √Communit √ √ √yAn individuals care pathways will consist of their journey which could for example consist of: • Phase 1 in hospital • phase 2 & 3 at home • Phase 4 in the community.Note that in a specific location some of these elements may not be necessary, for examplehospital based phase 2 and phase 4 rehabilitation may not be required. In this case protocolswill not be needed.Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 18 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationAppendix 3 How To Use The Cardiac Rehabilitation Need To Capacity ToolThe following sheets are intended to be used with information on individuals discharges alive following specified cardiac procedures oron discharges alive associated with a specified chronic cardiac condition. This information should be entered into the appropriate box forphase 1.There is variation in the length of various phases of cardiac rehabilitation iin different locations. The evidence base has not developed tothe point of proving effectiveness of one model over another. Thus the best estimate of the length of the local phase 1 programme for theaverage patient should be entered into the appropriate box.From the number of discharges per annum the total annual number of person-weeks of cardiac rehabilitation capacity can be calculated.When this is divided by 52 it indicates the mean weekly capacity required on the assumption that all patients progress once through eachphase.The percentage to complete phase 1 estimation should indicate the local percentage of individuals expected to complete this phasefollowing one or more attempts. This percentage figure will assist in calculating the number to complete phase 1 which is the startingpoint for phase 2 calculations.As phase 2 may be conducted in different settings there is a need to estimate the local percentage of individuals undertaking phase 2 inhome and in hospital settings based on either local experience or that elsewhere. The resulting numbers can then be inserted into thephase 2 calculations similar to those used for phase 1. If rehabilitation in a phase is not provided in a setting then please enter 0% forthat phase/setting cell.At the end of phase 2 individuals will move into one of three settings. Again an estimate of the percentage moving to each is required toenable the phase 3 calculations to be completed. This process also needs to be repeated for phase 4.Once all estimates have been inserted the number of individuals expected to complete phase 4 can be compared with the percentagedischarged alive and entering the programme. The resulting target percentage figure can be used as a check that assumptions made arerealistic. There is nothing to stop further copies of the tool being used with higher and lower estimates being entered to ensure that anyconclusions drawn are reasonable and robust.Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 19 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationIt is suggested that once these tables are completed and the resulting figures are agreed as sensible a final upward adjustment is madeto the capacity calculation at each phase to reflect the number of individuals expected to repeat that phase on one or more occasions.These final figures estimate how the local need translates into cardiac rehabilitation capacity.Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 20 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationService Capacity Calculations [Name of Health Community]Sheet for (complete one set of sheets for each condition):Condition Myocardial Coronary Stable Heart Cardiac Implantable cardiac Infarct revascularisation angina failure transplant defibrillators(Tick one only)Phase 1Phase 1 – Hospital BasedDischarged No of Weeks Average Weekly Capacity = (No to % to complete Number toAlive per Year of Phase 1 complete phase x No. of weeks)/52 Phase 1 complete Phase 1Phase 1 to Phase 2 TransitionNo. Completing % to Domiciliary No. to Domiciliary % to Hospital No. to Hospital %. to No. toPhase 1 Phase 2 Phase 2 Phase 2 Phase 2 Community Community Phase 3 Phase 3Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 21 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationPhase 2Phase 2 – Domiciliary SettingNo. from No of Weeks of Average Weekly Capacity = (No to % to complete Number toPhase 1 Phase 2 complete phase x No. of weeks)/52 Phase 2 complete Phase 2Phase 2 – Hospital BasedNo. from No of Weeks of Average Weekly Capacity = (No to % to complete Number toPhase 1 Phase 2 complete phase x No. of weeks)/52 Phase 2 complete Phase 2Phase 2 – Community BasedNo. from No of Weeks of Average Weekly Capacity = (No to % to complete Number toPhase 1 Phase 2 complete phase x No. of weeks)/52 Phase 2 complete Phase 2Phase 2 to Phase 3 TransitionNo. Completing % to Domiciliary No. to Domiciliary % to Hospital No. to Hospital %. to Community No. to CommunityDomiciliary Phase 2 Phase 3 Phase 3 Phase 3 Phase 3 Phase 3 Phase 3No. Completing % to Domiciliary No. to Domiciliary % to Hospital No. to Hospital %. to Community No. to CommunityHospital Phase 2 Phase 3 Phase 3 Phase 3 Phase 3 Phase 3 Phase 3No. Completing % to Domiciliary No. to Domiciliary % to Hospital No. to Hospital %. to Community No. to CommunityCommunity Phase Phase 3 Phase 3 Phase 3 Phase 3 Phase 3 Phase 32 Total to Domiciliary Total to Total to Community Phase 3 Hospital Phase Phase 3 3Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 22 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationPhase 3Phase 3 – Domiciliary SettingNo. from No of Weeks of Average Weekly Capacity = (No to % to complete Number toPhase 2 Phase 3 complete phase x No. of weeks)/52 Phase 3 complete Phase 3Phase 3 – Hospital BasedNo. from No of Weeks of Average Weekly Capacity = (No to % to complete Number toPhase 2 Phase 3 complete phase x No. of weeks)/52 Phase 3 complete Phase 3Phase 3 – Community BasedNo. from No of Weeks of Average Weekly Capacity = (No to % to complete Number toPhase 2 Phase 3 complete phase x No. of weeks)/52 Phase 3 complete Phase 3Phase 3 to Phase 4 TransitionNo. Completing % to Domiciliary No. to Domiciliary % to Hospital No. to Hospital %. to Community No. to CommunityDomiciliary Phase 3 Phase 4 Phase 4 Phase 4 Phase 4 Phase 4 Phase 4No. Completing % to Domiciliary No. to Domiciliary % to Hospital No. to Hospital %. to Community No. to CommunityHospital Phase 3 Phase 4 Phase 4 Phase 4 Phase 4 Phase 4 Phase 4No. Completing % to Domiciliary No. to Domiciliary % to Hospital No. to Hospital %. to Community No. to CommunityCommunity Phase Phase 4 Phase 4 Phase 4 Phase 4 Phase 4 Phase 43 Total to Domiciliary Total to Total to Community Phase 4 Hospital Phase Phase 4 4Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 23 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationPhase 4Phase 4 – Domiciliary SettingNo. from No of Weeks of Average Weekly Capacity = (No to % to complete Number toPhase 3 Phase 4 complete phase x No. of weeks)/52 Phase 4 complete Phase 4Phase 4 – Hospital BasedNo. from No of Weeks of Average Weekly Capacity = (No to % to complete Number toPhase 3 Phase 4 complete phase x No. of weeks)/52 Phase 4 complete Phase 4Phase 4 – Community BasedNo. from No of Weeks of Average Weekly Capacity = (No to % to complete Number toPhase 3 Phase 4 complete phase x No. of weeks)/52 Phase 4 complete Phase 4 Total completing Phase 4 % of discharges alive completing Phase 4Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 24 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationAppendix 4Myocardial InfarctionLHB Data Counts of individual patients with a primary diagnosis of myocardial infarction (ICD-10 I21, I22) during a spell of hospital care, by Local Authority of residence, 2002-06 200 200 200 200 200 Local Authority 2 3 4 5 6 Total Isle of Anglesey 107 125 104 92 96 524 Gwynedd 160 179 155 174 179 847 Conwy 211 217 214 260 257 1159 Denbighshire 179 202 168 179 183 911 Flintshire 229 249 218 236 