Evaluation of the National Infarct Angioplasty Project Pilots
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EVALUATION OF THE NATIONAL INFARCT ANGIOPLASTY PROJECT PILOTS
A. Background, Aims & Objectives
The Department of Health is currently funding up to ten pilot sites as part of the
National Infarct Angioplasty Project (NIAP) to test the feasibility of implementing a
countrywide primary angioplasty service for patients presenting with acute STelevation myocardial infarction (AMI). We aim to evaluate the pilot sites and address
the five elements of the brief produced by the NHS Service Delivery and
Organisation (SDO) R&D Programme.
The specific objectives will be: To gain an in depth understanding of patient and carer
experience of receiving care at the pilot sites, and measure differences in satisfaction
between the pilot sites and sites providing standard, thrombolysis-based care. To
assess the workforce implications of setting up an angioplasty service at the pilot
sites, and measure the effect of providing the service upon the angioplasty team,
support staff, and related staff groups. To describe the models of service delivery
established at the pilot sites in terms of their setting (geography, population, transport
and communications), structure (hospitals, referral networks, transfer and access
points) and components (staff, facilities, and equipment). To explore implementation
and feasibility issues by describing the processes involved in establishing primary
angioplasty (particularly the development of teams and leadership roles), identifying
facilitating factors and barriers to implementation, and assessing the implications of
establishing primary angioplasty for cardiology and other services. To compare the
costs and outcomes of providing angioplasty and thrombolysis, and estimate the
incremental cost-effectiveness of a comprehensive primary angioplasty service,
compared to standard, thrombolysis-based care, for the different organisational
service models adopted in the pilot sites.
B. Relevance to SDO Call for Proposals
This proposal is submitted directly in response to the SDO call for proposals
“Evaluation of the National Infarct Angioplasty Project Pilots” and addresses the
specific issues outlined in the brief.
C. Background, including NHS context and relevant literature
Acute ST-elevation myocardial infarction (heart attack) occurs when a coronary
artery is occluded by a blood clot. Treatment with an intravenous thrombolytic agent
to break down the clot is cheap, simple and effective, and can be provided in all
acute hospitals and by some ambulance services. Primary angioplasty, where a
catheter and a stent and/or balloon is used to restore blood flow, is more effective for
many patients, probably more costly and delivery requires specialist staff and
facilities.
Meta-analysis of randomised trials comparing primary angioplasty to intravenous
thrombolysis has established that primary angioplasty is associated with reduced
mortality, reinfarction, stroke and need for coronary artery bypass grafting, compared
to thrombolysis.1-3 Economic analyses suggest that, if both interventions are routinely
available, then primary angioplasty is likely to be cost-effective, although this costeffectiveness is likely to be dependent on the additional time it takes to initiate
angioplasty compared to thrombolysis.4 Although, on average, primary angioplasty is
likely to be considered cost-effective, the costs and benefits of the two alternative
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reperfusion strategies are likely to vary according to the type of centre (e.g. rural
versus urban setting).
These data provide evidence that, if both interventions are routinely available, then
primary angioplasty is likely to be the appropriate choice for most patients. However,
primary angioplasty is currently not routinely available to patients presenting to the
National Health Service (NHS) with AMI. It is available to some patients, depending
upon where and when they present to hospital, but routine provision of primary
angioplasty will require substantial re-organisation of services to ensure widespread
availability 24 hours per day. Establishing such a service requires a number of
organisational and economic questions to be addressed.
What models of service delivery could be used?
Primary angioplasty requires specialist staff and facilities. Several models have been
suggested for providing widespread access to primary angioplasty,5,6 but little data
exist to compare these models. Meta-analysis suggests that angioplasty is superior
to thrombolysis even when it requires inter-hospital transfer.7 Data from the United
States (US) suggest that centres with a higher volume of angioplasty procedures
have a lower mortality rate,8 and that the advantages of angioplasty over
thrombolysis are limited to hospitals with a high or intermediate volume of cases.9
Meanwhile, regionalisation of angioplasty services does not appear to increase travel
distances for most patients.10 This has prompted researchers to suggest a network
model similar to US trauma networks,6 in which patients bypass or are transferred
from local hospitals to specialist centres, although this approach does not appear to
be appropriate to the NHS.11
What are the barriers to implementing a primary angioplasty service?
