Patient centred angina care: A pragmatic model

The multi award winning and internationally acclaimed National Refractory Angina Centre (NRAC, pronounced en-rak) is a pioneer of modern consumer-centred service design and delivery. Over the past decade NRAC has evolved to meet the needs of the growing population of chronic stable angina sufferers for whom revascularisation is either technically unfeasible and (increasingly) those patients, having considered all the evidence, decide the risks of revascularisation aren’t worth it.

In other words NRAC is an NHS service designed for angina patients who cannot have a heart operation for one reason or another and patients who want to avoid an operation if it is possible. Unfortunately, most patients think there is no option and and undergo risky and expensive heart procedures without realising that simple and safe alternatives are available.

The care pathway provided at NRAC closely follows accepted regional, national and international guidelines ([i],[ii],[iii],[iv]) NRAC is presently the only NHS specialist service to offer the entire range of evidence-based treatment options for patients suffering with chronic refractory angina. Consistent with the current SIGN angina guidelines, NRAC’s care pathway begins with education, comprehensive rehabilitation and cognitive behavioural interventions where appropriate.

It is a sad fact, acknowledged by the American Heart Association, the European Society of Cardiology and the Healthcare Commission, that patient education is badly neglected. In our experience, many patients, who have undergone heart procedures, improve dramatically simply by understanding the truth about their condition. Patients invariably say that they wish they had learned more at the outset of their condition.

The secret of our success is that we have actively sought feedback on the service from every patient every day and modified how we did things in-line with their suggestions. Over time the service has evolved into the sort of service that patients genuinely want. We have recorded satisfaction scores from every patient since 2003 and the running average is over 97%.

How do we do it?

We valued our patients' feedback and made time to LISTEN and EXPLAIN. New patient clinics invariably take 2 hours and follow up clinics take an hour with a consultant.

Far from being an unaffordable luxury we have found that this amount of time is necessary to help patients get control of their lives. In the long run this is much less expensive than the rushed outpatient clinics that are the rule.

Audit and published research shows that enrolment in NRAC is associated with a clinically and statistically significant improvement in symptoms and quality of life, substantially fewer hospital admissions and only a minority of patients choose to proceed to invasive procedures, like bypass or angioplasty and stent (,[v][vi]). High-cost interventions such as spinal cord stimulation (SCS) or Enhanced External Counter Pulsation (EECP) can help and can be offered after proper consultation with the patient’s specialist commissioning team. Overall the costs saved are staggering.

See www.angina.blog.co.uk/ or www.anginablog.blogspot.com/

References

[i] http://www.cmcn.nhs.uk/guidelines/stable_angina.html
[ii] http://www.angina.org/
[iii] www.escardio.org/guidelines
[iv] SIGN guidelines on stable angina 2007
[v] Moore RK, Groves D, Bateson S, Barlow P, Hammond C, Leach AA, Chester MR. Health related quality of life of patients with refractory angina before and one year after enrolment onto a refractory angina program. European Journal of Pain. 2005;9:305-10
[vi] Moore RKG, Groves DG, Bridson J D, Grayson AD, Wong H, Leach A, Lewin RJP, Chester MR. A Brief Cognitive-Behavioral Intervention Reduces Hospital Admissions in Refractory Angina Patients J Pain Symptom Manage. 2007 Mar;33(3):310-316