chronic disease in nhs greater glasgow & clyde

Dr Anne Scoular, Consultant in Public Health Medicine | December 2014

CHRONIC DISEASE IN NHS GREATER GLASGOW & CLYDE

Insights from Local Enhanced Services Programme 2012-2014

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Contents

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II

III

IV

V

Index to figures & tables

Executive summary

Foreword

Introduction

Population need

2.1 Registered diagnoses

2.2 Disease prevalence

2.2 Premature disease

2.3 Multimorbidity

Clinical Service Delivery & Key Outcomes

3.1 Coronary Heart Disease

3.2 Type 2 Diabetes

3.3 Stroke/TIA

3.4 Chronic Obstructive Pulmonary Disease (COPD)

3.5 Left Ventricular Systolic Dysfunction (LVSD)

Conclusion

Appendix: CDM LES Review Final Report

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Index to figures and tables

Figure 1: Total chronic disease diagnoses in NHSGGC: 2012/13 vs 2013/14 (n) 11

Figure 2: Total number of chronic disease diagnoses in 2013/14, by partnership 11

Figure 3: Crude disease prevalence (per 1,000), by partnership, 2013/14 12

Figure 4: Crude disease prevalence (per 1,000), NHSGGC: 2012/13 vs 2013/14 12

Figure 5: % change in crude disease prevalence, by area: 2012/13 vs 2013/14 13

Figure 6: Age & sex standardised disease prevalence (per 1,000), by area, 2013/14 13

Figure 7: Premature male & female disease prevalence, by partnership, 2013/14 14

Figure 8: CDM LES patient cohort 2013/14: number of co-existent diagnoses 15

Table 1: CDM LES patient cohort 2013/14: details of co-existent diagnoses 15

Figure 9: CHD patients: age distribution 18

Figure 10: CHD patients: ethnicity recording & overview 18

Figure 11: CHD patients: detail of non-white ethnic groups, by partnership area 19

Figure 12: CHD patients: deprivation profile, by partnership area 19

Figure 13: CHD patients: exception coding, by partnership area 20

Figure 14: CHD patients: reason for exception coding, by partnership area 20

Figure 15: CHD patients: smoking status, by residential deprivation quintile 21

Figure 16: CHD patients: current smokers in each partnership area 21

Figure 17: CHD patients who smoke: smoking cessation referrals, by deprivation quintile 22

Figure 18: CHD patients who smoke: smoking cessation referrals, by partnership area 22

Figure 19: CHD patients: alcohol use 23

Figure 20: CHD patients: lipid control, by deprivation status 23

Figure 21: CHD patients: lipid control, by ethnic subgroup 24

Figure 22: CHD patients: lipid control, by age group 24

Figure 23: CHD patients: lipid control, by partnership area 25

Figure 24: CHD patients: % within target cholesterol range, by practice 25

Figure 25: CHD patients: % with AF, by age 26

Figure 26: CHD patients with AF: % receiving warfarin therapy, by age group 26

Figure 27: CHD patients with AF: therapy by partnership area 27

Figure 28: CHD patients with AF: % receiving warfarin therapy, by practice 27

Figure 29: Type 2 diabetes: age distribution 29

Figure 30: Type 2 diabetes: ethnicity recording & overview 29

Figure 31: Type 2 diabetes: detail of non-white ethnic groups, by partnership area 30

Figure 32: Type 2 diabetes: deprivation profile, by partnership area 30

Figure 33: Type 2 diabetes: exception coding, by deprivation quintile 31

Figure 34: Type 2 diabetes: exception coding, by partnership area 31

Figure 35: Type 2 diabetes: smoking status, by residential deprivation quintile 32

Figure 36: Type 2 diabetic patients who smoke: smoking cessation referrals, by deprivation quintile 32

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Figure 37: Type 2 diabetic patients who smoke: smoking cessation referrals, by partnership area 33

Figure 38: Type 2 diabetic patients: alcohol use 33

Figure 39: Type 2 diabetic patients: recorded levels of physical activity, by deprivation quintile 34

Figure 40: Type 2 diabetic patients: referrals to physical activity services, by partnership 34

Figure 41: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by deprivation quintile 35

Figure 42: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by partnership area 35

Figure 43: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by ethnic group 36

Figure 44: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by practice 36

Figure 45: Stroke/TIA patients: age distribution 38

Figure 46: Stroke/TIA patients: ethnicity 38

Figure 47: Stroke/TIA patients: deprivation profile, by partnership area 39

Figure 48: Stroke/TIA patients: exception coding, by deprivation quintile 40

Figure 49: Stroke/TIA patients: exception coding, by partnership area 40

Figure 50: Stroke/TIA patients: smoking status, by residential deprivation quintile 41

Figure 51: Stroke/TIA patients who smoke: smoking cessation referrals, by deprivation quintile 41

Figure 52: Stroke/TIA patients who smoke: smoking cessation referrals, by partnership area 42

Figure 53: Stroke/TIA patients: alcohol use 42

Figure 54: Stroke/TIA patients: functional problems, by age group 43

Figure 55: Stroke/TIA patients: recorded use of services relative to scale of functional problems 43

Figure 56: COPD patients: age distribution 45

Figure 57: COPD patients: ethnicity recording & overview 45

Figure 58: COPD patients: deprivation profile, by partnership area 46

Figure 59: COPD patients: exception coding, by deprivation quintile 47

Figure 60: COPD patients: exception coding, by partnership area 47

Figure 61: COPD patients: smoking status, by residential deprivation quintile 48

Figure 62: COPD patients who smoke: smoking cessation referrals, by deprivation quintile 49

Figure 63: COPD patients who smoke: smoking cessation referrals, by partnership area 49

Figure 64: COPD patients: alcohol use 50

Figure 65: COPD patients: MRC grade, by age group 50

Figure 66: COPD patients: referral to pulmonary rehabilitation, by partnership area 51

Figure 67: COPD patients: referral to pulmonary rehabilitation, by practice 51

Figure 68: LVSD patients: age distribution 53

Figure 69: LVSD patients: aetiology 53

Figure 70: LVSD patients: ethnicity 54

Figure 71: LVSD patients: deprivation profile, by partnership area 54

Figure 72: LVSD patients: exception coding, by deprivation quintile 55

Figure 73: LVSD patients: exception coding, by partnership area 55

Figure 74: LVSD patients: smoking status, by residential deprivation quintile 56

Figure 75: LVSD patients who smoke: smoking cessation referrals, by deprivation quintile 56

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Figure 76: LVSD patients who smoke: smoking cessation referrals, by partnership area 57

Figure 77: LVSD patients: alcohol use 57

Figure 78: LVSD patients: NYHA class, by partnership area 58

Figure 79: LVSD patients: cardiac therapy prescribed within last 12 months, by NYHA Class 59

Table 2: Detail of cardiac drug therapy in preceding 3 months, by NYHA Class 60

Figure 80: LVSD patients: overview of drug therapy over preceding year, by number of agents 61

Figure 81: Percentage of practice LVSD cohort receiving one or more therapies 61

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Executive summary

As at 31 March 2014, 146,461 patients were registered on one or more LES CDM disease registers, an increase of

2.4% compared with the 2012/13 cohort of 143,077 patients. A total of 194,714 chronic disease diagnoses was

recorded, representing an average of 1.3 conditions per patient.

Of the five disease areas, CHD was the most prevalent, closely followed by Type 2 diabetes. COPD prevalence

which showed a threefold variation across the NHSGGC partnerships. Crude prevalence of premature disease

showed marked spatial variation and was generally highest in partnership areas with more intense

socioeconomic deprivation. The gradient in premature disease prevalence was steepest for COPD and least

marked for CHD. For all conditions apart from COPD, the prevalence of premature disease was substantially

higher in men than in women. ‘Multimorbidity’ (generally defined as two or more co-existent chronic

conditions) was present in 38,411 (26%) of the current cohort.

CHD patients represent the largest single disease register in the CDM programme, closely followed by Type 2

diabetes. The proportion of patients who belonged to non-white ethnic subgroups was highest for Type 2

diabetes and CHD, however there was considerable variability at local partnership level. In South Glasgow, for

example, approximately 1 in 4 Type 2 diabetic patients belonged to an ethnic minority subgroups. The

deprivation distribution of patients with all disease areas differed strikingly across partnerships, but was most

polarised towards SIMD quintile 1 areas in COPD and CHD.

