This project won the RCGP North West Faculty Audit Prize Award – 2019.
This example describes the completion of an audit of ticagrelor prescription at Leigh Family Practice, assessing adherence to current NICE guidance (TA236) and offering recommendations based on the results of the audit.
The NICE guidance (TA236) recommends in Section 1.1 Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months as a treatment option in adults with acute coronary syndromes (ACS) that is, people:
• with ST-segment-elevation myocardial infarction (STEMI) – defined as ST elevation or new left bundle branch block on electrocardiogram – that cardiologists intend to treat with primary percutaneous coronary intervention (PCI) or
• with non-ST-segment-elevation myocardial infarction (NSTEMI) or
• admitted to hospital with unstable angina – defined as ST or T wave changes on electrocardiogram suggestive of ischaemia plus one of the characteristics defined in section 1.2.
Before ticagrelor is continued beyond the initial treatment, the diagnosis of unstable angina should first be confirmed, ideally by a cardiologist.
Aims and objectives
The aim of this study is to complete an audit of ticagrelor prescription at Leigh Family Practice, assessing adherence to current NICE guidance and offering recommendations based on the results of the audit.
1). To determine which patients currently registered to the practice are on ticagrelor treatment for ACS.
2). To determine which of those patients have been on the medication for over 12 months (if they have been has it been directed by specialist?)
3). To outline whether every patient has a stop date to their ticagrelor prescription.
4). To discuss with clinical and non-clinical staff in the GP practice as to factors that affect compliance with NICE guidance.
5). To offer recommendations based on the findings of the audit.
Reasons for implementing your project
Aspirin is generally offered to all patients after myocardial infarction and this is continued indefinitely unless they are aspirin intolerant or have an indication for anticoagulation.
A second antiplatelet, such as ticagrelor, is often offered in combination with aspirin for a defined period of time, generally up to 12 months.
There have been many reports of people continuing on dual antiplatelet therapy beyond the recommended time limit because of a lack of clarity about the duration of co-prescribing. This can lead to adverse unintended consequences for the patient taking the dual antiplatelets.
How did you implement the project
A search for all patients currently on ticagrelor was conducted followed by a comprehensive analysis of each patient records assessing when they were first prescribed the medication, what the indication was for prescription, whether any specific instructions for duration of treatment were made and whether patient had a stop date for the treatment in place.
Performance was measured by outlining the results of the audit and comparing them to a standard that was set.
Finally, recommendations based on the results of the audit would be made and a re-audit would be following the recommendations.
- 0% patients should receive dual therapy for greater than 12 months without a valid indication.
- 100% patients should have a stop date on the prescription unless there is a valid indication to continue therapy.
- One patient has received dual therapy for greater than 12 months without a valid indication 1/8 = 12.5%.
- Only 5 patients had a stop date on the prescription 5/8 = 62.5%.
The findings of this audit show that in the practice did not meet the standards set out. A patient was found to have been on ticagrelor for longer than the recommended time set out in NICE guidance and stop date not added in case of three patients.
- The patient who have had dual therapy for greater than 12 months without a valid indication should have medical review and ticagrelor stopped.
- The three patients who have no stop date should have this added on their medication comments and review date set to reflect this.
- Clinicians should add a stop date when initiating this medication in future unless there is a valid reason otherwise.
- This audit should be repeated in two months’ time.
After discussing all of the recommendations outlined above a re-audit of the practice was carried out the results of which are as follows:
- How many patients are currently prescribed dual antiplatelet including ticagrelor = 7.
- How many of the patients identified in question above have been prescribed dual antiplatelet therapy for greater than 12 months? = 0.
- How many of the patients identified in question above prescribed dual antiplatelet therapy for greater than 12 months have a valid indication for continuing therapy beyond 12 months documented within the patient’s notes or discharge letter? = 1.
- How many of the patients on dual antiplatelet therapy have a stop date on the prescription? = 7.
- No patient has received dual therapy for greater than 12 months without a valid indication 0%.
- All the 7 patients had a stop date on the prescription 100%.
Key learning points
This first audit cycle identified the patient who had had dual therapy for greater than 12 months without a valid indication, the patient had a medication review and ticagrelor stopped.
All patients on the dual antiplatelet therapy who had no stop date in the first audit cycle were identified and this was added on their medication comments and review date set to reflect this.
This audit will be repeated in 12 months’ time to ensure a sustained improvement and strict adherence to the guidance.