A number of barriers to implementation of primary angioplasty have been identified,6
mainly related to the difficulty of providing timely access to appropriate staff and
facilities, and strategies have been suggested to overcome these barriers. However,
both the barriers and solutions identified have been based on a paucity of empirical
data and those identified in other health care systems may not be transferable to the
NHS. For example, there are important international differences in the professional
groups delivering services and in the way health services are funded and organised.
What are the workforce implications of implementing a primary angioplasty
service?
One of the principal barriers to implementation of a primary angioplasty service is the
24-hour requirement for specialist medical and nursing staff.12 As outcomes from AMI
are related to staffing levels and staff specialisation,13,14 appropriate staffing is
essential to achieve anticipated outcomes. However, successful implementation may
take trained staff away from other important roles, such as on-call commitments and
emergency cover, and may have some negative consequences for the NHS.
What is the most cost-effective approach to providing primary angioplasty?
A number of cost-effectiveness analyses have established that, if both services are
routinely available, then primary angioplasty is likely to be considered a more costeffective use of resources than thrombolysis.3,15,16 However, these studies assume
that primary angioplasty is routinely available and use an average angioplasty cost
based upon current angioplasty service costs, which does not vary according to the
specific circumstances under which it is performed. This assumption is unlikely to
represent the true cost of providing emergency primary angioplasty. If provision
requires a substantial re-organisation of services, rearrangement of staff rosters or
knock-on effects for other services then the true cost of an emergency primary
angioplasty may be much higher than the average cost. Furthermore, it is probably
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inappropriate to consider primary angioplasty and thrombolysis to be distinct,
mutually exclusive strategies. Instead, the most cost-effective alternative to a
comprehensive angioplasty service will probably involve some selective,
opportunistic use of primary angioplasty, with thrombolysis as a back up. Therefore
the more appropriate comparison would be between a strategy that seeks to
maximise use of primary angioplasty (intervention), and one that only provides it in
an opportunistic manner (standard care). Finally, it is possible that costs and
additional time it takes to initiate angioplasty (compared to thrombolysis) may vary
between different models of service provision, such that some models may be more
cost-effective than others.
What do patients think of primary angioplasty and thrombolysis?
The views of service users should help determine the development of NHS services.
It is self-evident that patients and carers want effective services, but other factors
may have an important influence upon their experience. For example,
implementation of primary angioplasty may require centralisation of services, which
may run counter to patient and carer preferences. Patient views have been sought in
developing cardiac care,17 in the attempt to weigh the risks and benefits of
reperfusion strategies for myocardial infarction,18-20 and in comparing diagnostic
strategies for chest pain.21,22 The patient experience of angioplasty has been
explored,23 but comparison of primary angioplasty to thrombolysis has focussed upon
mortality, morbidity and cost-effectiveness.
The National Infarct Angioplasty Pilots
The British Cardiac Society (BCS) and the Department of Health have established a
joint working group to establish the feasibility of implementing a countrywide primary
angioplasty service. Up to ten pilot sites will be funded to set establish a service and
collect data. Meanwhile, other hospitals will continue to collect data from patients with
acute myocardial infarction as part of the Myocardial Infarction National Audit Project
(MINAP) database. We propose to evaluate the pilot sites and address the issues
outlined above.
D. Plan of investigation
Evaluation of changes to the organisation and delivery of emergency services
requires a multidisciplinary approach, involving researchers with experience of
working in this challenging area. We will use a mixture of qualitative and quantitative
methods, involving health service research, organisational research, work
psychology, epidemiology, and health economics. Members of our research team
have evaluated the role of chest pain units in the NHS (SG, SJC, KS, SC), the
influence of organisational factors upon waiting times in Accident and Emergency
(AC, SG), the role of NHS Direct (AOC), human resources in the health sector (SW),
and the value of revascularisation (RS,MJ).
A core research team of Steve Goodacre, Fiona Sampson, Alicia O’Cathain,
Katherine Stevens, Mark Sculpher (University of York), and Angela Carter will
undertake the project, with expert guidance from Simon Capewell (epidemiology),
Stephen Campbell (cardiology), Rod Stables (cardiology), Stephen Wood (work
psychology and organisational research), James Wardrope (prehospital care) and
Mark Jackson (Clinical Audit). A consumer representative (Enid Hirst) is helping to
develop the project and will establish a consumer group of people who have
experience of heart attack and/or angioplasty. A Steering Group comprising of an
independent Chair, independent member, consumer representative, stakeholder
representatives and the co-applicants will guide the project.