Exception coding provides some insights into the proportion of patients who were not sought for review. For

all disease areas, exception coding rates were higher in residents of more socio-economically deprived

neighbourhoods, although there was considerable variability between different partnerships. Overall, the

magnitude and distributional patterns of exception coding are likely to be contributing to inequalities in health

status within NHSGGC and require further attention in consultation with practices. The proportion of patients

exception coded was lowest for patients with LVSD (11%) and highest for COPD patients (19%).

Smoking is a major risk factor for all five disease areas within the current CDM programme. High smoking

prevalence remains a challenge, particularly in residents of the most deprived neighbourhoods. Smoking

cessation support is a powerful clinical intervention in its own right, however relatively low proportions of

patients were reported as ‘ready to stop’ and this subgroup had variable recorded rates of referral to smokefree

services. However, more encouragingly, there was considerable variability in these proportions at local level

and referral rates of patients at the ‘right’ stage of change were consistently higher in residents of the most

deprived areas. Overall, however, tobacco continues to generate substantial additional morbidity and mortality

within a population already bearing a heavy burden of chronic disease. This situation can be improved by

tackling overall rates of smoking in areas of deprivation and further upskilling clinicians with behavioural brief

interventions suitable for busy primary care professionals, building on the many novel ideas for improving the

health promoting opportunities within the CDM programme identified by general practice staff themselves

involved in the last year of the Keep Well programme (see separate report).

Specific clinical indicators are presented for each disease area:

In CHD care, achieving target total cholesterol values of ≤5 mmol/l was a NICE/European Cariguideline-

informed recommendation in the 2013/14 contract year, however this was achieved in only two thirds

of patients overall and an even lower proportion (60%) among CHD patients who lived in the most

deprived neighbourhoods compared with residents of more affluent areas (67%). Although ‘treating to

target’ has subsequently been the subject of considerable debate, there remain very strong trial data

that more aggressive lipid lowering is associated with a continued reduction in mortality and adverse

cardiovascular events.

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For Type 2 diabetes, recommended levels of physical activity (which has a major independent beneficial

effect on glycaemic control) were reached by only 38% of the cohort in the most deprived SIMD quintile

and 50% in the least deprived and referral rates to physical activity services were uniformly low (2%)

across all deprivation quintiles. Overall, a minority (18,760; 36%) of Type 2 diabetic patients had HbA1c

values compatible with good glycaemic control, with poorer glycaemic control was poorer in black

ethnic minority subgroup and among those with no recorded ethnicity, which may may reflect gaps in

structured, systematic care.

In stroke/TIA patients, a high proportion had functional problems which are highly amenable to

therapy, however recorded use of services appeared relatively low, although this may be partly

explained by incomplete Read code capture of the full range of relevant services.

In COPD, pulmonary rehabilitation should be offered to all people with COPD at MRC Grade 3 and

above who consider themselves functionally disabled by their condition. However, only around half of

patients in this category are referred, with considerable variation between partnerships and between

individual practices.

Clinical indicators for the LVSD programme suggest that a number of areas require attention. Firstly,

there are issues concerning the diagnostic precision of Read coding. A separate, detailed audit

undertaken within the local CDM programme in 2013 identified considerable variability in Read coding

for heart failure. This highlighted two broad types of issues: firstly, the extent to which patients with

heart failure were captured on any heart failure register; and secondly, the validity and precision of

documented subtypes of heart failure diagnoses. There is a need to clean practice heart failure registers,

standardise secondary care discharge letters and enhance support to improve and maintain accurate

coding across the whole system in the future.

Functional capacity assessment is a central component of clinical care for patients with heart failure. In

NHSGGC, however, over one third of LVSD patients within the primary care CDM programme had no

recorded NYHA class, although this proportion varied from 20 to 49% across different partnerships.

Therapeutic management of LVSD patients also requires more detailed audit. 4,600 (41%) patients

appeared not to have been recently (ie in the previous three months) prescribed a beta blocker and

3,426 (31%) appeared not to have been prescribed an ACE-I or ARB in the same period. Over a longer

retrospective time period (12 months), 3,083 (28%) of patients appeared not to have been prescribed a

beta blocker and 2,185 (20%) had not record of having received either an ACE-I or ARB. It is quite

conceivable that these apparent prescribing anomalies may be artefactual (as a result of extraction

problems) or a result of the inaccurate disease coding previously discussed, however it is a matter of

concern that the two main groups of drugs recommended in LVSD may not be prescribed in a sizeable

number of LVSD patients and needs more detailed analysis as a matter of urgency.

In summary, this report provides local intelligence on the scale and clinical performance of the CDM

programme in each of the five disease areas. Specific topics are highlighted for a possible future improvement

focus and it is proposed that these are clinically led by the CDM Review and Implementation Group as part of

the ongoing programme redesign process established in 2013, following the CDM LES programme review (Final

report embedded as Appendix 1). Greater emphasis is required on optimising coverage and delivery of clearly

defined, evidence based interventions that hold the greatest potential to change clinical outcomes, together

with investment of dedicated clinician time in person-centred consultations, workforce development to ensure

that the most effective use is made of that time, further improvements on the recent electronic template

changes and ‘whole system’ supportive infrastructure to ensure that a well organised, structured approach to

improving outcomes and health status for the increasing numbers of patients who will in the future need

effective community based care for chronic disease.

Foreword

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This paper provides insights into the clinical performance of NHS Greater Glasgow & Clyde’s Chronic Disease Management (CDM) programme, which delivers practice based CDM care for patients with five major chronic diseases:

Coronary Heart Disease (CHD)

Type 2 Diabetes

Stroke/TIA

Chronic Obstructive Pulmonary Disease (COPD)

Left Ventricular Systolic Dysfunction (LVSD).

The NHS Greater Glasgow & Clyde (NHSGGC) CDM programme is delivered in primary care, but strongly

underpinned by a whole population perspective across all aspects of service planning, coordinated by a

multidisciplinary planning group, with input from a Consultant in Public Health Medicine, a GP Medical

Editor, the Primary Care Support Team, four Managed Clinical Networks (Heart, Diabetes, Respiratory &

Stroke) and specialists in Information Management & Technology and in Health Improvement.

The programme is delivered via a General Medical Services (GMS) Local Enhanced Services (LES) contractual

arrangement, which evolved from a pilot programme initiated in 1999: ‘Glasgow’s Responsive Angina Secondary

Prevention Programme’ (GRASPP), targeting patients with coronary heart disease (CHD). With the advent of

the new GMS contract in 2004, the GRASPP programme became a CHD LES, along with analogous contracts

for Type 2 Diabetes and Stroke/Transient Ischaemic Attack (TIA). These service models were incrementally

extended to Chronic Obstructive Pulmonary Disease (COPD) and Left Ventricular Systolic Dysfunction (LVSD)

from November 2010.

Data extracted primarily for the purposes of LES contracting also generate valuable understanding of the needs

and characteristics of patients with chronic disease. Unfortunately, problems with data extraction led to a gap

in production of ‘Insights’ reports between 2010 and 2012, however these problems are now resolved and I am

pleased to provide, in the report that follows, an overview of these aspects of the CDM programme for the

contract year 2013/14.

This will be my last report as Public Health lead for the CDM programme, so I would like to take this

opportunity to wholeheartedly thank Frances Paton and her excellent team in Information Services for their

enormous support with data production for the ‘Insights’ reports over the past seven years. A huge thank you

is also due to everyone involved in delivering and supporting the entire CDM programme; every practice nurse,

our Primary Care Support team, our Medical Editor and our MCNs have all played a vital role in the

programme’s success and this continuing dedication to patient-centred care will ensure that it continues to

develop and go from strength to strength in the future.

Dr Anne Scoular, Consultant in Public Health Medicine

Keep Well/Enhanced Services Data Group Chair December 2014

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I Introduction

Chronic disease management (CDM) is a generic term for systematic delivery of coordinated healthcare for

populations with established LTCs. Its overall aim is to transform care for patients with chronic illnesses from

acute and reactive to proactive, planned and population-based. CDM has the following key features (Box 1):

The original evidence underpinning CDM came from a review of interventions to improve care for various chronically ill populations. A subsequent Cochrane Collaboration review concluded that several elements work synergistically together to strengthen provider/patient relationships and improve health outcomes. This Cochrane Review concluded that four elements had the most direct relationship to health outcomes: i) increasing provider expertise and skill ii) educating and supporting patients iii) making care delivery more team-based and planned iv) making better use of registry-based information systems.

