# Delivering Integrated Neurology HealthCare Dr. Zameel Cader 15 - PowerPoint PPT Presentation

# Delivering Integrated Neurology HealthCare Dr. Zameel Cader

15 million people in England (of which 7 million are migraine) – more than 1:4 have a neurological condition. Over half a million people are newly diagnosed each year • 38% Real-term increase in annual spending between 2006-7 & 2009-10 • 31% Increase in neurological inpatient admissions between 2004-5 & 2009-10, compared to 20% for the NHS as a whole • 32% Increase in emergency neurological admissions to hospital between 2004-05 & 2009-10, compared to 17% for the NHS as a whole.

Admission rate per 100,000 – Total elective and non- elective admissions with a primary or secondary diagnosis across conditions 2009/10 to 2012/13 across TVSCN Admissions per 100,000 across TVSCN 300 275 268 252 246 238 250 225 209 202 200 138 150 130 129 129 127 120 113 104 100 50 34 34 25 25 25 25 24 23 12 12 11 11 0 Epilepsy Headache and MS MND Movement Muscle Disorders ABI Migraine Disorders 2009/10 2010/11 2011/12 2012/13 Highest admissions across the area are for Epilepsy

Total elective and non elective costs 2009/10-2012/13 Costs of admissions across 2009/10-2012/13 $30,000,000 $25,000,000 $20,000,000 $15,000,000 $10,000,000 $5,000,000 $0 Epilepsy Headache and MS MND Movement Muscle ABI Migraine disorders disorders Elective Non Elective Costs across elective were just under £42 million for elective admissions across these 7 conditions and just under £75 million for non elective admissions equating to overall costs of £ 116,710,689 over four years in Thames Valley.

Top co-morbidities by disease category Disease Indicator Top Categories Total Spend Epilepsy Infections (UTI, RTI) £2,548,922 Headache & Migraine Pregancy related, syncope & UTI £1,125,214 Multiple Sclerosis Infections (UTI, RTI) £1,172,160 MND Infections (UTI, RTI) £203,082 Movement Disorders Infections (UTI) NoF & Senility £3,839,907 Muscle disorders Infections (UTI, RTI) £249,059 Neuropathy Infections (UTI), Ulcers (ll) £360,144 ABI Subdural Haemorrhage, SAH, Diffuse Brain Injury £1,291,356 The majority of comorbidities involve UTI

Outpatient Neurology • In DGH, e.g. RBH – Neurology is already CCG commissioned • In tertiary neuroscience centres, all Neurology is Specialist Commissioned (Wessex) – This will change in April 2015 when GP referrals will be CCG commissioned • Very difficult to obtain outpatient data because no outpatient coding

Outpatients NEUROLOGY GERIATRICS STROKE Attendances (1) 1.1 million 478,000 18,000 First (1) 426,000 185,000 8,000 Subsequent (1) 652,000 292,000 9,700 DNA (2) range (by Between 1.7% to provider) 20.0% Source: 1 Hospital Outpatient Activity - 2012-13 (Published 12/12/2013) – Treatment Speciality.xls 2 Compendium of Neurology Data, England - 2012-13 (Published 20/03/0214) – comp-of-neur-data-hes-out.xlsx – Table 21

Costs • OUH actual spend for 13/14 was £5,343,098 for neurology outpatients – New- £2,958,706 – F/Up - £2,384,392

‘Data is not being routinely used to inform service planning and provision across the pathway of care’ GP Practice 1 2 3 4 5 Total num of patients 7,836 4314 5472 3174 2945 (18y+) 995 917 732 493 909 Num of HA patients Num of headache 1.55 2.68 1.76 2.07 3.49 codes per patient Num of any diagnosis 19.94 29.00 40.12 35.64 30.05 code per patient - 2,857 127 4,801 1,708 SUS episodes t-1yr £- £475,383 £26,967 £1,024,232 £422,498 SUS cost t-1yr 1,303 2,267 4,166 7,361 2,196 Consults t-1yr Num of prescription 28.48 49.66 51.07 35.19 33.07 items -1yr per patient Prescription items t- 8.03 9.27 10.81 9.41 6.44 1yr per patient

Neurology Patient Flows Patient GP General Specialist ED Neurology Neurology Imaging/Investigations