226 1158 Wrexham 236 199 213 200 205 1053 Powys 179 199 199 190 179 946 Ceredigion 93 109 96 104 88 490 Pembrokeshire 253 262 240 261 232 1248 Carmarthenshire 233 216 229 291 269 1238 Swansea 351 347 285 244 229 1456 Neath Port Talbot 257 314 276 253 249 1349 Bridgend 264 256 231 257 252 1260 The Vale of Glamorgan 178 186 138 152 116 770 Cardiff 373 365 286 204 227 1455 Rhondda Cynon Taff 386 316 339 331 353 1725 Merthyr Tydfil 103 95 78 95 103 474 Caerphilly 334 313 330 319 287 1583 Blaenau Gwent 175 152 144 130 124 725 Torfaen 173 184 186 168 154 865 Monmouthshire 145 157 168 155 157 782 Newport 289 254 267 237 249 1296 490 489 456 453 441 2331 Wales 8 6 4 2 4 4Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 25 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationTrust Data Counts of individual patients resident in Wales with a primary diagnosis of myocardial infarction (ICD-10 I21, I22) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06 2002 2003 2004 2005 2006 Total Bro Morgannwg 474 502 505 527 484 2492 Swansea 532 569 366 325 335 2127 Cardiff and Vale 698 684 521 344 392 2639 Pontypridd and Rhondda 220 184 232 213 216 1065 North Glamorgan 240 216 177 247 249 1129 Gwent Healthcare 958 899 960 933 874 4624 Pembrokeshire and Derwen 210 221 217 235 211 1094 Ceredigion and Mid Wales 70 102 99 86 94 451 Carmarthenshire 230 210 238 309 264 1251 Conwy and Denbighshire 333 353 323 364 356 1729 North East Wales 346 298 323 293 315 1575 North West Wales 334 365 309 329 342 1679 Powys Teaching LHB 46 42 35 13 9 145 All English Providers 224 254 262 322 287 1349*annual totals do not match those in residence-based table above due to a small number of patients not having a validlocal authority code recorded. Counts of individual patients resident in Wales with a primary diagnosis of myocardial infarction (ICD-10 I21, I22) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06 2002 2003 2004 2005 2006 Total ABM 1006 1071 871 852 819 4619 Cardiff and Vale 698 684 521 344 392 2639 Cwm Taf 460 400 409 460 465 2194 Gwent Healthcare 958 899 960 933 874 4624 Hywel Dda 510 533 554 630 569 2796 North Wales 679 651 646 657 671 3304 North West Wales 334 365 309 329 342 1679 Powys Teaching LHB 46 42 35 13 9 145 All English Providers 224 254 262 322 287 1349*annual totals do not match those in residence-based table above due to a small number of patients not having a validlocal authority code recorded.Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 26 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationAtrial FibrillationLHB Data Counts of individual patients with a primary diagnosis of atrial fibrillation (ICD-10 I48)during a spell of hospital care, by Local Authority of residence, 2002-06 2002 2003 2004 2005 2006 Isle of Anglesey 116 124 120 137 163 Gwynedd 190 191 162 182 195 Conwy 227 240 227 268 239 Denbighshire 147 183 180 178 203 Flintshire 190 210 219 256 239 Wrexham 173 185 186 177 222 Powys 180 156 151 199 206 Ceredigion 70 81 96 90 94 Pembrokeshire 233 218 220 211 224 Carmarthenshire 244 256 306 262 257 Swansea 376 321 326 379 374 Neath Port Talbot 215 194 175 252 242 Bridgend 267 250 234 221 223 The Vale of Glamorgan 183 209 186 181 189 Cardiff 347 329 333 305 310 Rhondda Cynon Taff 331 325 345 299 280 Merthyr Tydfil 56 71 70 74 92 Caerphilly 239 201 227 226 217 Blaenau Gwent 101 82 88 91 74 Torfaen 128 103 104 121 109 Monmouthshire 102 111 135 139 114 Newport 181 164 121 173 160Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 27 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationTrust Data Counts of individual patients resident in Wales with a primary diagnosis of atrial fibrillation (ICD-10 I48) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06 2002 2003 2004 2005 2006 Bro Morgannwg 482 446 392 457 434 Swansea 478 425 424 484 493 Cardiff and Vale 583 570 573 528 535 Pontypridd and Rhondda 248 238 236 223 200 North Glamorgan 136 160 169 164 200 Gwent Healthcare 675 592 609 673 605 Pembrokeshire