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We plan to compare the pilot (intervention) sites to four control sites that do not
formally establish a primary angioplasty service. Evaluation will take a whole-system
approach. We anticipate that even pilot sites that successfully implement 24-hour
primary angioplasty will still use thrombolysis for at least a residual proportion of
patients. Likewise, control sites that do not develop a primary angioplasty service
may still use angioplasty opportunistically for some patients arriving during working
hours. Our evaluation will compare the overall effect on all patients with AMI at each
site, rather than focussing upon those who received the intended or principal service.
Routine data will be collected from all sites. Two intervention sites will be used for
detailed evaluation of the patient and carer experience. Two other intervention sites
will be selected to develop workforce and feasibility methods and identify the
economic implications of providing primary angioplasty. The Research Team will
meet regularly for joint discussions of methods and findings from these two pairs of
sites to ensure that the project benefits from the complimentry nature of the
evaluations.
We have requested an additional £25,000 to undertake micro-costing at four of the
intervention sites and all four control sites, and to cross-check routine data collected
at these sites. Micro-costing will allow us to accurately measure the actual costs of
primary angioplasty and thrombolysis, and measure variation in costs between the
different models of service delivery. Validation of MINAP data will allow us to address
concerns about the quality and completeness of this dataset, particularly at the
control hospitals where we would otherwise have very little control over data
collection. These additions to the project will substantially improve the quality of data
used in the economic model and hence the reliability of our estimates of costeffectiveness.
Patient and carer experience
Although patient satisfaction has been measured in the context of angioplasty,17
there is no validated instrument specific to the patient and carer experience of
angioplasty. Even if such an instrument existed, it might fail to fully capture
experience when used in the context of an innovative service such as the NIAP pilot
sites. We therefore propose a phased approach of developing an instrument,
followed by the use of this instrument to describe experiences in a range of pilot sites
and comparator hospitals.
Phase 1 will involve the two sites with designated special responsibility for the
evaluation of patient and carer experience. We will use qualitative methods to identify
key elements of the patient experience and develop NIAP-specific instruments for
measuring patient and carer satisfaction. We will then test the feasibility of using this
instrument, alongside a generic instrument, in a postal questionnaire. In phase 2 we
will use this questionnaire to measure patient and carer satisfaction at four of the pilot
sites and patient satisfaction at four control hospitals providing standard
thrombolysis-based care. We will select the four pilot sites with the highest proportion
of patients receiving angioplasty so that this aspect of the evaluation maximises the
contrast between intervention and control care. In Phase 3 we will use qualitative
interviews with patients and carers from the two original pilot sites to expand upon
results from the survey and identify possible solutions to issues identified.
Workforce implications
We will use a mixture of quantitative and qualitative methods to address the
questions outlined in the brief. We will administer self-complete questionnaires to
staff who work with patients that have treatment for AMI. We will then conduct semi-
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structured interviews and focus group discussions with these staff and others who
are associated with treatment for AMI, including members of the angioplasty team,
emergency department staff, ambulance staff and paramedics. A two/three day site
visit will be used as the principal vehicle to arrange and conduct interviews and focus
groups. This visit will also be used to undertake the specialist teamworking interviews
and ethnographic observation (or where not possible retrospective case discussion)
that will address the implementation and feasibility issues
It is anticipated that specific material will be produced for this study. These will be
developed on two sites working closely with the teams who are collecting economic
data to produce a holistic model of investigation, and will involve close collaboration
with researchers working at two other sites to develop the patient and carer
satisfaction evaluation. Once piloted these materials and methods will be
developed/edited and then used with the other intervention sites.
Description of models of service delivery
We will use data from routine sources, a telephone survey and site visits to describe
the models of service delivery developed by the pilot sites in terms of the following
parameters: Service setting: urban or rural; area covered; catchment population
(number, age and gender, coronary heart disease morbidity and mortality rates,
ethnicity and social deprivation); transport and communications networks. Service
overview: participating hospitals; teaching status; referral networks between
hospitals; ambulance services; other prehospital care; access route to the service.
