National Heart Failure Audit
Steering Group meeting minutes
3 April 2014, 13.30-15.30
rd
Boardroom, 3 floor 170 Tottenham Court Road, London W1T 7HA
1. Apologies and introductions
1.1 Present: Gemma Baldock-Apps, Janine Beezer, Henry Dargie, Gethin Ellis, Dawn Lambert,
Suzanna Hardman, Theresa McDonagh (chair), Richard Mindham, Polly Mitchell, Jim Moore,
Julie Sanders, Kathy Simmonds.
1.2 In attendance: Morag Cunningham
1.3 Apologies: John Cleland, Jackie Austin.
TM introduced Gethin Ellis, a new member of the Steering Group who will be representing
Cardiology in Wales and the Welsh Cardiac Networks.
2. Minutes of the last meeting and matters arising
3 (AP1): PM confirmed that Marion Standing had added life status information to the export, and
would be updating the online reports over the next few weeks. The reports and export format
would be circulated around the Steering Group before being release more widely to participating
hospitals.
Action 1: PM to circulate draft mortality data releases to Steering Group prior to release.
3. Annual report 2013/14 analysis plan
This has not been circulated yet, as it was discussed immediately prior to the current meeting. TM
noted that in 2013/14 the report would be shorter, with fewer Kaplan-Meier graphs, and with more
detailed analysis reserved for peer reviewed articles and online appendices. She gave a summary
of proposed changes to the analysis plan:
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Basic demographic and descriptive analyses will remain broadly similar, with a few pieces of
analysis being cut.
No cardiovascular or heart failure mortality (except perhaps headline figures) as these
showed little difference from all cause last year.
KM curves (1 year and 5 year mortality): LVSD v. HFPEF, cardiology v. other wards,
cardiology and HFNS follow-up, therapies for LVSD and additive benefit of therapies.
Readmission (30 day and 1 year): All-cause, CV and HF readmission.
Possible inclusion of analysis on relationship between length of stay and readmission.
Anonymised mortality and readmission by hospital (similar to the length of stay charts in
previous years)
Trends over 5 years (e.g. for in-patient mortality, prescription and referral rates).
GE notes that it would be very useful for Welsh and English figures for key indicators to be
published separately. He noted that this would be very useful for promoting data entry and quality
improvement locally. It was agreed that this would be easy to include alongside hospital-level
analysis.
Action 2: PM to write up proposed revisions to annual report analysis and circulate to Steering
Group for comment.
SH suggested that more copies of the annual report could be printed for the BSH. PM noted that
the number of reports produced for the BSH had been increased last year due to increased
demand, and that the BSH had kindly donated funding to the audit towards the costs of
production. SH suggested that PM contact Andrew Clarke now regarding continues financial input
from the BSH. TM noted that the PDF of the report could be included in the electronic revalidation
appraisal tool.
TM noted that the audit slides from the 2013 BSH meeting were not yet on the website.
Action 3: SH to remind BSH secretariat to include audit presentation slides on BSH website.
PM suggested that the audit could produce a set of slides alongside the annual report, which
could be used or adapted by hospitals for local presentations.
4. Dataset revision
PM reported that the dataset revision had gone ahead with only minor glitches, which were under
control. Philips, who develop CVIS (previously known as TOMCAT) clinical system have asked
whether we can extend the reporting period to 12 months, and have reported that their HF module
will not be ready for use until later in the year. They plan to release four upgrades (heart failure,
CRM, EPS ablation and BCIS) at once, and also are pushing for hardware upgrades in centres at
the same time.
TM noted that CVIS is mostly used in cath labs, and PM confirmed that not many centres (under
5) actually used CVIS to upload data to the HF audit. Many centres using CVIS found it easier to
directly enter data to the audit, with GBA and East Sussex Trust being a case in point.
PM said she had told Philips that extending the parallel reporting period for 12 months would be
unlikely to be possible – the audit is in the process of developing a risk model, and hospitals not
including data for new risk fields will be in danger of being excluded from this model, resulting in
no hospital-level mortality being published for them, and potentially skewing the model. PM
asked whether the Steering Group would consider extending the parallel reporting period at all.
