Services for the prevention of cardiovascular disease
This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg45
6 The commissioning and benchmarking tool
- 6.1 Identify indicative local service requirements
- 6.2 Review current commissioned activity
- 6.3 Identify future change in capacity needed
- 6.4 Model future commissioning intentions and associated costs
- 6.5 Potential savings
- 6.6 Potential health outcomes
Use the commissioning and benchmarking tool for integrated commissioning for the prevention of cardiovascular disease to determine the level of services that might be needed locally and to calculate the cost of commissioning the services.
The data used to populate the commissioning and benchmarking tool includes:
age of population
prevalence of modifiable risk factors for cardiovascular disease
risk exposure to modifiable risk factors
age-related modifiable risks for people aged 40 and older.
The commissioning and benchmarking tool selects the population at risk of cardiovascular disease using the nine Interheart study modifiable risk factors and, through interventions, identifies the risk reduction. Note that the commissioning and benchmarking tool does not have risk reduction rates for psychosocial stress, regular physical activity and diet. However, improving physical activity and diet overlaps with interventions that tackle other risk factors such as obesity and high cholesterol.
The commissioning and benchmarking tool helps you to assess local service needs using the indicative benchmarks as a starting point. You can amend the benchmarks to better reflect your local circumstances. For example, if your population is older than average or has significantly higher or lower rates of modifiable risk factors for cardiovascular disease, you may need to provide services for relatively fewer or more people.
You may already commission cardiovascular disease prevention interventions for your population. The tool provides tables in recurrent costs worksheet that you can populate to help you calculate your total current commissioned activity and costs.
Using the indicative benchmarks provided, or your own local benchmarks, you can use the commissioning and benchmarking tool to compare the activity that you might need to commission against your current commissioned activity. This will help you to identify the future change in capacity needed. Depending on your assessment, your future provision may need to be increased or decreased.
You can use the commissioning and benchmarking tool to calculate the capacity and resources needed to move towards the benchmark levels, and to model the necessary changes over a period of 5 years.
Use the tool to calculate the level and cost of activity you intend to commission and to consider the settings in which services that contribute to cardiovascular disease prevention services may be provided. The tool is pre-populated with data on the potential recurrent and non-recurrent cost elements that may need to be considered in future service planning, which can be reviewed and amended to accurately reflect your local circumstances.
Commissioning decisions should consider both the clinical and economic viability of the service, and take into account the views of local people. Commissioning plans should also take into account the costs of monitoring the quality of the services commissioned.
You can use the commissioning and benchmarking tool to calculate the potential savings associated with a service that contributes to the prevention of cardiovascular disease. For simplicity, savings are based on an estimated average cost of a cardiovascular disease event. Other costs are difficult to quantify because they depend on a number of variables. For example preventing cardiovascular disease may also help to prevent other non-communicable disease such as diabetes, chronic kidney disease, chronic obstructive pulmonary disease, dementia and some cancers. It may also contribute to improvements in mental health and wellbeing.
Population benefits in the first 5 years
For this tool we have taken a 5-year time frame and assumed some savings within this period; however, significant savings are likely to be achieved beyond 5 years.
The commissioning and benchmarking tool uses target (at risk) population estimates to estimate the proportion of the population who may successfully respond to interventions. This includes an assumption on uptake and compliance with interventions as a result of implementing the guidance. An estimate of 3% uptake and compliance over 5 years has been assumed for all risk factors as a default value in the tool. This is consistent with the more prudent targets included in the modelling undertaken for primary care trusts by Whitfield in 2009. Users can amend this figure to reflect local estimates.
A proportion of people who have a cardiovascular disease event do not recover. If there are fewer events there will be fewer deaths. In addition, reduced risk levels could lead to a lower percentage of patients dying as a result of a cardiovascular disease event. Cardiovascular disease risk modelling carried out for one primary care trust shows that if there is a 20% move each year over 5 years towards a reduction in cardiovascular disease risk factors of around 3–6%, the estimated number of premature deaths that could be avoided after 5 years is between 983 and 1476.
Crude estimates for life-years gained as a result of implementation are provided in the 'potential savings and outcomes' part of the tool. These use data from a US study that identified that approximately 44% of the fall in the death rate from coronary heart disease was a result of changes in risk factors.
Implementing a comprehensive approach to tackling cardiovascular disease risk factors could have a significant impact on the gap in life expectancy.
 Whitfield MD (2009) Modelling the potential impact of enhanced public health programmes on population level risk reduction in cardiovascular disease and subsequent acute hospital admission rates over a 5 year period. International health management consulting. Birmingham: Heart of Birmingham Primary Care Trust.
 Ford ES, Ajani A, Croft JB et al. (2007) Explaining the decrease in US deaths from coronary disease 1980–2000. New England Journal of Medicine 356: 23.