These components now form the basis of the CDM model which has been delivered in NHSGGC for over 15

years. Accumulated evidence continues to support this model as an integrated framework for improving both

the processes and outcomes of healthcare for patients with chronic disease. However it is vital that structured

approaches (building on those employed in the recently discontinued Keep Well programme; see below) are

designed into the CDM system to ‘inequalities-proof’ the basic CDM model, as there is abundant evidence that

interventions reliant on individual patients’ motivation to seek and maintain CDM care generally worsen

existing inequalities, unless systematic ‘inequalities proofing’ is used. CDM is underused in women and older

people with CHD, and those in lower socioeconomic strata are more likely to have angina but less likely to

consult their doctor.

Keep Well was launched in October 2006, part of the Scottish Government’s 2005 policy ‘Delivering for Health’.

Its initial focus was on health inequalities in cardiovascular disease (CVD). Its core element, the Keep Well

consultation (or ‘health check’), targeted individual residents in Scotland’s most disadvantaged areas, to whom

it offered appropriate interventions to address modifiable CVD risk factors and health behaviours (eg high

blood pressure, high cholesterol, smoking, overweight etc). In NHSGGC, the Keep Well health check also

sought to address the impact of wider social issues including poverty, employability, literacy and mental health

& wellbeing. In March 2010, in advance of publication of its final national evaluation report, the Scottish

Government announced its intention to mainstream the programme across NHS Scotland from April 2012.

However this decision was overturned a few years later, in December 2013, when the Scottish Government

announced its decision to end funding for Keep Well from March 2017. NHSGGC had evaluated Keep Well

extensively, which indicated that variation at three critical points largely explained practice-to-practice

variations that were likely to curtail the programme’s overall effectiveness:

Box 1: Key features of Chronic Disease Management (CDM) model

Population orientation (ie defined by a condition, not a service)

Comprehensive, multidisciplinary care

Integrated care continuum across entire disease cycle

Effective systems for coordination

Active client–patient management tools (health education, empowerment, self-care)

Structured, evidence-based approach

Use of guidelines, protocols and care pathways

Deployment of information technology and system solutions

Continuous audit and quality improvement

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Before engagement (effectiveness of engaging subgroups with greatest need)

At the consultation (effectiveness of initiating changes in health literacy, risk factors, health

associated behaviours and use of wider practice systems)

After the consultation (sustained change following the consultation, both at individual patient level

and in the overall responsiveness of local health improvement services)

An anticipatory care toolkit was developed during 2013 to translate these evaluation findings into practical

actions for practices; the toolkit has transferable value in wider aspects of chronic disease management in

primary care. In the last year of Keep Well (2014/15), NHSGGC commissioned practices to self-assess their

existing CDM programmes against the toolkit and were encouraged to further develop the toolkit in ways that

best fitted their own local context and systems. Flexibility, innovation and practical approaches to service

delivery was actively encouraged and practices were supported to share details of these activities, both with

other practices and with NHSGGC, using simple and clearly structured electronic methods and a highly

successful webinar series. This has generated a rich collection of ideas, evidence and actions developed by

practices in the context of their own CDM programme, with enormous transferability of organisational learning

to other practices that will further strengthen and enrich the CDM programme across the entire NHSGGC area

if supported and sustained. A brief summary of the full report from the Keep Well final (2014/15) contract year

will be available in early 2015 and this will bring useful transferable learning for all involved in the CDM

programme.

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II Population need

2.1 Registered diagnoses

As at 31 March 2014, 146,461 patients were registered on one or more LES CDM disease registers, an increase of

2.4% compared with the 2012/13 cohort of 143,077 patients (Figure 1).

Figure 1: Total chronic disease diagnoses in NHSGGC: 2012/13 vs 2013/14 (n)

Among the 146,461 patients in the 2013/14 contract year, a total of 194,714 chronic disease diagnoses was

recorded, representing an average of 1.3 conditions per patient. The distribution of these diagnoses across

partnership areas is shown in Figure 2 below.

Figure 2: Total number of chronic disease diagnoses in 2013/14, by partnership

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2.2 Disease prevalence

Of the five disease areas, CHD was the most prevalent, closely followed by Type 2 diabetes. COPD prevalence

which showed a threefold variation across the NHSGGC partnerships (Figure 3).

Figure 3: Crude disease prevalence (per 1,000), by partnership, 2013/14

Absolute numbers and crude rates of disease reflect ‘real world’ population prevalence of disease, which is obviously vital information for planning purposes. Crude prevalence of all diseases apart from CHD increased in NHSGGC between 2012/13 and 2013/4, however, there were major spatial variations in these trends across the Health Board area, reflecting underlying differences in population characteristics (Figures 4 & 5).

Figure 4: Crude disease prevalence (per 1,000), NHSGGC: 2012/13 vs 2013/14

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As shown in Figure 4, an 1.8% rise in crude Type 2 Diabetes prevalence occurred between 2012/13 and 2013/14,

with more modest rises in COPD and stroke/TIA prevalence of 1.1% and 0.8% respectively and little change in

LVSD (+0.2%) or CHD (-0.2%), however as highlighted in Figure 5, not all areas showed similar trends, for

example crude CHD prevalence showed markedly divergent patterns, even within Glasgow City.

Figure 5: % change in crude disease prevalence, by area: 2012/13 vs 2013/14

Some of this variation is likely to be due to differential changes in population structures; CHD, stroke and, to

a lesser extent, Type 2 diabetes are all commoner among older people and South Asian populations have an

approximately fourfold increased risk of Type 2 Diabetes. However, after standardisation for age and sex,

Glasgow City is clearly at the extreme end of a steep gradient in disease prevalence within GG&C (Figure 6).

Figure 6: Age & sex standardised disease prevalence (per 1,000), by area, 2013/14

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2.2 Premature disease

The prevalence of premature disease showed marked spatial variation and was generally highest in partnership

areas with more intense socioeconomic deprivation (Figure 7). For all conditions, the NE Glasgow partnership

area had the highest premature disease prevalence and East Renfrewshire or East Dunbartonshire shared the

lowest. The gradient in premature disease prevalence was steepest for COPD and least marked for CHD. For

all conditions apart from COPD, the prevalence of premature disease was substantially higher in men than in

women.

Figure 7: Premature male & female disease prevalence, by partnership, 2013/14

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2.3 Multimorbidity

‘Multimorbidity’ is generally defined as two or more co-existent chronic conditions. In the context of the five

conditions covered by the current NHSGGC LES programme, 38,411 (26%) of the current cohort of 146,461

unique patients have two or more of the five LES eligible conditions (Figure 8).

Figure 8: CDM LES patient cohort 2013/14: number of co-existent diagnoses

The specific combinations of comorbidity in the 2013/14 patient cohort are detailed in Table 1 below.

Table 1: CDM LES patient cohort 2013/14: details of co-existent diagnoses

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3. Clinical Service Delivery & Key Outcomes

The data presented in the sections that follow are based on clinical measurements recorded during the financial

year 2013/14. However, until April 2014 there has been no reliable coding mechanism for explicitly

differentiating patients who had these measurements recorded during a formal annual CDM review or in the

course of routine clinical care; in the past, various proxies, such as financial achievement and/or various

combinations of Read codes entered within a short time window, were used as a substitute for this, however

closer scrutiny of these proxies in 2013 has shown them to be unreliable. New Read codes for ‘completed annual

review’ were sought in late 2013 and these were implemented in April 2014, with the new clinical template

release. This will, in future, allow reporting of robust data on the proportion of each CDM cohort who received

a structured annual review during the relevant contract year.

In the meantime, exception coding is used as a way of providing some insights into the proportion of patients

in each disease area who were not sought for review. The concept of ‘exception reporting’ is a feature of the

GMS contract intended to ensure that practices are not penalised where it may not be clinically appropriate or

possible to undertake a specific activity due to particular circumstances, for example, patients persistently do

not attend for review or where a medication cannot be prescribed due to a contraindication or side-effect.