Service infrastructure: staff numbers, grades, profession and specialties;
interventional cardiology skills; rostering and on-call arrangements; facilities and
equipment; bed availability (general, coronary care and intensive care); cardiac
surgery services. Service activity levels: number of AMI treated (prehospital
thrombolysis, in-hospital thrombolysis and angioplasty), numbers of emergency and
elective admissions, revascularisation procedures, and cardiac operations
performed.
Implementation and feasibility
We will explore these issues alongside the evaluation of the workforce implications
and address the questions outlined in the brief by using a multiple case study
approach. This will involve face-to-face interviews, focus group discussions, and
observational / retrospective case study methods. The vehicle for the collection of
these data will be the site visit outlined in the workforce implications section.
Economic evaluation
Mark Sculpher and colleagues at the University of York have already developed a
cost-effectiveness model to compare angioplasty to thrombolysis.4 It considers costeffectiveness from the perspective of the NHS and uses data from the literature and
routine sources to provide an estimate of the incremental cost per QALY. The
analysis also looks at the variation in cost-effectiveness according to the time delay
to angioplasty. The value of the model for the pilot evaluation is that it can be used to
explore how the cost-effectiveness of primary angioplasty might vary between the
different types of service configuration seen in the pilot centres. In particular, it can
use centre-specific data on costs and times to reperfusion to assess variation in costeffectiveness across different models of service delivery.
We will collect data from the MINAP database and from a micro-costing study at
intervention and control sites to increase the robustness and scope of the costeffectiveness analysis. We will explore how variation in the models of service delivery
influences the cost-effectiveness of providing angioplasty and, working alongside the
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workforce and feasibility evaluations, we will identify factors that determine the true
cost of providing angioplasty.
E. Methods (including the plan of analysis)
Patient and carer experience
In phase 1 we will undertake qualitative interviews with both patients and carers post
discharge. Interviews will be based on a maximum-diversity sample of patients and
carers attending the pilot sites to include different ages, genders, arrival routes, and
living distance from the pilot sites. We will interview between 15 and 25 people in
their own homes using the critical-incident technique24 to determine positive and
negative aspects of key stages of the process, ensuring that we include issues
highlighted within the funding brief. We will also assess the feasibility of using a
postal questionnaire in Phase 2, specifically addressing difficult issues, such as the
identification of carers. We will develop an NIAP-specific instrument for patients, and
one for carers, based on Phase 1, other relevant qualitative studies,23 and evidence
around measuring patient satisfaction.25 We will also use a generic instrument
relevant to patients undergoing emergency care, based on refining the Picker
Institute patient experience questionnaires (www.pickereurope.org), and
questionnaires we have developed in the context of emergency cardiac care.21 The
NIAP-specific instrument is intended to capture views and experiences in detail, while
the generic questionnaire is intended to allow comparison between intervention and
control sites. The Consumer Group will review the questionnaires during their
development and, towards the end of this phase, we will pilot the use of the
questionnaires.
In Phase 2 we will send a postal questionnaire one week after hospital admission to
every patient with ST-elevation AMI, and their main carer, attending four of the pilot
sites over a nine-month period, ensuring that the samples are suitably screened for
severe adverse events. The patient questionnaire will include the NIAP-specific and
generic instruments, the carer questionnaire will include the NIAP-specific instrument
only. We expect a minimum of 75 patients from each site in this time period, totalling
at least 300 patients, and 200 carers (given that not all patients may have carers).
We will aim for a response rate of 75% with two reminders. To provide data for
comparison, we will identify 300 patients with ST-elevation AMI in four hospitals
offering the traditional approach to care based on thrombolysis. We will only post the
generic instrument to patients for direct comparison with pilot-site patients. This
sample size will have 80% power to detect a 0.75 point change on each 5-point
patient satisfaction question (alpha=0.05).21
Phase 3 will involve up to 20 interviews with patients and carers from the two original
pilot sites.
Interviews in phases 1 and 3 will be tape recorded and transcribed verbatim. The
priority of this element of the study is development of the patient and carer survey
and so the main role of the qualitative interviews will be to identify themes, items, and
language for the questionnaire, and elaborate upon findings of the survey. A simple
descriptive analysis, applying the early stages of the Framework approach will be
undertaken to identify emerging themes. A more in-depth qualitative analysis may be
undertaken if the quality of the data and time allow. The general patient questionnaire
will be analysed using SPSS to identify differences in patient’s experiences and
views between the new and traditional services overall. The NIAP specific patient
and carer questionnaires will be analysed using SPSS to identify differences in
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patient and carer experiences and views between the different models of the new
service.
