Services for people with chronic heart failure
This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg39
3 Determining local service levels for a chronic heart failure service
- 3.1 Current practice
- 3.2 Epidemiological data
- 3.3 Activity data - 'Hospital episode statistics' and other data
- 3.4 Published research
- 3.5 Expert clinical opinion
- 3.6 Conclusion
Before commissioning a service for people with chronic heart failure, commissioners should conduct a local needs assessment in order to determine local service levels for people with chronic heart failure. Available data suggest that the indicative benchmark rate for:
the number of adults aged 45 or over with suspected heart failure per year is 450 or per 100,000 population, or 0.45%
the number of adults aged 45 or over who should have their serum natriuretic peptides measured per year is 360 per 100,000, or 0.36%.
The population benchmark is based on the following sources of information:
epidemiological data on the prevalence/incidence of chronic heart failure
'Hospital episode statistics' (HES) data to establish the rate of emergency admissions for chronic heart failure
current practice on detection rates of chronic heart failure
published research on chronic heart failure
expert clinical opinion of the topic-specific advisory group, based on experience in clinical practice and literature review. Use the chronic heart failure commissioning and benchmarking tool section within this guide (section 6) to determine the level of service that might be needed locally and to calculate the cost of commissioning the service using the indicative benchmark and/or your own local data.
Analysis of data extracted from IMS Disease Analyser, a database that holds data from a sample of GP practice systems, indicates that the annual incidence of diagnosed heart failure (that is, the average detection rate of new cases in a year) is around 0.07% of the population or 0.15% of the population aged 45 years or over.
In England, 0.15% of people aged 45 years or over will be newly diagnosed with heart failure each year. It is estimated that around a third of cases of suspected heart failure result in a diagnosis (see published research section). Therefore it is calculated that around 0.45% of people aged 45 years and over will present in England each year with suspected heart failure.
Of those who present with suspected heart failure, around 20% will have had a previous myocardial infarction (MI). These individuals, in accordance with NICE clinical guideline 108, will be referred for specialist assessment and echocardiography within 2 weeks to confirm the diagnosis.
NICE clinical guideline 108 on chronic heart failure recommends measuring serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NTproBNP]) in individuals with suspected heart failure without previous MI.
Data extracted from IMS Disease Analyser also showed that around 6%of individuals with newly diagnosed cases of heart failure currently have serum natriuretic peptides measured.
Future practice to meet the above recommendation will require 100% of individuals with suspected heart failure without previous MI to have serum natriuretic peptides measured. This would currently be approximately 0.36% or 360 per 100,000 population aged 45 or over per year.
An estimated 46% of people, with suspected heart failure who have serum natriuretic peptides measured will have raised or high levels and will be referred for specialist assessment and echocardiography to confirm the diagnosis.
Using the above assumptions, this equates to around 0.17% or 170 per 100,000 population aged 45 or over who would need to be referred for specialist assessment and echocardiography to confirm the diagnosis. This is an increase on current levels.
In addition, commissioners should be aware that the 20% of people with suspected heart failure who have had a previous diagnosis of MI will also need to be referred for specialist assessment and echocardiography to confirm the diagnosis.
Hospital episode statistics data shows that in 2009/10 approximately 10,500 individuals in England with a primary diagnosis of heart failure underwent transthoracic echocardiography. This is much lower than the number of patients who would be expected to have the procedure if the recommendation was fully implemented.
The incidence of heart failure varies significantly between different studies. However, all the studies examined showed that the incidence of heart failure increases rapidly with age. Figure 1 illustrates that the greatest incidence of heart failure for both men and women is the 75 and over age group.
Figure 1 Incidence of heart failure by age and gender in England
The quality and outcomes framework (QOF) data from 2009/10 shows the prevalence of diagnosed heart failure at 0.7% of the England population. This is a lower prevalence than other studies. One reason is that heart failure is known to be under-diagnosed in primary care. Access QOF data to show local prevalence of diagnosed heart failure.
The 'Hospital episode statistics' (HES) database contains details of all admissions to NHS hospitals in England. It includes private patients treated in NHS hospitals, patients who were resident outside England and care delivered by treatment centres (including those in the independent sector) funded by the NHS.
Analysis of 2009/10 HES data suggests that the number of emergency admissions into secondary care for heart failure was around 110 per 100,000 population. Admissions into secondary care showed wide variation across the country.
The National Heart Failure Audit 2010 states that heart failure is one of the most common reasons for:
emergency medical admissions (around 5% of emergency admissions)
hospital bed-days occupancy.
Heart failure readmission rates are among the highest for common conditions – the 2010 national heart failure audit shows a 20% readmission rate. This readmission rate could be an underestimate, with some studies showing around 1 in 4 patients are readmitted within 3 months.
It has been estimated that the effective management of heart failure after an acute admission can reduce re-admission into secondary care by 30–50% in the short and medium term.
As seen, a proportion of people with diagnosed heart failure will be at high risk of emergency admission and readmissions. This group of patients is likely to benefit from the coordinated care of a multidisciplinary heart failure team and this could impact on the local service provision needed. The PARR (Predicting and Reducing Re-admission to Hospital) tool can support commissioners to identify the local high risk population and plan service requirements. See also the National Cardiovascular Disease (CVD) profiles.
HES mortality data reveals the large number of finished admission episodes for heart failure resulting in death. Around 16% of finished admission episodes result in death within 30 days of admission, 90% of which are in hospital. This rises to 25% within 90 days of admission, and around 80% of these deaths are in hospital.