For each clinical area, data are provided on the size and characteristics of each of the five chronic diseases

currently within the disease programme, followed by selected indicators of clinical care.

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3.1 Coronary Heart Disease

Key points

CHD remains the biggest single contributor to deaths and disability in NHSGGC and, at 59,352 patients,

is the largest disease register in the CDM programme. In some areas of NHSGGC (notably South

Glasgow), approximately 1 in 5 CHD patients belong to ethnic minority subgroups.

25,638 (43%) CHD patients live in neighbourhoods classified by the Scottish Index of Multiple

Deprivation (SIMD) as the most intensely deprived in Scotland (SIMD Quintile 1). This proportion was

highest in NE Glasgow.

Exception coding provides some insights into the proportion of patients who were not sought for

review. Overall, 8,005 (13.5%) CHD patients were exception coded; this proportion was highest among

residents of SIMD quintile 1.

Smoking cessation in patients with existing CHD reduces the likelihood of a recurrent event, need for

further interventions and cardiovascular death by a factor of around half. Unfortunately, however, 9,780

patients with CHD in NHSGGC continue to smoke, with a particularly high smoking prevalence (23.3%)

in the most deprived neighbourhoods, dropping steeply to 5.9% in the least deprived

However, a very small proportion (around 6%) of current smokers were assessed as ready to stop. Of

these, fewer than half were recorded as having been referred to smoking cessation services,

In NHSGGC, a post-treatment total cholesterol value of 5 mmol/l is achieved in only two thirds of

patients; this is lower (at 60%) among CHD patients living in the most deprived neighbourhoods

compared with residents of more affluent areas (67%).

7823 (13%) of the overall cohort had atrial fibrillation (AF), although its prevalence rises steeply with

increasing age. AF carries a four to five-fold increased risk for stroke, but this can be reduced with

systematic stroke risk assessment and anticoagulation when indicated. Approximately half of

NHSGGC’s CHD patients with AF were receiving warfarin therapy, however there were large variations

between practices in the proportion of their CHD cohorts receiving warfarin

3.1.1 Rationale for indicators

CHD remains the biggest single contributor to deaths and disability in NHSGGC, despite a substantial

reduction in mortality rates over the past four decades. Around two thirds of this reduction has been achieved

through preventative medical therapies and reduction of cardiac risk factors, including use of aspirin, Beta-

blockers, Angiotensin-converting enzyme inhibitors (ACEI), lipid-lowering therapies, smoking cessation and

physical activity promotion. The CDM programme aims to support practitioners to deliver these interventions

systematically in ways that fit with individual patients’ circumstances.

3.1.2 Demographic characteristics

A total of 59,352 patients were registered on the CHD disease register during the financial year 2013/14, of whom

33,869 (57.1%) were male and 25,483 (42.9%) female. The cohort’s age profile is shown in Figure 9.

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Figure 9: CHD patients: age distribution (n=59,352)

Although ethnicity recording has improved in recent years, this is still not complete, with no ethnicity recorded

in 4,987 (8.4%) patients. 20 patients declined to disclose their ethnicity. Of those with known ethnicity, the

proportion belonging to minority ethnic groups was highest in South Glasgow, at 18.3%, and lowest in N

Lanarkshire (Figure 10). Further detail of the composition of ethnic minority subgroups in each partnership

area is shown in Figure 11.

Figure 10: CHD patients: ethnicity recording & overview (n= 59,352)

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Figure 11: CHD patients: detail of non-white ethnic groups, by partnership area

Overall, 25,638 (43%) of CHD patients live in neighbourhoods classified by the Scottish Index of Multiple

Deprivation (SIMD) as the most intensely deprived in Scotland (SIMD Quintile 1). This proportion was highest

in NE Glasgow, where 70% of CHD patients live in SIMD Quintile 1 areas, and lowest in East Dunbartonshire,

at 7% (Figure 12).

Figure 12: CHD patients: deprivation profile, by partnership area (n=59,352)

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3.1.3 Access to CDM programme

8,005 (13.5%) patients were exception coded; this proportion was similar across partnerships (Figure 13). The

proportion of patients who were exception coded was highest among residents of SIMD quintile 1 (most

deprived) neighbourhoods, at 14.6%, falling linearly to 10.6% in those living in the least deprived areas. Reasons

for exception coding showed predictable differences that broadly reflect partnerships’ distinct age and social

structures (Figures 13 & 14).

Figure 13: CHD patients: exception coding, by partnership area (n=59,352)

Figure 14: CHD patients: reason for exception coding, by partnership area (n=8,005)

3.1.4 Clinical care

Smoking cessation in patients with existing CHD reduces the likelihood of a recurrent event, need for further

interventions and cardiovascular death by a factor of around half. Smoking cessation is probably the most

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important intervention the NHS can provide for a smoker with CHD, with the number of CHD smokers needed

to treat (NNT) of 13 to prevent one death. Unfortunately, 9,780 patients with CHD in NHSGGC continue to

smoke, with a high smoking prevalence (23.3%) in the most deprived neighbourhoods, dropping steeply to

5.9% in the least deprived (Figure 15).

Figure 15: CHD patients: smoking status (n=59,352)

The estimated number of CHD patients in each partnership area who were recorded as being smokers in the

2013/14 contract year is shown in Figure 16.

Figure 16: CHD patients: current smokers in each partnership area (n=59,352)

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However, a very small proportion (around 6%) of current smokers were assessed as ready to stop. Of these,

fewer than half appeared to have been referred to smoking cessation services, although considerable local

variability in referral rates is noted. More encouragingly, there was some evidence of higher referral rates

among smokers who wanted to stop living in the more deprived areas (Figures 17 & 18).

Figure 17: CHD patients who smoke: smoking cessation referrals, by deprivation quintile (n=9,780)

Figure 18: CHD patients who smoke: smoking cessation referrals, by partnership area (n=9,780)

Alcohol intake was poorly recorded, with documentation of current intake only available in around two thirds

of CHD patients; this raises a possibility of selection bias towards patients with lower intakes, as clinicians may

be more hesitant to explore detail in those with higher intakes; among those with documented values, 2,658

(7%) were noted as drinking over the recommended limits.

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Figure 19: CHD patients: alcohol use (n= 59,352)

NICE guidance (CG181) on secondary prevention of cardiovascular disease recommends high-intensity statin

treatment with the aim of achieving a reduction of at least 40% in non-HDL cholesterol values; European

guidelines specify a target post-therapy cholesterol level of 5 mmol/l. In NHSGGC, this is achieved in only two

thirds of patients and is lower (60%) among CHD patients living in the most deprived neighbourhoods than

among residents of more affluent areas (67%) (Figure 20).

Figure 20: CHD patients: lipid control, by deprivation status (n= 59,352)

24

Variations were also observed between ethnic subgroups in proportion of patients with cholesterol values

within the ‘target’ range varied, although small numbers in Black and Chinese subgroups limit interpretation

of this observation (Figure 21).

Figure 21: CHD patients: lipid control, by ethnic subgroup (n= 59,352)

The proportion of patients with cholesterol values in the target range increased progressively with age, until

the age of 80 onwards. This is in line with current approaches to avoiding polypharmacy among older adults

(Figure 22).

Figure 22: CHD patients: lipid control, by age group (n= 59,352)

25

There were considerable variations across partnerships and also between individual practices in the proportion

of patients within the ‘target’ cholesterol range (Figures 23 and 24).

Figure 23: CHD patients: lipid control, by partnership area (n= 59,352)

Figure 24: CHD patients: % within target cholesterol range, by practice (n= 59,352)

26

Atrial fibrillation (AF) is a relatively common arrhythmia in the CHD population. 7823 (13%) of the overall

cohort had atrial fibrillation, however a steeply rising prevalence occurs in older age groups (Figure 25).

Figure 25: CHD patients: % with AF, by age group (n= 59,352)

Detection and management of AF is vitally important, because it carries a four to five-fold increased risk for

stroke, estimated to account for between 6 and 24% of all ischaemic strokes. For this reason, stroke risk

assessment and appropriate thromboprophylaxis is a central component of AF management. Various stroke

risk stratification schema have been developed to categorise patients into low, moderate and high risk strata,

so that the patients at highest risk can be identified for warfarin therapy. In the 2013/14 year, approximately

half of NHSGGC’s CHD patients with AF were receiving warfarin therapy, increasing with age until the age of

80 (in keeping with the rising prevalence of AF in older age groups) (Figure 26). There were large variations

between practices in the proportion of their cohorts receiving warfarin, although the data are not standardised

for age so could partly be attributed to differences in age structure (Figure 28).

