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Type and Title of Submission


Title:

Developing an evidenced based Antiplatelet prescribing Algorithm, and encouraging its usage across Primary and Secondary care.

Description:

A local guideline, in the form of an algorithm (Appendix 1) was developed by a group of doctors and pharmacists from primary and secondary care, with a special interest in Coronary Heart Disease (CHD). The guidance was based on available evidence including SIGN (1.) and NICE (2.) guidance, final draft NICE Technology Appraisals on Clopidogrel prescribing (3,4.) and a Welsh Medicines Resource Centre Newsletter (5.)Since its launch in October 1998, the prescribing of the antiplatelet agent Clopidogrel (Plavix) had grown exponentially across the Locality, to a level significantly higher than the rest of Wales (6.)and there had been concern that, the evidence base (7,8.) did not justify the growth in the use of the drug.

Category:

Clinical

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

TA80;TA90. - Acute coronary syndromes - clopidogrel;Secondary prevention of occlusive vascular events

Category(s) that most closely reflects the nature of the submission:

Implementation policy
Audit tool

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

The chief aim was to identify whether the implementation of an 'Evidence Based Algorithm' could reduce the level of inappropriate prescribing of Clopidogrel, within a general practice population. In addition, this project was an opportunity to improve clinicians' knowledge and hence appropriate prescribing of oral antiplatelet therapies. This in turn would improve patient care, and hopefully reduce side effects.

Objectives

1.Development of the aforementioned algorithm. The guidance was based on available evidence including SIGN (1)and NICE (2)guidance, final draft NICE Technology Appraisals on Clopidogrel prescribing (3,4) and a Welsh Medicines Resource Centre Newsletter (5) . 2. To encourage usage of the algorithm, by both primary and secondary care prescribers. The National Service Framework for Coronary Heart Disease (CHD) recommends that all identified CHD patients receive evidence based care. 3.To develop an audit tool that could be readily applied to primary care computer data systems to capture relevant prescribing patterns with minimal disruption to practices, thereby maintaining any improvements made to safe, appropriate, oral antiplatelet prescribing. This was in keeping with the general practitioners committee (GPC), which recommends that general practitioners (GPs) prescribe both within their knowledge remit and appropriately for their patients' best interests (9).

Context

A local guideline, in the form of an algorithm (Appendix 1) was developed by a group of doctors and pharmacists from primary and secondary care, with a special interest in Coronary Heart Disease (CHD). A pharmacist and clinical leads in primary and secondary care, formed the nucleus project team, and were responsible for raising awareness of the proposals and encouraging implementation of the algorithm. The guideline was piloted by a single large general practice of 16,000 patients to check the feasibility of the review process. The algorithm, national guidance and pilot study findings were then presented and discussed at a meeting of local GPs, pharmacists, and cardiologists. Each practice in the locality agreed to perform a similar review. This would form one of the three actions agreed with the LHB prescribing advisor under the Quality and Outcomes Framework of the New GMS Contract for 2004-05. Sign Guideline 50 (10), outlines methods of improving the likelihood that evidence is put into practise. The proposal had to be 'Bought into' by all relevant prescribers. At a protected learning time session at which many GPs across the locality were present, the clinical leads and pharmacy lead presented the process, and Pilot study findings. Practitioners were encouraged to air their views and queries, over the evidence, the review process and the time/financial implications of the proposal, thus allowing further modifications to the process. Subsequently, it was agreed that this same review process would be repeated by all Practices across the Locality. Within secondary care, a clinical lead 'Championed' the algorithm across all specialities. It was agreed by all consultant staff that the algorithm would be applied to each patient, and that clopidogrel should be made a consultant only prescription. Hospital pharmacists had the authority to clarify the indication and duration of treatment, for each patient prior to discharge.

Methods

1. The Algorithm was successfully developed and utilized across the prescribing community. 2. The audit tool was successfully developed and utilized across Primary care. 3. PACT data shown in the graphs below demonstrate both the initial improvement and the maintenance of this improvement as measured by a reduction in clopidogrel prescribing.

Results and evaluation

PACT DATA for the Prescribing of Clopidogrel across the Bridgend LHB was compared to the rest of Wales. See PACT Data graphs attached.The method of using clinical champions to develop and promote the change process had not been utilized at such a local level. Often there was little cohesive dialogue between the three key providers of health care to the community. The clinical champions and pharmacists debating and amending ideas with their peer groups before agreeing on implementation of the proposal has helped overcome the barriers that commonly exist between the LHB, primary and secondary care. Such a model has been harnessed and applied to other areas, particularly involving redesign of service delivery to good effect. The main outcome was to show an improvement in adherence to the prescribing guideline, thereby ensuring safe, evidence based, effective antiplatelet prescribing, in line with GMC guidance(9.). In primary care as most practices took the opportunity to review those patients taking clopidogrel, it meant that other areas of their medical care (eg lipid management, BP control etc) would have been reviewed simultaneously. It also gave patients the opportunity to discuss concerns about proposed treatment changes. Maintaining good usage, of the algorithm through regular educational updates, and use of the prescribing incentive schemes, have helped prove the sustainability of the project.

Key learning points

Having a small committed project team, with access to a willing 'Pilot Practice', allowed early modification and refinement of the proposal, prior to launching across the locality. For successful cross-boundary changes to occur, 'Champions' with good communicative skills still need a strong, evidence based, relevant message to deliver. Continued adherence to the new proposal, requires continued education. The fact that the algorithm was evidence based, improved patient care, was relatively straight forward to audit, and simple to follow, was championed by 'clinical leaders', being introduced with widespread support by all prescribers, and was linked to financial rewards for participating practices, is in keeping with reasons why protocols and guidelines are followed (10,11.).

View the supporting material

Contact Details

Name:Ian O'Connor
Job Title:GP
Organisation:Oak Tree Surgery
Address:Whitethorn Drive, Brackla
Town:Bridgend
County:Mid-Glamorgan
Postcode:CF31 2PQ
Phone:07974737975
Email:Ian.O'Connor@gp-w95010.wales.nhs.uk

 

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This page was last updated: 30 September 2009

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.