NHS Atlas of Variation for People with Respiratory Disease


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NHS Atlas of Variation for People with Respiratory Disease

  1. 1. The NHS Atlas of Variationin Healthcare forRespiratory DiseaseSeptember 2012 Copyright 2011 Right Care
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  3. 3. “Robust guidance has been published by NICE andother bodies to support evidence-based management of chronic obstructive pulmonary disease (COPD), asthma and other lung conditions, and yet in this NHS Atlas of Variation in Healthcare for People with Respiratory Disease a stark picture is presented of the variation in the quality of care and outcomes experienced by people ..in different parts of England”3
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  5. 5. Why does unwarranted variation matter? John Wennberg, who has championed research into clinical variation over four decades and who founded the pioneering Dartmouth Atlas of Health Care, concludes that: “much of the variation … is accounted for by the willingness and ability of doctors to offer treatment rather than differences in illness or patient preference”. Wennberg defines unwarranted variation in healthcare as variation that cannot be explained on the basis of illness, medical evidence, or patient preference. Wennberg J (2010) Tracking Medicine: A Researcher’s Quest to Understand Health Care. Oxford University Press.5
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  7. 7. Where people live significantly affectstheir likelihood of being admitted tohospital with COPD and dying from it.This shows that proactivemanagement of COPD is better issome parts of England than othersFor PCTs in England, the rate ofCOPD emergency admissions tohospital ranged from 76.9 to 421.6per 100,000 population (5-foldvariation).When the five PCTs with the highestrates and the five PCTs with thelowest rates are excluded, the rangeis 87.6–340.5 per 100,000 population,and the variation is 3.9-fold.7
  8. 8. Although there are legitimate reasons forexception-reporting, the difference Map 2between the published QOF achievementand actual coverage varies substantially atPCT level.Patients who are excepted are at high riskof not receiving appropriate pro-activechronic disease management andtherefore of experiencing worse outcomes.Options for action to increase access tochronic disease management in COPD:• Calculate the actual QOF coverage by including excepted patients in denominator• Benchmark and share local exception reporting data• Identify the systems to maximise patient- reach used in the best-performing practices• Support local practices with high exception rates to implement best-practice systems 8
  9. 9. For PCTs in England, the rate of deathswithin 30 days of an admission for COPDranged from 3404.6 to 11,826.1 per100,000 population (3.5-fold variation).When the five PCTs with the highest ratesand the five PCTs with the lowest ratesare excluded, the range is 4237.5–10,119.0 per 100,000 population, and thevariation is 2.4-fold.Some of the difference in death rateswithin 30 days of an admission for COPDmay be due to differences in:›› case-mix;›› population composition.However, some of the difference in deathrates is likely to be due to variation in thequality of clinical care provided before,during and following admission tohospital. 9
  10. 10. Case-study: Integrated COPD services across 14 PCTsEast of England Changes that have been instigated include, amongst others:Integrated care wasdeveloped in the 14 PCTs in ›› agreeing patient pathways acrossthe East of England by organisations;commissioning integrated ›› self-management plans;services and the introduction ›› multidisciplinary meetings; ›› universal availability of pulmonaryof innovations by local rehabilitation and home oxygenproviders and commissioners. assessment and review; ›› community COPD clinics;This work has been facilitatedby the local respiratory Outcome data from South East Essex afternetworks in each PCT with the the introduction of an integrated serviceinvolvement of all provider show:organisations, commissionersand patients. ›› a reduction of 19% in COPD admissions; ›› a reduction of 24% in COPD bed-days; ›› a saving of £650,000 per year.10