Figure 26: CHD patients with AF: % receiving warfarin therapy, by age group (n=7,823)

27

Figure 27: CHD patients with AF: therapy by partnership area (n=7,823)

Figure 28: CHD patients with AF: % receiving warfarin therapy, by practice (n=7,823)

28

3.2 Type 2 Diabetes

Key points

A total of 57,738 patients were registered on the Type 2 diabetes register in 2013/14, of whom 26,010

(45%) were female and 31,728 (55%) male. There were striking variations in the ethnic composition of

Type 2 diabetic cohorts at local partnership level; in South Glasgow, one quarter of the cohort belonged

to non-white ethnic groups.

The distribution of Type 2 diabetes was less polarised towards SIMD quintile 1 areas than occurs with

other conditions, but still reflects a higher prevalence of underlying risk factors (particularly central

obesity and smoking) in areas with the most severe socio-economic deprivation.


review. Overall, 15% of Type 2 diabetic patients living in NHSGGC’s most deprived neighbourhoods

were exception coded; this proportion declined, with decreasing levels of deprivation, to 11% in SIMD

quintile 5.

As previously discussed, smoking worsens clinical outcomes from diabetes, increasing risk of death,

CHD and stroke and also contributes independently to poorer overall disease control. Smoking

cessation is therefore a very powerful clinical intervention, reducing these risks to that of non-smokers

within 5-10 years. Smoking prevalence in Type 2 diabetics shows a similar social gradient to that for

other chronic conditions, however the proportion of patients who were smokers in each SIMD quintile

was slightly lower. Only a small proportion (around 6%) of Type 2 diabetic smokers were assessed as

ready to stop. Of this subgroup, referral rates to smoking cessation services varied between 18 and 73%

across different partnership areas.

Physical activity has a major beneficial effect on glycaemic control. Recommended levels of physical

activity were achieved in only 38% of the cohort in the most deprived SIMD quintile and 50% in the

least deprived. Formal referral rates to physical activity services were uniformly low (2%) across all

deprivation quintiles,

Overall, 18,760 (36%) of patients had HbA1c values compatible with good glycaemic control. There was

a modest socio-economic gradient in this proportion, but little difference between partnership areas.

Overall glycaemic control was poorer in black ethnic minority subgroup and also among those with no

recorded ethnicity; the latter may reflect gaps in structured, systematic care.


Type 2 diabetes is an important cause of disability in its own right, as well as increasing risk of CHD and other

vascular disease. Its prevalence is increasing rapidly in NHSGGC, particularly in our most disadvantaged

subpopulations. Those who are least well educated are more likely to have diabetic retinopathy, heart disease

and poorer disease control. They are more likely to feel that their condition has an adverse effect on their lives

and be seen as non-adherent by healthcare professionals than those who are higher earners and educated to a

higher standard. The CDM programme aims to provide systematic coverage of the NHSGGC Type 2 diabetic

population with high impact clinical interventions which, delivered together and in a person-centred way,

substantially reduce morbidity and mortality; these interventions include: blood pressure monitoring and

control; effective lipid management; good long term glycaemic control (defined as maintenance of a target

HbA1c value of 48 - 59 mmol/l); and promotion of physical activity, which is increasingly recognised as having

a major clinically significant beneficial effect on glycemic control, independent of its weight loss.


A total of 57,738 patients were registered on the Type 2 diabetes register during the financial year 2013/14, of

whom 26,010 (45%) were female and 31,728 (55%) male. The cohort’s age profile is shown in Figure 29.

29

Figure 29: Type 2 diabetes: age distribution

There were striking variations in the ethnic composition of Type 2 diabetic cohorts at local partnership level;

in South Glasgow, one quarter of the cohort belonged to non-white ethnic groups (Figure 30). The specific

composition of non-white ethnic groups also varied considerably across partnerships (Figure 31).

Figure 30: Type 2 diabetes: ethnicity recording & overview

30

Figure 31: Type 2 diabetes: detail of non-white ethnic groups, by partnership area

Although less polarised towards SIMD quintile 1 areas than occurs with other conditions, the distribution of

Type 2 diabetes still reflects a higher prevalence of underlying risk factors (particularly central obesity and

smoking) in areas with the most severe socio-economic deprivation (Figure 32). Smoking is now proven to be

an independent risk factor for development of diabetes, as well as increasing the risk of complications in those

who already have the disease.

Figure 32: Type 2 diabetes: deprivation profile, by partnership area

31

3.2.3 Access to CDM programme 8,024 (14%) patients were exception coded, for one or more of the reasons listed below:

Informed dissent 4,401

Patient unsuitable 2,718

Housebound 1,389

Failure to attend diabetic clinic 381

Lives in a nursing home 225

Long stay hospital inpatient 18

15% of Type 2 diabetic patients living in NHSGGC’s most deprived neighbourhoods were exception coded; this

proportion declined with decreasing levels of deprivation, to 11% in quintile 5 (Figure 33). The proportion of

exception coded diabetic patients was highest in Renfrewshire (1,447 patients; 17% of cohort) and lowest in East

Renfrewshire (393 patients; 11% of cohort) (Figure 34).

Figure 33: Type 2 diabetes: exception coding, by deprivation quintile

Figure 34: Type 2 diabetes: exception coding, by partnership area

32

As previously discussed, smoking worsens clinical outcomes from diabetes, increasing risk of death, CHD and

stroke by 48%, 54% and 44% respectively and poorer overall disease control. Smoking cessation is therefore a

very powerful clinical intervention, reducing these risks to that of non-smokers within 5-10 years.

Smoking prevalence in Type 2 diabetics shows a similar social gradient to that for other chronic conditions,

however the proportion of patients who were smokers in each SIMD quintile was lower (Figure 35).

Figure 35: Type 2 diabetes: smoking status, by residential deprivation quintile

As with CHD, only a small proportion (around 6%) of current smokers were assessed as ready to stop. Of this

subgroup, referral rates to smoking cessation services ranged between 18 and 73% across different partnership

areas. Referral rates were highest, at 46%, for smokers living in the most deprived SIMD quintile (Figures 36

and 37).

Figure 36: Type 2 diabetic patients who smoke: smoking cessation referrals, by deprivation quintile

33

Figure 37: Type 2 diabetic patients who smoke: smoking cessation referrals, by partnership area

Moderate to heavy consumption of alcohol interferes with glycaemic control and increases the risk of some

diabetic complications, including peripheral neuropathy, dyslipidaemias, erectile dysfunction and, possibly,

retinopathy. However, in 2013/14, only 75% of the Type 2 diabetic cohort had a recorded level of alcohol intake

in 2013/14 (Figure 38). Of those, 2,552 (6%) exceeded usual recommended limits, although it should be noted

that ‘safe’ limits of alcohol consumption for diabetic patients are poorly defined and may be lower than for the

general population.

Figure 38: Type 2 diabetic patients: alcohol use

34

As previously noted, physical activity has a major clinically significant beneficial effect on glycaemic control.

Current guidelines recommend that patients with type 2 diabetes should undertake at least 150 minutes per

week of moderate-intensity aerobic exercise, however this was achieved in only 38% of the cohort in the most

deprived SIMD quintile and 50% in the least deprived (Figure 39). Formal referral rates to physical activity

services were uniformly low (2%) across all deprivation quintiles, with minor variations across partnerships,

although it should be noted that informal signposting towards physical activity opportunities may numerically

outnumber recorded referrals (Figure 40).

Figure 39: Type 2 diabetic patients: recorded levels of physical activity, by deprivation quintile

Figure 40: Type 2 diabetic patients: referrals to physical activity services, by partnership

35

3.2.4 Clinical care

HbA1c is an indicator of average blood glucose concentration over the previous three months and provides a

population-level proxy for level of disease control. Higher average HbA1c levels correlate strongly with all-cause

mortality and cardiovascular disease risk. Overall, 18,760 (36%) of patients had HbA1c values of between 48

mmol/l and 59 mmol/l (commensurate with ‘good’ glycaemic control). There was a modest socio-economic

gradient, but little difference between partnership areas (Figures 40 and 41). There were major differences

between individual practices in the proportion of their cohort with HbA1C values within this range (Figure 44).