Workforce implications
Staff involved with providing angioplasty services will be identified by prior contact
with the Trust. We will send a questionnaire to relevant staff by internal mail (25-50
anticipated at each site) who will complete this questionnaire during work time. It will
examine the changing aspects of their work role, flexible working and managing a 24
hour service, support and training, teamworking and work factors (e.g. autonomy,
role clarity, influence in decision-making peer and leader support).
This survey will be developed specifically for this study but will use measures found
reliable and valid for health service populations.26 These data will be complemented
by the use of focus groups and semi-structured interviews with key stakeholders to
examine the impact of the angioplasty service on the workforce and explore the wider
implications of providing an emergency angioplasty service, such as cardiologists not
being available for the general medical rota and changes to emergency referral
patterns. Additional focus groups will examine the impact of angioplasty on other
associated workforces (e.g. radiography, ambulance services and the emergency
department). Observational data will be collected, and where this is not possible it will
be collected retrospectively through discussion of cases after treatment.
The questionnaire will be issued to staff two weeks before the site visit. A team of
researchers and a clinician will conduct the interviews (including teamworking
interviews that will examine the exact nature of the service delivery team, how team
members work together and how their specific roles integrate) and focus groups
supervised and trained by a chartered occupational psychologist. The occupational
psychologists will also be responsible for the design and delivery of the questionnaire
survey. The model for the site visit will be piloted within the first six months of the
project (phase one) to enable any practical adjustments to be made. It is anticipated
data will be collected on 6-8 sites during the period September 2006 to March 2007.
Data will be analysed using quantitative and qualitative methods. Themes gathered
at interview and focus groups will be validated by the participant(s). Content analyses
will be used to develop a complete description of the activities that take place during
the treatment of AMI and the challenges this work presents to the workforce, key
stakeholders and the Trust in developing a 24-hour service.
Description of models of service delivery
We will use the following data sources to assemble this information: the NIAP pilot
study database, the MINAP database, the British Cardiovascular Intervention Society
(BCIS) database, the Central Cardiac Audit Database (CCAD), Hospital Episode
Statistics (HES), and routine Department of Health statistics. We will also undertake
a telephone questionnaire survey of each pilot site after one year of operation to
cross-check data from routine sources and obtain data not identified elsewhere. We
will use the site visits to further characterise models of service delivery and explore
whether quantitative descriptions of services reflect staff perceptions of the actual
services delivered.
Implementation and feasibility
Specialist teamworking interviews will be conducted with key members of staff
(supported by data from the staff survey) to describe the size and composition of the
teams and the impact the emergency angioplasty service may have had on
teamworking. In addition, semi-structured interviews and focus groups will be
conducted with staff to explore the issues of implementing the service and factors
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perceived to have facilitated or opposed effective delivery. The site visit will also
allow a period of ethnographic observation/case study exploration of the service
delivery. The timetable for site visits and analysis will be as for the workforce
implications element of the proposal.
Economic evaluation
Data on the time to angioplasty, the time to thrombolysis and the type of thrombolysis
used will be extracted from the MINAP database at all of the intervention sites and
the four control sites. In addition, at four intervention and four control sites we will
undertake micro-costing to measure the true costs of providing angioplasty in
different models of service delivery, and we will check the validity and completeness
of the MINAP data.
At each of these sites, data will be collected on staff costs, equipment, consumables,
drugs and procedures associated with the intervention (angioplasty or thrombolysis).
Resources will be identified in collaboration with staff at the unit. A resource-use
questionnaire will be developed from these discussions, which will subsequently be
administered by a research nurse at each site. Data will be collected on 60 patients
at each site, which is approximately 30% of the annual throughput of patients in each
unit. This will give a total of 240 patients in each arm. Care will be taken to stratify
patients by day and night time admission in order to capture these potentially
important differences. The resource use data will be valued using local unit costs
where available or national unit costs. We will use, as far as possible, centre-specific
cost data, estimated in collaboration with local finance departments using a
standardised protocol.
We will also use the MINAP database to collect centre-specific data on case mix.
This will allow us to develop the model, which currently uses effectiveness data from
clinical trials, to estimate the cost-effectiveness of angioplasty in a typical NHS
population.
All the new data collected will be synthesized with the data in the existing costeffectiveness model and an incremental cost per QALY will be estimated.