It was noted that to make allowances for Philips would be unfair on all other companies and
hospitals who had managed to upgrade their systems in time for the new dataset roll-out. The
Steering Group was generally not happy to extend the period of running the two datasets in
parallel.
Action 4: PM to find out which hospitals are using the CVIS HF module, and which are using it to
upload data to the audit.
5. Best practice tariff
TM and PM have met with Monitor and the Department of Health twice to discuss a proposed
best practice tariff for heart failure. Best practice tariffs pay a higher rate when centres meet
certain quality indicators, and a lower rate when they fail to do so. The aim is to give a financial
incentive for good quality care, much like CQUIN payments or QOF in primary care. An initial
proposal has been made for a heart failure best practice tariff to be based on audit data.
TM noted that she had initially been enthusiastic, assuming that there would be an incentive
offered for good performance, and considering a link between audit participation and good
performance with financial reimbursement to be a good way of improving HF services. However it
had emerged that there was no additional money for the scheme, so there would be a penalty for
non-compliant Trusts, such that if they don’t meet targets they could lose over 10% of their heart
failure funding.
There is a workshop on 16 April, with PM, TM and SH will attend, along with other HF
professionals, including HF nurses and cardiologists.
It was noted that we want to improve HF care, but don’t want to unintentionally take resources out
of HF and compound problems in poorly performing centres. Commissioning of services is done
locally, so it may be difficult or impossible to reapportion money centrally at the end of the year –
instead two fixed tariffs would be used. This could potentially mean that overall a significant
amount of funding is taken out of heart failure, if many hospitals fail to meet the target. This would
penalise underperforming hospitals, and potentially make matters worse for them. It was noted
that an overspend/underspend one year could be balanced out the next, to avoid long term
financial loss.
SH said that there was the possibility of staggering the introduction of the penalty/incentive so that
Trusts have time to change their practice without being hit with a large financial shortfall. The
scheme would work alongside existing incentive projects such as CQUIN, and would not replace
them. JM noted that QOF has been very successful in improving HF management in primary
care.
If audit data was used to evidence best practice, participation in the audit could be used initially,
along with, or followed by two or three other measures (e.g. specialist input, prescription rates,
referral rates). Ideally we need to see examples of BPTs for other chronic conditions, to see what
measures they have used and how/whether they have worked. This would have a potential
benefit for the audit in terms in increased participation and data quality. JM reported that in
Gloucestershire, discussions about participation in the HF audit had centred on whether there
were any financial penalties for non-participation.
PM noted that the commissioners would need the data from NICOR, and it had been suggested
that it would be required every quarter. This would require hospitals to have quarterly deadlines
for data submission, and for NICOR to link to ONS and produce hospital-level analysis four times
per year. This was deemed unachievable. JB noted that CQUIN payments were calculated on an
annual basis.
Action 5: PM to pass JM’s email on to Department of Health contact, for suggested invitation to
workshop to discuss best practice tariff.
6. Primary care project
PM and JM outlined a proposed primary care audit project, using data from JM’s community HF
audit in Gloucestershire.
Gloucestershire Care Services has carried out an extensive audit for 10 years into the care
delivered by their community heart failure service. The data captured by this audit covers the
diagnosis, medication and referrals for all patients using the service, and collects very similar
information to the National Heart Failure Audit dataset.
The National Heart Failure Audit has been considering for some time whether and how to extend
into primary care. Exploring the potential for extending the audit into primary care is one of the
contracted deliverables from HQIP.
The first stage of this proposed project would involve the Gloucester Care Services data being
imported into the National Heart Failure Audit database, using the main audit dataset and data
definitions. This would enable linkage of the primary care records to ONS and HES data, in order
to obtain longer term outcomes data for these patients, at minimal additional cost to the audit.
This could result in an initial research project to explore whether the long term outcomes of these
patients.