Figure 41: Type 2 diabetes: HbA1c status, by deprivation quintile

Figure 42: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by partnership area

36

Overall glycaemic control was poorer in black ethnic minority subgroup and also among those with no recorded

ethnicity; the latter may reflect gaps in structured, systematic care.

Figure 43: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by ethnic group

Figure 44: Type 2 diabetes: % cohort with HbA1c values of 48-59 mmol/l, by practice

37

3.3 Stroke/TIA

Key points

31,165 current patients were on the NHSGGC practices’ stroke/disease register, with equal distribution

between men and women. Around two thirds of patients were over 70, however almost 12,000 younger

adults in NHSGGC have this diagnosis, with premature stroke/TIA particularly concentrated in

disadvantaged areas. The vast majority of patients with stroke/TIA are white Caucasian.

The deprivation distribution of patients with stroke/TIA differed strikingly across partnerships, with

comparatively few patients in East Renfrewshire and East Dunbartonshire living in socio-economically

deprived neighbourhoods.

Exception coding provides some insights into the proportion of patients who were not sought for review

and the proportion of stroke/TIA patients who were exception coded was, together with COPD,

amongst the highest of all disease areas, which means that almost 1 in 5 (5,731; 18.4%) patients and their

carers did not receive the benefits of the LES CDM interventions.

Survivors of acute stroke are at a considerable risk of suffering additional cardiovascular events and

given the substantial evidence of smoking as a risk factor for first-ever stroke and ischaemic heart

disease, cessation of smoking is strongly recommended to reduce these risks. Unfortunately, 5221 (17%)

of the stroke/TIA cohort remain current smokers, reaching a prevalence of 24% in the most deprived

areas. Relatively few stroke/TIA patients were recorded as wanting to stop, with very small numbers of

referrals to services

A high proportion of stroke/TIA patients have functional problems which are highly amenable to

therapy, however recorded use of services was relatively low, although it should be noted that the full

range of relevant services is incompletely captured by available Read codes.


Stroke and TIA are both manifestations of cerebrovascular disease, a disease which shares common risk factors

with CHD, including high blood pressure, high blood cholesterol, poor diet, obesity, smoking, physical

inactivity, excessive alcohol intake, diabetes and socio-economic deprivation. Its incidence and mortality rates

increase with age. The CDM programme aims to provide systematic coverage of the stroke and TIA patients

population with optimal lipid lowering therapy, monitor BP control, support patients with smoking cessation

and provide antithrombotic or anticoagulant therapy (dependent on the type of stroke); in combination, these

interventions reduce risk of recurrent stroke and also reduce mortality. Functional rehabilitation in patients

with specific disabilities also significantly reduces the odds of deterioration in personal activities of daily living.


31,165 current patients were on the NHSGGC practices’ stroke/disease register in 2013/14, of whom 15,771 (50.6%)

were women. Around two thirds of patients were over 70, however it should be highlighted that almost 12,000

younger adults have this diagnosis and thus it should not be considered as an exclusively older person’s health

issue (Figure 45). As shown previously, premature chronic disease is particularly concentrated in disadvantaged

areas of NHSGGC, with early stroke in young adults a particularly challenging issue for families and services.

38

Figure 45: Stroke/TIA patients: age distribution

The vast majority of patients with stroke/TIA are white Caucasian (Figure 46).

Figure 46: Stroke/TIA patients: ethnicity

The deprivation distribution of patients with stroke/TIA differed strikingly across partnerships, with

comparatively few patients in East Renfrewshire and East Dunbartonshire living in socio-economically

deprived neighbourhoods (Figure 47).

39

Figure 47: Stroke/TIA patients: deprivation profile, by partnership area


Exception coding in patients with stroke is, together with COPD, the highest of all disease areas, which means that substantial numbers of patients may not be receiving access to the enhanced CDM system supported by the LES. Overall, 5,731 (18.4%) patients were exception coded, for one or more of the reasons listed below:



Housebound 1,550


Failure to attend cardiac clinic 154

Long stay hospital inpatient 16 19% of stroke/TIA patients living in NHSGGC’s most deprived neighbourhoods were exception coded; this proportion declined slightly to 15% in quintile 5 (Figure 33). The proportion of exception coded diabetic patients was highest in South Lanarkshire (282 patients; 20% of cohort) and lowest in East Renfrewshire (291 patients; 15% of cohort) (Figure 48).

40

Figure 48: Stroke/TIA patients: exception coding, by deprivation quintile

Figure 49: Stroke/TIA patients: exception coding, by partnership area

3.3.4 Clinical care

Survivors of acute stroke are at a considerable risk of suffering additional cardiovascular events and given the

substantial evidence of smoking as a risk factor for first-ever stroke and ischaemic heart disease, cessation of

smoking is strongly recommended to reduce these risks. Unfortunately, 5221 (17%) of the stroke/TIA cohort

remain current smokers, reaching a prevalence of 24% in the most deprived areas (Figure 50)

41

Figure 50: Stroke/TIA patients: smoking status, by residential deprivation quintile

Relatively few stroke/TIA patients were recorded as wanting to stop, with very small numbers of referrals to

services (Figures 51 and 52).

Figure 51: Stroke/TIA patients who smoke: smoking cessation referrals, by deprivation quintile

42

Figure 52: Stroke/TIA patients who smoke: smoking cessation referrals, by partnership area

The relationship between alcohol consumption and cardiovascular risk is a complex one, with a J-shaped

association between alcohol consumption and ischaemic stroke; light to moderate alcohol consumption

protects against ischaemic stroke, but heavier consumption substantially increases risk. The relationship is

different for haemorrhagic stroke, which has a more linear relationship with alcohol consumption. Episodic

heavy drinking (binge drinking) appears to confer additional independent risks for all types of stroke, doubling

risk compared with non-binge drinkers. Current recommendations advise patients with stroke/TIA to drink no

more than 3 units of alcohol a day for women and 4 for men. This appears to be broadly the case for the vast

majority of NHSGGC’s stroke/TIA cohort, although recording of alcohol intake remains suboptimal (Figure 53).

Figure 53: Stroke/TIA patients: alcohol use

43

A high proportion of stroke/TIA patients have functional problems which are highly amenable to therapy, however recorded use of services was relatively low, although the full range of relevant services is incompletely captured by available Read codes.

Figure 54: Stroke/TIA patients: functional problems, by age group

Figure 55: Stroke/TIA patients: recorded use of services relative to scale of functional problems

44

3.4 Chronic Obstructive Pulmonary Disease (COPD)

Key points

Of the 35,299 patients with COPD, the majority (19,865; 56%) were female and over half were younger

than 70. The overwhelming majority of COPD patients were white Caucasian. The epidemiology of

COPD closely mirrors that of tobacco smoking, both being highly concentrated in areas with severe

socio-economic deprivation. Over half of NHSGGC’s COPD patients live in SIMD quintile 1

neighbourhoods.

Exception coding provides some insights into the proportion of patients who were not sought for review. In patients with COPD, over 6,000 (almost one in five) patients were exception coded, thereby losing the opportunity to benefit from the COPD LES. This proportion was similar across all deprivation quintiles, however there was substantial variability between different partnerships

Smoking cessation is the single most effective and cost-effective therapy that can be offered to COPD

patients. It improves outcomes at all stages of COPD and is the only evidence-based treatment proven

to prevent further deterioration of lung function. However, only 939 (8%) of smokers with COPD were

recorded as being ‘ready to stop’. This proportion was similar in all deprivation quintiles. Fewer than

half of these patients had a record of referral to a smoking cessation service, although the proportion

referred was highest in patients living in the most deprived SIMD quintile

In NHSGGC, pulmonary rehabilitation is offered to all people with COPD at MRC Grade 3 and above

who consider themselves functionally disabled by their condition. However, only around half of

patients in this category are referred, with considerable variation between partnerships and individual

practices


COPD is a progressive long term lung disease that causes cough, breathlessness, nutritional disturbances and

muscle wasting. COPD prevalence is strongly socially patterned, closely correlated with smoking rates, which

are much higher in disadvantaged neighbourhoods. Morbidity and mortality from COPD in NHSGGC remain

high and are disproportionately increasing in women relative to men. The clinical goals of CDM for patients

with COPD are to slow disease progression, minimise symptoms, improve health status, prevent and treat

exacerbations and reduce the risk of dying from the disease. Although there is no ‘cure’ for COPD, smoking

cessation and long term oxygen therapy for those with respiratory failure reduce mortality. Medicines

optimisation, pulmonary rehabilitation in patients with more advanced disease (MRC Grades 3 and above) and

other therapies also improve other important patient outcomes, including unscheduled hospitalisation.