  11. 11. For people with asthma, the risk ofbeing admitted with an acuteexacerbation can vary up to threetimes depending on where they live.Some of this variation can beaccounted for by differences in localpopulation characteristics, but muchis unwarranted due to differences inthe quality of asthma care, and thesupport people receive to managetheir condition.Emergency admission to hospital isa major adverse outcome forpatients. The degree of variationobserved shows that in manylocalities there is substantial scopefor reducing emergency events.11
  12. 12. For PCTs in England, theemergency admission rate forchildren with asthma ranged from38.7 to 732.6 per 100,000population aged 0–17 years (19-foldvariation).When the five PCTs with the highestrates and the five PCTs with thelowest rates are excluded, thevariation is 5-fold.Action to reduce emergencyadmissions requires a wholepathway approach, including publichealth, and primary and secondarycare. Parental education and schoolmedication management are vital togood care.12
  13. 13. One of the reasons for variation in the emergency admission rate could be deprivation: there is a moderate correlation between frequency of emergency admission and the level of socio-economic deprivation (r=0.56; Figure 14.1). However, this may not be the sole explanation for the degree of variation observed because a comparison of the 10 most deprived PCTs shows a 19-fold variation in emergency admission rates and a 2.1-fold variation among the 10 least deprived PCTs13
  14. 14. Case-study: SIMPLE approach to asthma management NHS Leicester City Leicester City was identified as having very high emergency admission rates for asthma, which were substantially above the national average. NHS Leicester City developed a Medicines Use Review (MUR) service. Implementation of the service is expected: The service was designed to be delivered by community pharmacists ›› to reduce the number of asthma for people with asthma. The service is exacerbations and hospital built on the SIMPLE approach to admissions; asthma management. ›› to improve the prescribing of cost- effective medicines; An educational toolkit was developed to support pharmacists undertaking ›› to reduce the over-prescription of the asthma reviews. steroids.14
  15. 15. Obstructive sleep apnoea (OSA) syndromehas conservative prevalence estimates of1–2%; the vast majority of people sufferingfrom this disorder are undiagnosed.Access to diagnostic assessment for peoplewith sleep disorders remains patchy; failureto diagnose is common, and interventionrates remain low relative to the prevalenceof sleep problems.Action to increase the diagnosis of sleepdisorders includes:• Improving understanding of expected and observed prevalence of sleep- related conditions• Raising awareness in primary care to promote prompt referral• Assessing the demand for and capacity of local sleep services 15
  16. 16. For PCTs in England, the ADQ ofcombination (ICS and LABA)inhalers ranged from 51,954 to167,259 ADQ per 1000 patients onGP COPD and Asthma registers(3.2-fold variation).When the five PCTs with the highestADQs and the five PCTs with thelowest ADQs are excluded, therange is 73,260 to 141,695 per1000 patients on GP COPD andAsthma registers, and the variationis 1.9-fold.When used appropriately,combination inhalers have a clearevidence base. However, they arevery expensive: three of the top fivehighest spend items prescribed inEngland are respiratory inhalers. 16
  17. 17. Clinicians can improve theclinical effectiveness and costeffectiveness of respiratoryprescribing throughresponsible guidance-basedprescribing.This is likely to improvepatients’ quality of life, reducethe risk of deteriorationsufficient to requirehospitalisation, reduce the riskof harm from ICS, and reduceexpenditure. 17
  18. 18. Case-study: Improving inhaler technique Isle of Wight PCT The PCT developed a programme to Isle of Wight PCT found that it had train healthcare professionals in: high levels of emergency ›› use of the inhaler; admission for asthma and high ›› patient training; spend on inhaled medication. ›› assessment of inhaler technique When used effectively, 20% of the Patients receiving training were issued medication in a metered dose with a training aid to help them maintain inhaler (MDI) reaches the lungs the correct technique (the other 80% is swallowed), Within the first year of the programme: whereas with a poor technique the percentage inhaled falls to ›› expenditure on selective beta-agonists between 0% and 10%. fell by 22.7% – a saving greater than seven times the initial investment by Isle of Wight PCT; Therefore, an intervention to ›› prescription numbers fell by 25.2%; improve inhalation techniques was ›› emergency admissions due to asthma identified as a cost-effective way were reduced by 50%. of improving patient outcomes.18