and Derwen 214 194 192 188 195 Ceredigion and Mid Wales 52 57 73 71 84 Carmarthenshire 249 267 335 280 256 Conwy and Denbighshire 314 353 329 385 397 North East Wales 279 283 304 287 321 North West Wales 349 357 338 381 404 Powys Teaching LHB 44 40 23 27 28 Velindre 1 2 1 0 0 All English Providers 195 220 215 280 285 Counts of individual patients resident in Wales with a primary diagnosis of atrial fibrillation (ICD-10 I48) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06 200 200 200 200 200 Current Trust 2 3 4 5 6 ABM 960 871 816 941 927 Cardiff and Vale 583 570 573 528 535 Cwm Taf 384 398 405 387 400 Gwent Healthcare 675 592 609 673 605 Hywel Dda 515 518 600 539 535 North Wales 593 636 633 672 718 North West Wales 349 357 338 381 404 Powys Teaching LHB 44 40 23 27 28 Velindre 1 2 1 0 0 All English Providers 195 220 215 280 285Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 28 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationHeart FailureLHB Data Counts of individual patients with any mention of heart failure (ICD-10 I50) during a spell of hospital care, by Local Authority of residence, 2002-06 Local Authority 2002 2003 2004 2005 2006 Isle of Anglesey 214 216 216 258 239 Gwynedd 359 356 389 407 444 Conwy 483 496 470 508 494 Denbighshire 395 467 410 451 403 Flintshire 554 581 566 591 540 Wrexham 456 457 437 425 457 Powys 565 541 506 531 613 Ceredigion 234 250 276 265 245 Pembrokeshire 472 491 477 528 457 Carmarthenshire 763 764 783 767 758 Swansea 998 918 995 1022 907 Neath Port Talbot 677 690 724 778 678 Bridgend 750 664 655 647 637 The Vale of Glamorgan 371 335 361 381 339 Cardiff 727 642 801 829 807 Rhondda Cynon Taff 836 784 824 884 754 Merthyr Tydfil 231 248 225 202 202 Caerphilly 639 630 650 600 543 Blaenau Gwent 362 396 426 393 363 Torfaen 333 340 329 317 326 Monmouthshire 271 337 335 329 320 Newport 424 424 398 398 395Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 29 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationTrust Data Counts of individual patients resident in Wales with any mention of of heart failure (ICD-10 I50) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06 2002 2003 2004 2005 2006 Bro Morgannwg 1259 1224 1204 1222 1155 Swansea 1512 1326 1531 1579 1353 Cardiff and Vale 1160 1011 1220 1268 1268 Pontypridd and Rhondda 497 489 520 610 512 North Glamorgan 576 588 572 511 492 Gwent Healthcare 1858 1966 1943 1863 1739 Pembrokeshire and Derwen 409 427 390 434 389 Ceredigion and Mid Wales 187 197 219 241 216 Carmarthenshire 739 789 761 736 721 Conwy and Denbighshire 814 836 770 890 828 North East Wales 757 755 690 662 626 North West Wales 654 671 708 772 787 Powys Teaching LHB 347 291 246 192 217 Velindre 11 9 10 14 24 All English Providers 350 452 477 538 616 Counts of individual patients resident in Wales with any mention of of heart failure (ICD-10 I50) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06 200 200 200 200 200 Current Trust 2 3 4 5 6 277 255 273 280 250 ABM 1 0 5 1 8 116 101 122 126 126 Cardiff and Vale 0 1 0 8 8 107 107 109 112 100 Cwm Taf 3 7 2 1 4 185 196 194 186 173 Gwent Healthcare 8 6 3 3 9 133 141 137 141 132 Hywel Dda 5 3 0 1 6 157 159 146 155 145 North Wales 1 1 0 2 4 North West Wales 654 671 708 772 787 Powys Teaching LHB 347 291 246 192 217 Velindre 11 9 10 14 24 All English Providers 350 452 477 538 616Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 30 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationPercutaneous Transluminal Coronary AngioplastyLHB Data Counts of individual patients with any mention of PTCA (OPCS codes K49, K50, K75) during a spell of hospital care, by Local Authority of residence, 2002-06 Local Authority 2002 2003 2004 2005 2006 Isle of Anglesey 38 52 44 67 62 Gwynedd 56 63 94 89 82 Conwy 52 50 72 85 107 Denbighshire 33 42 66 67 61 Flintshire 89 97 98 122 131 Wrexham 84 107 99 91 84 Powys 28 40 71 89 103 Ceredigion 23 26 50 53 61 Pembrokeshire 39 88 113 90 84 Carmarthenshire 64 104 136 157 148 Swansea 184 