Commissioning an anticoagulation therapy service

Anticoagulation therapy is most commonly required for patients at high risk of thromboembolism, either following an episode of venous thromboembolism or in those with atrial fibrillation (AF) or prosthetic heart valves.

AF is the most common sustained cardiac arrhythmia, and if left untreated is a significant risk factor for stroke and other morbidities. It is often only detected after patients present with serious complications of AF, such as stroke, thromboembolism or heart failure. Patients with AF who develop a stroke have greater mortality, more disability, more severe strokes, longer duration of in-hospital stay and a lower rate of discharge to their own homes ^[1],^[2],^[3]. Appropriate anticoagulation therapy (adjusted-dose warfarin) in people with AF can reduce mortality and morbidity^[4].

Benefits

The potential benefits of robustly commissioning an effective anticoagulation therapy service include:

• ensuring that appropriate patients receive anticoagulation therapy and monitoring promptly, which should be in line with the national service framework for coronary heart disease, and for patients with AF the
• reducing the risk of thromboembolic stroke in AF, which may impact positively on stroke service requirement and NICE clinical guideline CG36 on AF capacity
• reducing inequalities in access to anticoagulation therapy
• improving anticoagulation control in patients, and reducing drug-associated complications
• better value for money, through helping commissioners to manage their commissioning budgets more effectively and implementing more cost effective treatments - this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

Key clinical issues in providing an effective anticoagulation therapy service are:

• accurately identifying all patients with AF who require anticoagulation therapy in line with the NICE clinical guideline CG36 on AF according to the stroke risk stratification algorithm
• providing effective anticoagulation therapy
• providing a quality-assured service
• ensuring there is ongoing monitoring to reduce bleeding risk.

National priorities

National priorities and initiatives relevant to commissioning an anticoagulation therapy service include:

• World class commissioning.
• The NHS in England: The operating framework for 2009/10.
• Providing appropriate evidence-based care for patients with AF; see standard 5 and chapter 8 (Arrhythmias and sudden cardiac death) of the national service framework for coronary heart disease, and also the NICE clinical guideline CG36 on AF
• The National enhanced service for anticoagulation therapy.
• The Care closer to home initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• Considering the impact of patient choice.
• The Expert patients programme.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with Standards for better health.

Although many or all of these priorities above may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

¹ Wolf PA, Abbott RD, Kannel WB (1991) Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 22 (8): 983-988.

² Lin HJ, Wolf PA, Kelly-Hayes M et al. (1996) Stroke severity in atrial fibrillation. The Framingham Study. Stroke 2: 1760-1764.

³ Jorgensen HS, Nakayama H, Reith J et al. (1997) Stroke recurrence: predictors, severity, and prognosis. The Copenhagen Stroke Study. Neurology 48: 891-895.

⁴ Lip GY, Tello-Montoliu A (2006) Management of atrial fibrillation. Heart 92 (8): 177-82.