Improving anticoagulation in patients with atrial fibrillation using the GRASP AF audit tool (part of the GRASP suite of tools delivered by PRIMIS in partnership with NHS England)

The aim of the project was to optimise anticoagulation for stroke prevention in patients with AF, based on anticoagulation recommendations in NICE guidance.

Objectives included:

 • To identify patients not being treated according to NICE guidance (i.e. those treated with antiplatelet monotherapy for stroke prevention and those not receiving anticoagulation despite a CHA2DS2-VASc score of ≥2)

• To reassess treatment in these patients, and alter prescribed medication in line with NICE guidance

• To assess the impact of the changes made in terms of adherence to NICE recommendations and the number of expected AF-related strokes in the area.

AF is a major risk factor for stroke, and people with AF who have strokes are more likely to suffer serious long term disability than other stroke patients.(1, 2) Oral anticoagulation is three to four times more effective than aspirin in preventing AF-related stroke, with no reported increased risk of bleeding compared to aspirin.(3, 4) However, around a third of patients at high risk of stroke are still being treated with antiplatelet monotherapy for stroke prevention.(5) That’s why West Hampshire CCG decided to make optimal anticoagulation in AF a priority in its stroke prevention activities. An audit of all 51 practices in the CCG in September 2014 identified 10,813 patients with AF at high risk of stroke (CHA2DS2-VASc score >1).

In this group:

• 3,893 people (36%) were receiving antiplatelet monotherapy or no treatment

• 4,758 people (44%) were not receiving treatment with oral anticoagulants

• 167 AF-related strokes were expected per year

(1) British Medical Association. General Medical Services (GMS) contract Quality and Outcomes Framework (QOF). Guidance for GMS contract 2014/15 (2) Gladstone DJ, Bui E, Fang J, Laupacis A, Lindsay MP, Tu JV, et al. Potentially preventable strokes in high-risk patients with atrial fibrillation who are not adequately anticoagulated. Stroke. 2009;40(1):235-40. (3) Hart RG, Pearce LA, Aguilar MI. Meta-analysis: Antithrombotic Therapy to Prevent Stroke in Patients Who Have Nonvalvular Atrial Fibrillation. Annals of Internal Medicine. 2007;146(12):857-67. (4) Mant J, Hobbs FDR, Fletcher K, Roalfe A, Fitzmaurice D, Lip GYH, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. The Lancet.370(9586):493-503. (5) AFA Association. Grasp the initiative: action plan. 2014.

We worked with PRIMIS and West Hampshire CCG to train practice staff (including GPs, practice nurses, pharmacists and pharmacy technicians) to use the GRASP-AF audit tool.

This began with technical training for 40 practice managers and IT leads on how to download, install and run the tool. Following on from this, the West Hampshire project team organised evening education meetings for 80 GPs.

These covered the need to change local habits, how to navigate the GRASP-AF reports to find priority patients, and advice on best practice from haematology, cardiology and stroke consultants. All 51 practices in West Hampshire ran the GRASP-AF audit tool following the training. After this, they carried out appropriate clinical improvement work, including offering patients oral anticoagulants if appropriate.

All practices ran the GRASP-AF audit tool again in March 2015 to assess the improvement achieved at individual practice level and across the CCG as a whole.

There were some barriers at the start of the project, for example some practices had difficulty downloading and understanding the software. We overcome this by directing practices to the PRIMIS helpline for support. The time required to run the audit was also a problem initially, although practices became more familiar with the tool throughout the project. After training from PRIMIS most found the second audit straightforward to complete. The project cost £2,500 to implement; this was provided by Boehringer Ingelheim as a Medical and Educational Goods and Services grant.

Progress was monitored by a second audit, using the GRASP-AF audit tool. This showed improvements in a number of key metrics:

• Reduction in the number of untreated patients and patients receiving antiplatelet monotherapy. 345 fewer patients (4%) were receiving antiplatelet monotherapy or no treatment at the second audit (March 2015) than in the first audit.

• Increase in the number of high-risk patients receiving oral anticoagulants. 741 more high-risk patients (5%) were receiving treatment with oral anticoagulants at the second audit, compared with the first audit.

• Increased compliance with NICE guidance, as a result of reduction in patients receiving antiplatelet monotherapy for stroke prevention and increase in high-risk patients (CHA2DS2-VASc score >2) receiving oral anticoagulation.

• Reduction in total expected AF-related ischaemic strokes. The second audit showed a 10% reduction in expected strokes per annum, compared with the first audit. This means 16 expected strokes avoided per year. Furthermore, from April to July 2015 there were seven fewer actual strokes than in the same period in 2014. This is a significant cost saving, given that one stroke is estimated to cost around £11,000 (£44,000 including social care costs).

The involvement of all stakeholders (CCG, GP practices, Boehringer Ingelheim and PRIMIS) was the most important factor in the success of the project:

• The Medicines Management team facilitated the running of the audit tool in practices. They also held whole practice meetings to discuss the results and helped formulate an action plan for improvement in each practice.

• Practices took ownership of running the audit and in implementing the action plan for improvement.

• Boehringer Ingelheim and PRIMIS provided technical support at the practice meetings, and made sure that stakeholders were engaged and communicating effectively. The project was a team effort, with all stakeholders working together to improve the lives of patients in West Hampshire.