209 257 245 232 Neath Port Talbot 69 115 153 159 168 Bridgend 59 93 110 151 173 The Vale of Glamorgan 48 70 76 103 122 Cardiff 106 210 216 241 283 Rhondda Cynon Taff 97 112 122 137 143 Merthyr Tydfil 21 26 42 42 51 Caerphilly 61 86 120 138 156 Blaenau Gwent 21 40 32 24 37 Torfaen 18 33 29 54 64 Monmouthshire 24 27 25 39 53 Newport 39 41 49 74 105Trust Data Counts of individual patients resident in Wales with any mention of PTCA (OPCS codes K49, K50, K75) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06 200 200 200 200 200 2 3 4 5 6 ABM (Swansea) 475 650 842 896 910 Cardiff and Vale 397 626 682 806 968 All English Providers 377 446 545 612 629Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 31 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationCoronary Artery Bypass GraftLHB Data Counts of individual patients with any mention of CABG (OPCS codes K40 - K46) during a spell of hospital care, by Local Authority of residence, 2002-06 Local Authority 2002 2003 2004 2005 2006 Isle of Anglesey 51 36 31 22 21 Gwynedd 86 67 43 44 51 Conwy 58 51 56 39 48 Denbighshire 47 48 34 29 46 Flintshire 80 88 70 60 63 Wrexham 81 58 58 60 55 Powys 46 48 89 60 63 Ceredigion 31 33 33 34 56 Pembrokeshire 73 72 56 84 74 Carmarthenshire 98 113 103 146 121 Swansea 152 139 135 136 152 Neath Port Talbot 79 116 108 125 116 Bridgend 76 96 96 98 84 The Vale of Glamorgan 68 67 75 52 58 Cardiff 150 174 175 108 135 Rhondda Cynon Taff 131 136 86 107 88 Merthyr Tydfil 34 34 34 23 27 Caerphilly 87 81 121 96 85 Blaenau Gwent 36 18 44 26 25 Torfaen 34 42 45 44 41 Monmouthshire 41 41 37 49 35 Newport 70 69 75 56 57Trust Data Counts of individual patients resident in Wales with any mention of CABG (OPCS codes K40 - K46) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06 200 200 200 200 200 2 3 4 5 6 ABM (Swansea) 546 602 553 585 628 Cardiff and Vale 616 645 691 535 539 All English Providers 447 379 358 375 332Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 32 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationImplantable DefibrillatorsLHB Data Counts of individual patients with any mention of cardiac defibrillator implant (OPCS code K59) during a spell of hospital care, by Local Authority of residence, 2002-06 Local Authority 2006 Isle of Anglesey 6 Gwynedd 8 Conwy - Denbighshire 8 Flintshire 17 Wrexham 18 Powys - Ceredigion - Pembrokeshire - Carmarthenshire - Swansea - Neath Port Talbot - Bridgend - The Vale of Glamorgan - Cardiff - Rhondda Cynon Taff 6 Merthyr Tydfil - Caerphilly - Blaenau Gwent - Torfaen - Monmouthshire - Newport - *a count of five patients or less is denoted by -Trust Data Counts of individual patients resident in Wales with any mention of cardiac defibrillator implant (OPCS code K59 during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06 2006 Cardiff and Vale 14 All English Providers 68Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 33 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)
    • National Public Health Service for Wales Need and Capacity For Cardiac RehabilitationImplantable DefibrillatorsLHB Data Counts of individual patients with any mention of coronary stent placement (OPCS code K75) during a spell of hospital care, by Local Authority of residence, 2002-06 Local Authority 2006 Isle of Anglesey 57 Gwynedd 65 Conwy 100 Denbighshire 59 Flintshire 123 Wrexham 82 Powys 61 Ceredigion - Pembrokeshire - Carmarthenshire 6 Swansea - Neath Port Talbot - Bridgend - The Vale of Glamorgan 20 Cardiff 66 Rhondda Cynon Taff 26 Merthyr Tydfil 10 Caerphilly 29 Blaenau Gwent 8 Torfaen 15 Monmouthshire 15 Newport 28 *a count of five patients or less is denoted by -Trust Data Counts of individual patients resident in Wales with any mention of coronary stent placement (OPCS code K75) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06 2006 Cardiff and Vale 199 All English Providers 582Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 34 of 34 Intended Audience: Cardiac Networks/ NHS Wales (Intranet)