Of the 35,299 patients with COPD, the majority (19,865; 56%) were female and the remaining 15,434 (43.7%)

male. Just over half are younger than 70 (Figure 56).

45

Figure 56: COPD patients: age distribution

The overwhelming majority of COPD patients were white Caucasian (Figure 57).

Figure 57: COPD patients: ethnicity recording & overview

The epidemiology of COPD closely mirrors that of tobacco smoking, both being highly concentrated in areas

with severe socio-economic deprivation. Over half (19,919; 56%) of NHSGGC’s COPD patients live in SIMD

quintile 1 neighbourhoods (Figure 58).

46

Figure 58: COPD patients: deprivation profile, by partnership area


Exception coding in patients with COPD is high, with almost one in five patients exception coded, suggesting suboptimal access to the clinical interventions provided by the COPD LES. Reasons for exception coding in the 6,525 patients affected were:



Housebound 1,178


Failure to attend respiratory clinic 134

Long stay hospital inpatient 12 The proportion of COPD patients who were exception coded was similar across all deprivation quintiles, however there was greater variability between different partnerships (Figures 59 & 60).

47

Figure 59: COPD patients: exception coding, by deprivation quintile

Figure 60: COPD patients: exception coding, by partnership area

48

3.4.4 Clinical care

Smoking cessation is the single most effective and cost-effective therapy that can be offered to COPD patients. It improves outcomes at all stages of COPD and is the only evidence-based treatment proven to prevent further deterioration of lung function. Following smoking cessation, the annual decline in FEV1 is usually reduced, sometimes to the level of non-smokers. As previously indicated, the overwhelming majority of COPD patients are living in deprived circumstances (Figure 61).

Figure 61: COPD patients: smoking status, by residential deprivation quintile

Only 939 (8%) of smokers with COPD were recorded as being ‘ready to stop’. This proportion was similar in all

deprivation quintiles. Fewer than half of these patients had a record of referral to a smoking cessation service,

although the proportion referred was highest in patients living in the most deprived SIMD quintile (Figures 62

& 63).

49

Figure 62: COPD patients who smoke: smoking cessation referrals, by deprivation quintile

Figure 63: COPD patients who smoke: smoking cessation referrals, by partnership area

50

Recording of alcohol intake was relatively complete and the proportion of patients exceeding recommended

limits 5% overall, with little variation between areas (Figure 64).

Figure 64: COPD patients: alcohol use

The MRC dyspnoea scale is a well validated, clinically meaningful scale that quantifies disability resulting from

COPD. It extends from Grade 1 (not troubled by breathlessness except on strenuous exercise) to Grade 5 (too

breathless to leave the house, or breathless when dressing or undressing). Unfortunately, over one quarter of

COPD patients did not have a recorded MRC Grade. Of the remainder, the largest single category was Grade 2

(short of breath when hurrying or walking up a slight hill). The age distribution of patients was similar at each

MRC Grade (Figure 65).

Figure 65: COPD patients: MRC grade, by age group

51

Pulmonary rehabilitation is an important component of management of more advanced COPD. It relieves

dyspneoa and fatigue, improves emotional function and enhances patients' control over their condition. These

improvements are substantial and clinically significant. Pulmonary rehabilitation has been shown to improve

exercise capacity, reduce breathlessness, improve health-related quality of life and decrease healthcare

utilisation. In NHSGGC, pulmonary rehabilitation is offered to all people with COPD at MRC Grade 3 and above

who consider themselves functionally disabled by their condition. However, only around half of patients in this

category are referred, with considerable variation between partnerships and individual practices (Figures 66 &

67).

Figure 66: COPD patients: referral to pulmonary rehabilitation, by partnership area

Figure 67: COPD patients: referral to pulmonary rehabilitation, by practice

52

3.5 Left Ventricular Systolic Dysfunction (LVSD)

Key points

Diagnostic precision of Read coding: A separate, detailed audit undertaken within the local CDM

programme in 2013 identified considerable variability in Read coding for heart failure. This highlighted

two broad types of issues: firstly, the extent to which patients with heart failure were captured on any

heart failure register; and secondly, the validity and precision of documented subtypes of heart failure

diagnoses. This will not be further addressed here (separate report is available on request), but should

be borne in mind when considering the data presented. A separate piece of work is now being

undertaken in early 2015 to clean practice registers, make standardise secondary care discharge letters

and provide enhanced support to maintain accurate coding across the system in the future.

Of the 11,160 patients with LVSD, 6,936 (62.2%) were male and 4,224 (37.8%) female. The majority were

aged 70 years or more. Most patients had a record of their ethnic group and in most areas white

Caucasian ethnic subgroups accounted for well over 90% of the local LVSD cohort; South Glasgow was

a notable exception, where 9% of patients belonged to non-white ethnic groups. 4,876 (44%) LVSD

patients lived in areas of very high deprivation, although, as for other conditions, this was highly

variable across different partnerships


review. Levels of exception coding were lower for LVSD than for other conditions within the CDM

programme; 1218 (10.9%) patients were exception coded, with higher proportions among more socio-

economically deprived patient subgroups and considerable variability between different partnerships

1,603 patients were current smokers. In keeping with the other chronic disease conditions, however, a

very small proportion of these (82; 5%) were assessed as ‘ready to stop’, with a further drop-off in the

proportion of these patients who actually received a referral and considerable variability at local level

Functional capacity assessment is a central component of clinical care for patients with heart failure. In

NHSGGC, however, over one third of LVSD patients within the primary care CDM programme had no

recorded NYHA class, although this proportion varied from 20 to 49% across different partnerships.

Therapeutic management requires more detailed analysis and it is conceivable that the anomalies noted

below may be partly a result of inaccurate disease coding (see above). 4,600 (41%) patients did not

appear to have been recently (ie in the previous three months) prescribed a beta blocker and 3,426 (31%)

patients appeared to have been prescribed neither an ACE-I nor an ARB in the same period. Over a

longer period of 12 months, 3,083 (28%) of patients appeared not to have been prescribed a beta blocker

and 2,185 (20%) did not appear to be receiving either an ACE-I or ARB. Overall, 94% of the entire cohort

was prescribed at least one of the listed cardiac drugs, however this proportion showed marked

variation across NHSGGC practices.


Heart failure (impaired efficiency of the heart as a pump) affects 1-2% of the adult population in the UK, rising to a prevalence of 10% in patients aged 70 or older. Left ventricular systolic dysfunction (LVSD) is the commonest underlying cardiac abnormality and outcomes for patients with this type of heart failure have improved enormously in recent years as a result of more systematic use of ACE inhibitors and beta-blockers, both of which have been shown to increase both duration and quality of life. Cardiac rehabilitation also improves functional capacity and quality of life. The CDM programme in NHSGGC is intended to provide more structured care for this patient group.


Of the 11,160 patients with LVSD, 6,936 (62.2%) were male and 4,224 (37.8%) female. The majority were aged

70 years or more (Figure 68).

53

Figure 68: LVSD patients: age distribution

Documentation of the underlying aetiology was poor; this information was missing (and conceivably unknown)

in 4,359 (39%) patients (Figure 69). Of the remainder, the vast majority of cases were attributed to ischaemic

heart disease.

Figure 69: LVSD patients: aetiology

Most patients had a record of their ethnic group and in most areas white Caucasian ethnic subgroups accounted

for well over 90% of the local LVSD cohort; South Glasgow was a notable exception, where 9% of patients

belonged to non-white ethnic groups (Figure 70).

54

Figure 70: LVSD patients: ethnicity

Socio-economic disadvantage increases incidence of heart failure by 30-50% and is also associated with higher

hospital readmission rates and shorter survival. In NHSGGC, 4,876 (44%) LVSD patients lived in areas of very

high deprivation, although, as for other conditions, this was highly variable across different partnerships

(Figure 71).