Probabilistic sensitivity analysis will be used to address the uncertainty in the input
parameters of the cost-effectiveness analysis. The decision uncertainty will be
described using a cost-effectiveness acceptability curve.
We will develop a regression model using the patient-level cost data and MINAP data
to determine how much of the variation in cost can be explained by differences in the
models of service delivery used, having controlled for case mix. Findings from the
workforce and feasibility evaluations will be used to explain how different models of
service delivery may be associated with different costs. The different costs for each
potential model of service delivery will then be used in the cost-effectiveness model
to explore the relative cost-effectiveness of the different approaches to service
delivery.
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Hartwell D, Colquitt J, Loveman E, et al. Clinical effectiveness and cost-effectiveness
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F. Benefits of this research to the NHS
Primary angioplasty has the potential to save lives and reduce morbidity from heart
attacks and stroke throughout the NHS. However, this potential will only be realised if
appropriate services are established to deliver primary angioplasty, and resources
are used efficiently. Failure to establish appropriate services could result in poor
outcomes, disruption of other key cardiac services, inefficient use of resources or the
development of services that are unacceptable to patients.
This project will have the following benefits for the NHS: Identification of the
important elements of the patient experience and measurement of patient and carer
satisfaction will allow development of services that are acceptable to patients and
carers. Investigation of workforce issues will allow strategic planning so that any
future service development is appropriately staffed and is not detrimental to other
services. Identification of barriers to implementation, and potential solutions, will help
to ensure that countrywide implementation, if undertaken, is appropriate.
Characterisation of different models of angioplasty service delivery that would be
feasible in the NHS will assist planners to develop services that are appropriate for
their local setting. Economic evaluation will assist policy-makers in deciding whether
the costs of establishing primary angioplasty services are worthwhile, compared to a
realistic alternative of an opportunistic use of angioplasty alongside thrombolysis, and
will identify which model(s) of service delivery is (are) most cost-effective.
G. Stakeholder involvement
The Project Steering Group will include a patient representative (Enid Hirst), and
professionals responsible for managing and delivering cardiac (Stephen Campbell,
Rod Stables) and emergency (Jim Wardrope) services. We have also approached
the British Heart Foundation and British Cardiac Patients association for
representatives to assist with project guidance.
Enid Hirst is assembling a consumer group of people who have experience of AMI or
angioplasty to help to guide the project. This group will review the proposal, advise
on any ethical issues arising from the research, help to develop materials for the
patient and carer evaluation, and will provide feedback on outputs from the project.
Evaluation of the National Infarct Angioplasty Project Pilots
Version 001
18/11/2005
H. Plans for the dissemination of results
At the end of the project we will produce an integrated report of the research that will
be sent to the National Co-ordinating Centre for SDO, the National Institute for
Clinical Excellence, the Department of Health, the British Cardiac Society and the
British Cardiac Intervention Society.Copies of the Executive Summary of the report
will be sent to individuals responsible for commissioning and providing acute cardiac
services, patient representative groups, professional organisations involved in acute
cardiac care, and key policy-makers. Copies of the report will be made available to
participants of the studies.
We will build upon contacts developed in previous projects with the Coronary Heart
Disease and Emergency Services Collaboratives to disseminate findings through
meetings, email and personal contacts. We will write scientific articles based on the
findings that will draw wider conclusions regarding the development and organisation
of cardiac services, for presentation at scientific meetings and for publication in
international, peer-reviewed journals, in both the medical and health management
areas.
I. Project Timetable
Description of
service models
Implementation
and feasibility
Workforce
implications
Patient & carer
experience
Economic
evaluation
Month of project
1-3
4-6
7-9
10-12
Collection of routine data
13-15 16-18 19-21 22-24
Survey of
Analysis &
pilot sites
reporting
Piloting site
Data
Analysis &
visit
collection
reporting
(site visits)
Piloting site
Data
Analysis &
visit
collection
reporting
(site visits)
Phase 1
Phase 2 & 3
Analysis &
data collection
data collection
reporting
Set up data
Data collection and
Analysis and
collection and extraction
modelling
extraction
J. Interim Reports
We will produce an interim report at 12 months that will outline the models of service
delivery developed, the results of piloting site visits, early information on patient and
carer needs, initial cost data, and the planned model for economic evaluation.
We will also produce progress reports at 6 and 18 months.