This would be a platform for the linkage between the community data and regional secondary
care data from Gloucestershire Hospitals Trust – this could explore whether patients are admitted
to hospital, either before or after their inclusion in the community audit, and track their medicines
management across these two services.
Gloucestershire Care Services have already agreed that they would be keen to be part of the
project, and to share their data with the audit. Gloucestershire Hospitals Trust has also expressed
interest, and is in the process of getting an SpR involved in the National Audit tot retrospectively
enter data on HF patients admitted to the Trust.
Furthermore, there is the possibility of linking with non-specialist primary care data for the
Gloucestershire region, i.e. those heart failure patients who are not treated by the specialist heart
failure service, using QOF data. JM has spoken to the primary care audit group attached to the
local CCG, who have indicated that they are keen to do this, but the practicalities and information
governance needed to be explored.
PM noted that there were a few IG issues that needed to be explored, including whether NICOR
is currently allowed to hold primary care data under the existing S251 approval.
Action 6: Organise TC in the next couple of weeks with JM, TM, PM and representatives from
Gloucestershire Hospitals Trust to discuss primary care linkage project.
7. Research update
HD gave an overview of the ongoing research projects using NHFA data:
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Bristol University project looking at the measurement of BNP in primary and secondary care.
Oxford University project looking at the variation in hospital care of heart failure patients that
can be attributed to characteristics of the hospital’s organisational structure.
Project led by TM, undertaking a propensity analysis, matching patients based on
demographic and aetiological characteristics, to investigate the impact of specialist care on
outcomes.
In-house analysis for Novartis, looking at the admission characteristics of heart failure
patients, and their eligibility for serelaxin. An abstract has been accepted for the ESC
(European Society of Cardiology) conference in Barcelona for this project.
The MAPP-HF project, which looks to analyse the progression of HF across primary and
secondary care, and identify earlier opportunities for prevention and treatment.
Initial discussions with John Deanfield about a programme of work looking at diabetes and HF
programme.
TM raised the issue of charging researchers for data extracts, which has been discussed at the
NICOR PLG (professional liaison group) meeting, and asked JS for an update of the NICOR
position on this.
JS noted that NICOR does not charge for the data itself, but rather covers the costs of extracting
and cleaning data, preparing extracts, and managing the data sharing process. A NICOR policy
was devised in 2011 to charge academic research groups £5,000 per extract, and an additional
£5,000 if linkage to another dataset was required. Commercial research groups would be charged
a minimum of £10,000. Under the HQIP contract, NICOR is contractually obliged to charge for
research extracts. In February, all audit academic groups were reminded to use the existing
NICOR charging policy, as it had previously been applied sporadically. At the same time, NICOR
is reviewing the charging process, to ensure that it accurately reflects the costs of managing and
preparing the data.
TM noted that the NHFA has previously charged commercial organisations (Novartis, Servier) and
grant funded academic research groups (George Centre in Oxford, and Bristol University) for
analysis and data extracts. The audit has taken a more lenient approach for investigator-led
research and non-grant-funded projects, and has waived the charge in these instances. TM
expressed concern that the audit would be required to charge £5,000 for investigator-led projects,
and suggested that this may obstruct smaller, but nonetheless valuable research projects. TM
noted that the PLG had discussed the suggestion that each audit had the ability to waive the fee
for three projects per year. She asked whether the audit could also use money brought in from
grant funded/commercial projects to support unfunded projects.
JS said that the charges would not apply retrospectively for projects where a NICOR data sharing
agreement had already been signed. As part of the new charging strategy NICOR will look at
each audit potentially being able to waive the fees for a fixed number of projects- perhaps 3. The
possibility of audits being able to subsidise projects that are unable to source their own funding
would also be discussed.
TM noted that the propensity analysis is to be carried out by an external researcher, Ian Ford,
who would be paid £10,000 for the work. She asked whether he or the audit would have to be
charged for releasing this extract to him. JS confirmed that as long as there was no cost to
NICOR, no charge would be levied, and that the audit could use industry funding to cover the
costs of this analysis.