The Burden of Headache 6.7 million people living with migraine in England (Neurological Alliance, 2014) • 80% have disabling attack interfering with work, home, socialisation (Steiner 2005) – Leading cause of neurological disability (World Health Report, WHO 2001) – The most prevalent neurological LTC (>diabetes+asthma+epilepsy) – 4% of adults consult a GP each year for headache/migraine (Latinovic et al. 2006) • Direct cost to the NHS: £1 billion per year (Ridsdale 2007) • GP consults and medications: £468 p.p per year – Gross under-estimate as frequent comorbidity with anxiety/depression – 80% of all admissions for headache are emergency (HSCIC 2013) • Commonest neurological reason for A&E attendance – 1 in 5 headache patients in Neurology O/P have attended A&E in last 6 months (Gahir et – al. 2006)

GP Management of Headache >95% of headache seen by NHS managed by GPs • 5 in every 100 patients see GP for headache • 4% of these referred generating 25% caseload for Neurology • outpatients Analysis of ~90 000 patients in GP records database (1987-2005), • Kernick and Stapley 2008 – 70% of patients did not receive a diagnosis – 24% diagnosed with primary headache disorder – 6% were diagnosed as secondary headache • >80% sinus headache – but when reviewed most of these meet criteria for migraine

Why are patients referred? • Patients and GPs’ are worried about secondary headache caused by brain tumour • Risk of tumour is 0.15% • Main difference between referred and non- referred group are anxiety about cause of headache and number of GP consults for the headache (Ridsdale 2007) – No difference in levels of disability caused by headache

What happens in Neurology Outpatients • Aside from anecdote, largely unknown – What proportion patients needed a referral? – What proportion of patients have imaging appropriately – What proportion of patients are followed-up – What proportion of patients with primary headaches have correct management and significant improvement in headache burden

Goals for optimum headache care provision • Emergency and urgent headaches (e.g. meningitis, SAH, stroke, tumour) are referred and seen quickly • Patients with headache seeking help from NHS achieve a diagnosis (note 70% non-diagnosis) – most likely to be migraine • Majority of patients with primary headaches are effectively self-managed or through their GP • Medication overuse is minimised

Improving Patient Self-Care Patient Support Patient Education Days Groups Expert Patient Charities Headache Ambulance Community Service Pharmacy Nurse Encouraging local patient • networks Patient awareness days • Signposting resources • Web and social media • Local fundraising • Patient Champions •

Benefits of an empowered patient group • Patient experience improves • Reduce significant burden upon GP practice, A&E and Neurology outpatients • More compliant with medication and less liable to medication overuse

Improving First Contact Patient Clinical GP Decision GP Trainin Support Tool g • Improve headache GPwSI diagnosis • Improve treatments • Reduce re-attendance • Reduce medication overuse • GP champions

An Integrated Headache Service Education/Patient support meeting facilitated by specialist team • and run by patient expert(s) Nurse led telephone or physical clinics for all follow-up visits • Clinics operated in GP practice by GPwSI and outreach Consultant • clinics GP training events • Rapid Intervention team to prevent emergency admission arising • through severe pain Advice telephone/email service for patients and GPs •

Adapting model for other neurological conditions • Common neurological conditions may benefit from an integrated service with up-skilling of patients and GPs • E.g. – Funny turns and fits – Movement disorders

Integrated Neurology Service Education/Patient support meeting facilitated by specialist team • and run by patient expert(s) Nurse led telephone or physical clinics for all follow-up visits • Clinics operated in GP practice by GPwSI and outreach Consultant • clinics GP training events • Rapid Intervention team to prevent emergency admission • Advice telephone/email service for patients and GPs •

Rapid Community Intervention: URGeNT Emergency admissions where neurology is secondary diagnosis is • major cost for neurology – ~116 million GBP over 4 years in the Thames Valley Principal primary diagnosis is UTI or Pneumonia • Rapid intervention may prevent unnecessary admissions and make • significant impact on costs through reduced admissions or LOS URGeNT: Urgent Response General Neurology Team • – A team of neuro/chest physio’s & nurses who could respond to a pt. within 12hrs 7 day- a- week service – Need identified by Neurology LTC (MS, PD, MND..)

Proposal • Develop a neurology clinical decision support tool to be implemented on GP systems and/or mobile device for use by ED nurses/doctors • Establish a headache service to demonstrate benefit of integrated care: – Headache nurse and consultant with outreach clinic – Headache GPwSI – Email/Telephone support service for patients and GPs • Implement URGeNT