Not all people with suspected heart failure are subsequently diagnosed with heart failure. The proportion of people referred who are subsequently diagnosed with heart failure varies between studies and services. The mid- point of these estimates suggests that around 30%–40% of patients with suspected heart failure have the diagnosis confirmed,,. For the purpose of this benchmark a figure of one-third has been used.
The prevalence of heart failure is expected to rise in the future as a result of an ageing population, improved survival of people with ischemic heart disease and more effective treatments for heart failure. The 2006 study 'Effect of socioeconomic deprivation on the population risk of incident heart failure hospitalisation' showed a link between social deprivation and the risk of developing heart failure, irrespective of baseline cardiorespiratory status and cardiovascular risk factors.
The consensus opinion of the topic advisory group was that:
It may be possible to increase the detection and diagnosis rates of people with heart failure by raising awareness among clinicians of the public health importance of heart failure, and by improving referral pathways, access to diagnostic services and access to coordinated care.
Commissioners should examine local observed versus expected prevalence and incidence to determine potential levels of unmet need in their populations and possible levels of misdiagnosis.
Commissioners may find it helpful to examine their local emergency admissions rates for heart failure, see the commissioning and benchmarking tool and other data such as Quality and Outcomes Framework (QOF) and prescribing data to assess current service provision.
Examining length of hospital stay may also prove helpful as some people with heart failure may be discharged before they are clinically stable.
The auditing of heart failure services to assess if there is age and gender bias may also prove useful.
Based on the epidemiological data and other information outlined above, it is concluded that the benchmark for the number of people aged 45 or over with suspected heart failure who should have serum natriuretic peptides measured is 0.36% or 360 per 100,000 population, per year. This is based on the following assumptions:
The annual incidence of diagnosed heart failure (that is, the average detection rate of new cases per year) is around 0.15% of the population aged 45 years or over.
It is estimated that around a third of cases of suspected heart failure result in a diagnosis. Therefore around 0.45% of the population aged 45 years or over will present with suspected heart failure.
Of those who present with suspected heart failure around 20% will have had a previous myocardial infarction (MI) and will be referred for specialist assessment and echocardiography to confirm the diagnosis.
Approximately 0.36% or 360 per 100,000 population aged 45 or over would have serum natriuretic peptides measured to confirm the diagnosis.
Around 46% of people with suspected heart failure who have serum natriuretic peptides measured will have raised or high levels and will be referred for specialist assessment and echocardiography to confirm the diagnosis.
This equates to around 0.17% or 170 per 100,000 population aged 45 or over who would need to be referred for specialist assessment and echocardiography to confirm the diagnosis.
Therefore the population benchmark for the number of people aged 45 or over with suspected heart failure who should have the diagnosis confirmed through testing is 0.36% or 360 per 100,000 population, per year.
Commissioners should use their local needs assessment to determine local service provision. Commissioners should note that the benchmark rates do not represent NICE's view of desirable, or maximum or minimum, service levels.
Commissioners should use this benchmark and local data to facilitate local discussion on optimum service levels. There is considerable variation in the prevalence and identification of chronic heart failure. This is influenced by the social, economic and demographic profile of the local population. Therefore commissioners are encouraged to consider local assumptions.
Use the chronic heart failure commissioning and benchmarking tool to determine the level of service that might be needed locally and to calculate the cost of commissioning the service using the indicative benchmark and/or your own local data.
 Patients aged 45 and above available in their practice for the whole of the 12 months from 01/01/2009 to 31/12/2009 with a diagnosis of heart failure during 2009 (medical event) and no previous diagnosis.
 Patients age 45 and over available in their practice for the whole of the 12 months from 01/01/2009 to 31/12/2009 with a diagnosis of heart failure during 2009 (medical event) and no previous diagnosis.
 Incidence of adults (18+) with newly diagnosed case of heart failure with a diagnosis of myocardial infarction (MI) anywhere in their record - as medical event. Study Year 01/01/2010 to 31/12/2010.
 Incidence of adults (18+) with newly diagnosed cases of heart failure who had test to measure serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NTproBNP]) [searching Tests and Medical Event] Study Year 01/01/2010 to 31/12/2010.
 National Institute for Health and Clinical Excellence (2010) Chronic heart failure (costing tool). NICE clinical guideline 108. London: National Institute for Health and Clinical Excellence. Available from www.nice.org.uk/guidance/CG108
 Shared learning database submission (2011) Local variation shared learning example: a commissioning toolkit for use of natriuretic peptide assessment for suspected heart failure in primary care. Available from www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/examplesofimplementation/eximpresults.jsp?o=447
 Transthoracic echocardiography procedure OPCS4 U20.1 Available from www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/codingstandards/opcs4 Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision) (OPCS)
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 Zaphirioua A, Robb S, Murray-Thomas T et al. (2005) The diagnostic accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: results of the UK natriuretic peptide study. European Journal of Heart Failure 7: 537–41. Available from www.eurjhf.oxfordjournals.org/content/7/4/537.full
 Owan T, Hodge D, Herges R et al. (2006) Trends in prevalence and outcome of heart failure with preserved ejection fraction. New England Journal of Medicine 355: 251–9
 Stewart S, Murphy NF, McMurray JJ et al. (2006) Effect of socioeconomic deprivation on the population risk of incident heart failure hospitalisation: an analysis of the Renfrew/Paisley Study. European Journal of Heart Failure 8: 856–63