The Anticoagulant Programme East London (APEL), rolled out in Tower Hamlets, City & Hackney and Newham, aimed to increase the proportion of people with atrial fibrillation (AF) treated appropriately with anticoagulants. It also aimed to reduce inappropriate antiplatelet therapy, using three synergistic interventions to alter professional behaviour: altering professional knowledge and belief by summarising local stakeholder consensus on new evidence and NICE guidance with related education; facilitating change with computer software supporting clinical decisions and patient review optimising anticoagulation; and motivating change through evaluative feedback showing individual practice performance relative to peers.
This example was originally submitted to demonstrate implementation of NICE CG180. This guidance has been updated and replaced by NG196. This example continues to align with recommendations in the updated guidance. The guideline NG196 should be referred to if replicating any aspect of this example.
Aims and objectives
The aim of this initiative was to increase the proportion of people with AF treated appropriately using anticoagulants, and reduce inappropriate antiplatelet therapy in three inner east London primary care trusts (PCTs): City and Hackney, Newham and Tower Hamlets in line with the NICE guidance on the management of atrial fibrillation.
UCL Partners is adapting and diffusing this work to support improvement in anticoagulation across 21 CCG partners with a population of 6 million, initially starting in Camden and Enfield. The aims of this programme of work are to:
1) improve at scale an increase in anticoagulation
2) ensure that patients and clinicians are better informed about person-focused diagnosis, treatment and management of AF.
We will evaluate the health outcomes for the population as well as assess the engagement and motivation of patients and clinicians. To complement this work and to drive sustainable and continuous improvement work has recently commenced on scoping the need for a capability programme to support primary care and defining an evidence based educational package.
Reasons for implementing your project
Over the last 10 years, the increase in the proportion of people with AF on anticoagulants has been slow at around 1% per year, with only 50% receiving anticoagulant treatment in 2011. In the period before the intervention, between April 2008 and April 2011, in all three inner east London PCT's combined, the proportion of people with CHA2DS2-VASc >1 on an anticoagulant increased slowly from 50.8% (1943/3825) to 52.6% (2085/3964): a non-significant increase of 2.2% in 3 years. The Anticoagulation Programme East London (APEL) was started in April 2011. It aimed to improve antithrombotic treatment of AF by altering professional knowledge and beliefs, influencing clinical activity, and increasing motivation.
How did you implement the project
The APEL programme started in April 2011 with the aim of influencing improvement in antithrombotic treatment of AF by altering professional knowledge and beliefs, influencing clinical activity and increasing motivation. Changing professional beliefs required provision of new summary clinical guidelines with associated peer education. The Clinical Effectiveness Group at Queen Mary University of London, which is funded by the PCT's to support quality improvement, helped develop new summary guidance with local stakeholders (GP's, consultants, and prescribing advisers). This was published and sent to all participating practices and made available online. The guidance was also accessible in the routinely used GP clinical record, such that a single click on the data entry template opened up the guidance or decision support algorithms. Peer education consisted of a multidisciplinary primary care team meeting in each of the three localities to discuss the evidence and implementation of improvement in AF anticoagulation.
The new guidance was supported with software tools to improve decision making and implementation of care pathways for reviewing and assessing patients with AF and changes in their treatment.
Software included the APEL tool, which was installed on all practice computers and practice staff taught how to use it. This provided an accessible summary of treatment status of individual patients with AF and overall practice performance. This included relevant details such as co-morbidities, palliative care, housebound, serious mental illness, alcohol use, falls, bleeding, non-steroidal anti-inflammatory drugs, and the CHA2DS2-VASc, CHADS2 and HAS‑BLED scores. Standard data entry templates were used by all practices to ensure fidelity and completeness of coding. 'Pop-up' on-screen computer prompts were used by some practices as reminders if patients were on aspirin or no treatment. In April 2011, a baseline audit was circulated to practices that showed the proportion of patients with AF on anticoagulants and aspirin so that comparisons could be made between identifiable practices in the locality. Financial incentives may further improve performance but were not used in the current study. Finally, an audit of current use of anticoagulants and antiplatelet agents was sent to every practice showing their performance in relation to the other identifiable practices in their PCT. They could see how they were doing in relation to their peers.
Data were available from 139/143 practices in the three inner London Boroughs of Newham, City and Hackney, and Tower Hamlets. Four practices could not contribute because they used a different computer system.
Before the intervention between April 2008 and April 2011, in all three PCT's combined, the proportion of people with CHA2DS2-VASc >1 on an anticoagulant increased slowly from 51% to 53%, a non-significant increase of 2.2% in 3 years.
After the intervention which started in April 2011, the proportion of people on anticoagulants increased from 53% in April 2011 to 60% by April 2013, an increase of 7.2% in 2 years. P<0.001.
In people aged >80 years or over, anticoagulant prescription 2009 to 2013 increased by 9.0% (from 45.3% to 54.3%), whereas for people <80 years="" it="" increased="" by="" 6="" from="" 52="" to="" 59="" 2="" br=""> Before intervention the proportion of people with CHA2DS2-VASc >1 on antiplatelets showed little change in the period 2008 to 2011, 39% to 38%. From April 2011 there was a decline in antiplatelet use from 38% to 30%; a reduction of 7.4%. P<0.001).
The proportion of people with AF on neither anticoagulants nor antiplatelet agents was 10.3% in April 2008 and 9.9% in April 2013, and did not change significantly.
Key learning points
This study covers three entire local health economies in some of the most socially diverse and disadvantaged boroughs in the UK, indicating the feasibility of improvement even in challenging local circumstances. No patients were excluded from this study. The interventions (guidance, education, software enhancements, and evaluative feedback) are potentially available within every CCG and are generalisable. The initial involvement and cooperation of all stakeholders (haematologists, cardiologists, community and hospital prescribing advisers, PCT managers, GP's and their practice teams) was an essential part of the intervention, requiring a series of meetings and consultations to ensure that the strategy and content are agreeable to all participants. Clinical cardiovacsular leads in each CCG became active local 'champions' promoting clear objectives and actions. Since the end of the programme, financial incentives have been added to anticoagulation targets to support further improvement in two of the CCG's.
There are two home advantages in east London. Almost all practices use a single web-enabled computer system (EMIS), which permits access to standard data entry templates, prompts, software tools such as the APEL tool, and evaluative reporting. This was of considerable benefit to this project. However, this functionality is potentially replicable across all computer systems, but may take more time to implement where CCG's use a diversity of systems. The Clinical Effectiveness Group was important in helping to co-ordinate work with GP's, PCT managers, prescribing advisors and hospital consultants to devise a coherent plan including IT support to practices and the evaluation audits. This academic partnership may be a local factor in improvement.