  19. 19. Smoking is the main reason for thegap in healthy life-expectancybetween higher and lower socioeconomic groups. COPD affectsaround 3m people in England:85% of cases are caused bysmoking.There is a 2.3- fold variationamong PCTs in England in therate of successful smoking quitterswhen the top and bottom 5 PCTstaken out.This suggests that some PCTs aremore effective than others atsupporting smoking cessation. 19
  20. 20. Case-study: Stop-smoking stickersEast Kent Hospitals University NHS Foundation Trust In May 2011, a new referral route was put in place to ensure that patients attending outpatients departments A sticker was introduced as an aide- memoire into the inside back cover of each set of outpatient notes to be completed by the relevant staff In the 9 months following member at booking. introduction of the sticker system: The sticker provides a prompt not only ›› referrals to the stop-smoking for supporting patients to quit smoking service quadrupled from 206 to 834 but also to ensure that smoking status ›› there was a statistically is recorded in the notes. significant increase in the number of successful 4-week quitters.20
  21. 21. What can we do about unwarranted variation? “Knowledge does not, unfortunately, always lead to action. Publicising the existence of unwarranted variations and their causes does not guarantee that they will be tackled1” The narrative about unwarranted variation is the most crucial step on the pathway from data to change. The narrative helps clinicians and commissioners to understand the magnitude of the problem locally, the impact on population outcomes and the opportunity costs of not reducing unwarranted variation.1. Appleby J, Raleigh V (2011) Variations in Health Care – the Good, the Bad and the Inexplicable. TheKing’s Fund. http://www.kingsfund.org.uk/publications/healthcare_variation.html21
  22. 22. The grieving process ..some clinicians will lack the expertise to interpret data in detail and some may respond defensively… After the Kubler Ross bereavement cycle22
  23. 23. Essential steps in the use of data to drive change If clinicians and commissioners are to use data to drive change locally, several essential steps need to be taken23
  24. 24. Importance of the narrative in driving change24
  25. 25. Improving outcomes in respiratory disease: the role of clinical commissioning groups When they become fully operational in 2013, clinical commissioning groups will be held to account for the delivery of outcomes for their patients through the indicators in the NHS Outcomes Framework. Clinical commissioning groups will therefore have an express responsibility not only for the quality of the services they commission but also for the quality of primary care provided by constituent local practices.25
  26. 26. Improving outcomes for people with respiratory disease – resources available ›› Department of Health (2011) An Outcomes Strategy for COPD and Asthma: NHS Companion Document. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic yAndGuidance/DH_134000 ›› NHS Medical Directorate (2012) COPD Commissioning Toolkit. A Resource for Commissioners. https://www.wp.dh.gov.uk/publications/files/2012/08/chronic- obstructive-pulmonary-disease-COPD-commissioning-toolkit.pdf ›› NHS Improvement – Lung; resources on the website: http://www.improvement.nhs.uk/lung/ ›› IMPRESS – Improving and integrating respiratory services; resources on the website: http://www.impressresp.com/ ›› Quality Intelligence East. INHALE – Interactive Health Atlas for Lung conditions in England. http://www.inhale.nhs.uk/26
  27. 27. “The central message of the NHS Atlas of Variation in Healthcare is that it is possible to achieve better outcomes for patients. Although data may be open to more than one interpretation, the power of the Atlas lies not in the answers it provides but in the questions it raises.”27
  28. 28. www.rightcare.nhs.uk/atlas In print You can order free printed copies using the online form on our website Online High and Low resolution PDFs are available for download Interactive A fully interactive InstantAtlastm is available online28
  29. 29. Follow Right Care online - Subscribe to get a weekly digest of our blog in your inbox - Receive Occasional eBulletins - Follow us on Twitter @qipprightcare www.rightcare.nhs.uk29