JS noted that no charge would be applied for clinical audit or service improvement projects (e.g.
individual clinicians carrying out local quality improvement projects). Clinical audit in this sense is
to be defined as measuring data against existing standards. Anything extending beyond this
should be considered research. The audit research group should make a decision as to whether
or not a given project should be considered an audit or research project.
SH described the importance of the BSH having access to collective audit data in order to drive
change in practice, and specifically asked JS to confirm that the BSH would not be asked for a fee
if they requested collective audit data for their membership (individual Trusts already have
access). JS was able to confirm that this usage would not incur a fee.
8. NICOR update
JS gave a brief update of NICOR-wide activities:
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HQIP contracts for 2014-16 will be signed this week.
This will enable new staff to be recruited, specifically a data manager and another analyst.
SOPs are being developed to formalise many of the processes within NICOR.
UCL has awarded NICOR an impact award for a heart failure PhD project. This means that
UCL provides half the funding for a 3-year PhD project (around £30,000). The rest of the
funding should be provided by industry.
NICOR is applying for grants to link both the National Diabetes Audit and the UK Renal
Registry with the NICOR audits.
A series of new cardiovascular health technology registries are being started within NICOR,
as part of the NHS England ‘Commissioning Through Evaluation’ scheme. The UK TAVI
registry is no longer funded by commissioners, and all funding now comes from industry.
A new website had been launch – feedback is welcome.
NICOR is running a patient and public engagement even in 8 May, to ascertain what
information patient and the public want to see from NICOR, and how they would like us to
provide it.
9. Prospective methodology pilot
Exploring the possibility of a prospective audit is now one of the HQIP contracted deliverables.
Prospectively identifying patients removes the need for pulling the notes for each patient, saving
considerable time and effort. It also gives heart failure clinicians the opportunity to impact on
audited patients’ care while they are still hospitalised – currently patients are only audited postdischarge, meaning that their management cannot be altered.
The pilot will run from September to November 2014. Around 10 hospitals will be involved, and it
should aim for variation in location and size of centres. The data for this three month period will be
compared to the NHFA audit and HES data for these centres in the same three month period in
2013.
TM noted that most patients arrive either in A&E, and are then moved to an AMAU or
CCU/cardiology ward. Potential heart failure patients should be flagged up on arrival to hospital,
either using their EPR, or by someone daily visiting the admission wards and identifying patients
with symptoms and signs of heart failure. The symptoms should be confirmed by BNP - if used and echo, and at this point, if the echo shows significant dysfunction, the patient should be
flagged for inclusion in the audit.
GE noted that a person would need to check the electronic flagging of patients, as this was often
inaccurate or incomplete.
DL asked whether patients coded as having heart failure, but not captured by this process, should
also be audited. It was deemed that this would be too much work, but acknowledged that in order
for the project to be thorough these patients would need to be examined to determine whether
they are actually heart failure admissions or not.
TM noted that there was no additional money to fund this project, and the incentive for centres to
take part was their inclusion in subsequent publications.
PM confirmed that around 10 centres had already expressed interest. GE added that he would be
interested in taking part as well.
10. AOB
No other business was raised.
Date and time of next meeting: Thursday 3 July, 13.30-15.30
Appendix: Action Points
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Action
PM to circulate draft mortality data releases to Steering Group
prior to release.
PM to write up proposed revisions to annual report analysis and
circulate to Steering Group for comment.
SH to remind BSH secretariat to include audit presentation
slides on BSH website.
PM to find out which hospitals are using the CVIS HF module,
and which are using it to upload data to the audit.
PM to pass JM’s email on to Department of Health contact, for
suggested invitation to workshop to discuss best practice tariff.
Organise TC in the next couple of weeks with JM, TM, PM and
representatives from Gloucestershire Hospitals Trust to discuss
primary care linkage project.
Owner
PM
Completed?
PM
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SH
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PM
PM
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JM, PM
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