Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

1. Royal College of Surgeons in IrelandColáiste Ríoga na Máinleá in Éirinn European 4th Joint Task Force on CVD Prevention in Clinical Practice in the context of the National Cardiovascular Health Policy 2010-2019 Hannah McGee, PhD, FEHPS, FESC

3. “Changing Cardiovascular Health” [10 year plan: 2010-2019] CVH Policy Group Terms of Reference ‘…to develop a policy framework for the prevention, detection and treatment of cardiovascular disease including stroke and peripheral arterial disease, which will ensure an integrated and quality assured approach to their management’.

4. CVD Medication Use - GMS Scheme (1998-2006)

5. SLÁN 2007: Hypertension management • (N=1207, aged 45+) • Normotensive (<140/90mmHg)(no meds) 40% • Hypertensive • On medication (<140/90mmHg) 8% • On medication (>140/90mmHg) 18% • NOT on medication (>140/90mmHg) 34%

6. SLÁN 2007: Hypertension management • Normotensive (<140/90mmHg)(no meds) 40% • Hypertensive • On medication (<140/90mmHg) 8% • On medication (>140/90mmHg) 18% • NOT on medication (>140/90mmHg) 34% • Not Treated: • Men/women: 40 / 27% • Age 45-64 / 65+ 34 / 33% • Social class (1-2/3-4/5-6): 35 / 33 /39%

7. POLICY: Structure and Recommendations • 69 recommendations • Recommendation • Lead agency

8. POLICY: Structure and Recommendations • 69 recommendations • Recommendation • Lead agency • SIX SECTIONS • Prevention and Health Promotion • Primary Care • Hospital and Emergency Care Services • Cardiac and Stroke Care and Rehabilititon • Workforce Planning for the Policy • A National Framework for Quality in Cardiovascular Health

9. POLICY: Prevention and Health Promotion • 10-year population targets: • Smoking • annual 1% reduction prevalence • Annual 1% reduction in initiation rates • Healthy body weight [Healthy eating /physical activity] • - halt rise in 5 years • - restore 1998 levels by 2019 • Salt consumption • EU 2012 Directive (16% reduction) • Alcohol use • Strategic Task Force on Alcohol targets (2007)

10. POLICY: Primary Care I • Patient/public awareness • blood pressure & cholesterol levels, family history, waist circumference, stroke signs/symptoms • High risk approach - extend definition using ESC’s 4th Joint SocietiesTask Force (2007) approach • established disease, family members - premature atherosclerosis/multiple risk factors • Risk identification & management • Single nationally agreed protocol • Opportunistic assessment (with systematic approach) • Phased evaluation of systematic assessment model

11. Population risk: systematic opportunistic assessment in general practice? SLÁN 2007: Attending GP in the previous year (gender, age and social class (%))

12. POLICY: Primary Care II • Stroke prevention • blood pressure • - rigorous assessment, treatment, monitoring • atrial fibrillation • - age 65+: pulse assessment in GP • - anticoagulation services • Heart failure management • Early detection: • - education of primary care teams • - liaison specialist HF nurses

13. POLICY: Rehabilitation • Commonalities - cardiac & stroke • Secondary prevention for all • from TIA/mild strokes to complex cardiac cases - heart failure/PAD • Step-down strategies from hospital to primary care services • Staff training - chronic disease model: build on CR experience

14. POLICY: National Framework for Quality in Cardiovascular Health • Standards • Evidence-based guidelines/ performance indicators/ information & data requirements/updating guidelines • National Guidelines Coordination (liaise DoHC/HIQA) • Surveillance • Information systems - registers, data standards, population surveys, audit • ICT - infrastructure, capacity & training • Research and evaluation • Health Technology Assessment agenda

15. POLICY: What happens next? • Policy delivery • 1. HSE Service Plan - Clinical Directorate priorities set • Appointments: Stroke, Acute cardiac, Heart failure, Primary care • 2. Cabinet Sub-Committee on Health: monitor population targets • 3. Overall: CVH Policy Monitoring Group to be established • Full formal review at 5 years (2015) • CVH Policy Monitoring Group

17. Hospital discharges by CVD diagnosis (1998-2008)

18. Hospital discharges by CVD diagnosis (1998-2008)

19. Hospital discharges by CVD diagnosis (1998-2008)

20. Hospital bed days by CVD diagnosis (1998-2008)

21. Hospital bed days by CVD diagnosis (1998-2008)

22. Hospital bed days by CVD diagnosis (1998-2008)

23. Hospital bed days by CVD diagnosis (1998-2008)

24. POLICY: Workforce Planning • Medical Staffing • Consultant workforce: • Cardiology: Joint Working Group (2004) – 10 per 500,000 needed • (preventive cardiology & heart failure expertise for network coverage) • Stroke: combination geriatric medicine/neurology with special interest in stroke/geriatric medicine/rehabilititon medicine • (5 acute stroke, 2-3 for other services, additional rehabilitiation physician expertise per 500,000) • NCHD workforce:service need/capacity for next generation • Multidisciplinary Team Staffing (+ICT) • Primary Care Staffing (PCTs)

25. POLICY: Structures - Networks • Regional networks • Serving populations of c.500,000 • Every hospital provides a complete range of services • (cardiac or stroke) either on-site or in formal partnership with others in the network) • Equitable - all can access same range of services • Hospitals Two types: • GENERAL cardiac(stroke) centre (provides sub-acute and chronic care) • COMPREHENSIVE cardiac(stroke) centre (provides acute care) • Some consultant and other staff with ‘network’ responsibilities

26. POLICY: Hospital Care I • Clinical management - cardiac (ACS) • STEMI & treatable within 180 mins: primary PCI • Centres with access, workforce expertise and adequate cover • STEMI & not treatable within 180 mins: thrombolysis • Timely provision = priority • Structures - cardiac • PCI: full range of imaging facilities/ 2 labs for timely access • CCU reconfigured - Critical Cardiac Care focus • Thrombolysis: pre-hospital/advanced paramedic and hospital combination

27. POLICY: Hospital Care II • Services • Emergency services: advanced paramedics/ICT essential • Rapid Access Chest Pain Services • Heart failure - ambulatory services: shared care model • PAD services: vascular service access • Cardiac surgery: workforce adequate • - Protected ICU beds (single room) the priority • Congenital heart disease /GUCH: needs separate focus

28. POLICY: Hospital Care III • Clinical management - stroke • Thrombolysis: ‘consultant stroke physician’ administered • 24/7 cover needed • Structures - stroke • Stroke units: capacity, MD Teams, care protocols, early start to rehabilitation; discharge plan • TIA/Stroke Prevention Clinics: same day assessment; timely access to vascular surgery where needed • Neuroradiology/Vascular Surgery: services access

29. Philosophy - REDUCING THE INCIDENCE OF CVD: The European Heart Health Charter “Every child born in the new millenium has the rightto live until the age of at least 65 without suffering from avoidable cardiovascular disease” (June 2007)