Figure 71: LVSD patients: deprivation profile, by partnership area

55


Levels of exception coding were lower for LVSD than for other conditions within the CDM programme; 1218 (10.9%) patients were exception coded. Reasons for exception coding in these patients were:

Housebound 533

Patient unsuitable 417

Informed dissent 330


Failure to attend cardiac clinic 46

Long stay hospital inpatient 7 The proportion of LVSD patients who were exception coded was higher among more socio-economically deprived patient subgroups and there was also major variability between different partnerships (Figures 72 & 73).

Figure 72: LVSD patients: exception coding, by deprivation quintile

Figure 73: LVSD patients: exception coding, by partnership area

56

3.5.4 Clinical care

Although no prospective studies have quantified the effects of a smoking cessation intervention on outcomes

in patients with heart failure, observational data support the association between continued smoking and both

increased heart failure mortality and increased rates of hospital admissions due to worsening heart failure

compared with non-smokers. Accordingly, every effort should be made to support LVSD patients with smoking

cessation. The proportions of current smokers declined with each SIMD quintile (Figure 74).

Figure 74: LVSD patients: smoking status, by residential deprivation quintile

In keeping with the other chronic disease conditions, of the 1603 smokers, a very small proportion (82; 5%)

were assessed as ready to stop and there was a further drop-off in the proportion of these patients who

actually received a referral, with considerable variability at local level (Figures 75 & 76).

Figure 75: LVSD patients who smoke: smoking cessation referrals, by deprivation quintile

57

Figure 76: LVSD patients who smoke: smoking cessation referrals, by partnership area

Alcohol intake was not recorded in 4,272 (38%) patients. Of the remainder, few were consuming above the maximum recommended alcohol intake for their gender (Figure 77).

Figure 77: LVSD patients: alcohol use

Functional capacity is a powerful important predictor of prognosis in heart failure; the New York Heart

Association (NYHA) functional class is a central component of clinical care for patients with heart failure. It

ranges from Class I (known cardiac disease, but no symptoms or limitation in ordinary physical activity) to

Class IV (severe limitations; symptoms at rest and mostly bedbound). In NHSGGC, however, 4,044 (36.2%) of

LVSD patients within the primary care CDM programme had no recorded NYHA class, although this

proportion varied from 20 to 49% across different partnerships (Figure 78).

58

Figure 78: LVSD patients: NYHA class, by partnership area

Angiotensin-converting Enzyme Inhibitor (ACE-I) pharmacotherapy significantly reduces mortality and

hospitalisation rates in patients with chronic heart failure. Angiotensin II receptor blockers (ARBs) mimic the

effect of ACE inhibitors and are generally used in patients who cannot tolerate an ACE inhibitor, usually due

to cough. Beta blocker therapy also reduces both all-cause and cardiovascular mortality and is strongly

recommended for all patients with heart failure due to left ventricular systolic dysfunction. SIGN guidelines

currently recommend that LVSD patients in all NYHA functional classes should be started on both beta blocker

therapy as soon as their condition is stable, as well as either an ACE-I or ARB. There is also evidence that

patients with moderate to severe heart failure due to LVSD may receive benefit from spironolactone.

Prescribing of this group of cardiac therapies (ACE-Inhibitors, ARBs, beta blockers, loop diuretics and/or

spironolactone) in the preceding 12 months in the LVSD cohort is shown in Figures 79-81. This showed a

predictable rise in number of co-prescribed pharmacotherapies with increasing NHYA class (Figure 79).

Specific detail of the different combinations of drugs prescribed in the most recent three months is shown in

Table 2. It is obviously not appropriate to comment in detail on the types of drug combinations in the absence

of more detailed clinical information, however it is noteworthy that 4,600 (41%) patients did not appear to have

been recently (ie in the previous three months) prescribed a beta blocker and 3,426 (31%) patients appeared to

have been prescribed neither an ACE-I nor an ARB in the same period. Over a longer period of 12 months,

3,083 (28%) of patients appeared not to have been prescribed a beta blocker and 2,185 (20%) did not appear to

be receiving either an ACE-I or ARB. Overall, 94% of the entire cohort was prescribed at least one of the listed

cardiac drugs, however this proportion showed marked variation across NHSGGC practices (Figures 80 & 81).

59

Figure 79: LVSD patients: cardiac therapy prescribed within last 12 months, by NYHA Class

60

Table 2: Drug therapy prescribed in last 3 months, by NYHA Class

No of Drugs

Drug combination

No NYHA class

recorded

Class 1 Class 2 Class 3 Class 4 Total

No drugs prescribed in period (subtotal) 931 267 486 159 19 1,862 1 Spironolactone only 0 0 0 0 0 0

1 Loop diuretic only 197 46 128 47 9 427

1 Beta blocker Only 180 114 142 20 0 456

1 ARB Only 60 67 72 10 0 209

1 ACE Inhibitor Only 297 252 222 28 1 800

1 drug prescribed in period (subtotal) 734 479 564 105 10 1,892 2 Spironolactone & diuretic 19 5 23 22 3 72

2 Spironolactone & beta blocker 0 0 0 1 0 1

2 Spironolactone & ARB 0 0 0 0 0 0

2 Spironolactone & ACEI 0 0 3 2 0 5

2 Diuretic & beta blocker 205 67 159 67 4 502

2 Diuretic & ARB 66 52 115 19 2 254

2 Diuretic & ACEI 270 113 281 67 6 737

2 Beta blocker & ARB 116 129 144 18 3 410

2 Beta blocker & ACEI 649 648 513 53 4 1,867

2 ARB & ACEI 7 4 3 1 0 15

2 drugs prescribed in period (subtotal) 1,332 1,018 1,241 250 22 3,863 3 Spironolactone, diuretic & beta blocker 33 13 28 29 3 106

3 Spironolactone, diuretic & ARB 8 10 11 8 0 37

3 Spironolactone, diuretic & ACEI 58 25 53 31 6 173

3 Spironolactone, beta blocker & ARB 0 0 1 0 0 1

3 Spironolactone, beta blocker & ACEI 1 0 7 2 0 10

3 Spironolactone, ARB & ACEI 0 0 0 0 0 0

3 Diuretic, beta blocker & ARB 150 92 197 49 3 491

3 Diuretic, beta blocker & ACEI 518 327 638 177 3 1,663

3 Diuretic, ARB & ACEI 10 1 8 2 1 22

3 Beta blocker, ARB, ACEI 14 9 8 2 0 33

3 drugs prescribed in period (subtotal) 792 477 951 300 16 2,536 4 Spironolactone, diuretic, beta blocker & ARB 42 26 94 33 3 198

4 Spironolactone, diuretic, beta blocker & ACEI 187 113 288 124 1 713

4 Spironolactone, diuretic, ARB & ACEI 2 0 0 0 0 2

4 Spironolactone, beta blocker, ARB & ACEI 0 0 0 0 0 0

4 Diuretic, beta blocker, ARB & ACEI 19 12 41 7 0 79

4 drugs prescribed in period (subtotal) 250 151 423 164 4 992 5 Spironolactone, diuretic, beta blocker, ARB & ACEI 5 1 8 0 1 15

5 drugs prescribed in period (subtotal) 5 1 8 0 1 15

GRAND TOTAL

4,044

2,393

3,673

978

72

11,160

61

Figure 80: LVSD patients: overview of drug therapy over preceding year, by number of agents

Figure 81: Percentage of practice LVSD cohort receiving one or more therapies

62

IV Conclusion

In summary, this report provides local intelligence on the scale and clinical performance of the CDM programme in each of the five disease areas. Specific topics are highlighted for a possible future improvement focus; these include addressing variations in access to the programme, new, locally tailored approaches to smoking cessation support and quality improvement initiatives focusing on the numerous areas of clinical variation that are highlighted in this report. Overall, greater emphasis is required on optimising coverage and delivery of clearly defined, evidence based interventions that hold the greatest potential to change clinical outcomes. Investment of dedicated clinician time in person-centred consultations, alongside workforce development to ensure that the most effective use is made of that time, will both help to drive up performance. ‘Whole system’ supportive infrastructure must continue to work towards a well organised, structured approach to community based care for chronic disease in NHSGGC.

V Appendix

CDM LES Review Final report, December 2013:

CDM ENHANCED

SERVICES REVIEW_161213.pdf

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