Twenty one GP practices across Fylde and Wyre CCG agreed to participate in a project which gave local priority for medicines optimisation around atrial fibrillation. The focus was on appropriate anti-coagulation and safe introduction of NOACs (new oral anti-coagulants).
This example was highly commended in the 2015 NICE Shared Learning Awards.
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 This guidance has been updated and replaced by NG196.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
Aim: to increase anti-coagulation in atrial fibrillation (AF)
- to identify patients not currently on AF registers
- to identify patients with AF and a CHADS2VASC2 score >2 not on an anti-coagulant
- to optimise best treatment, especially patients prescribed anti-platelets
- to offer education and information about management with anti-coagulants
- to offer patients time and expertise to discuss concerns about anti-coagulants
- to offer a shared learning approach to clinical staff with regard to AF and anti-coagulants.
Reasons for implementing your project
The starting point was to identify AF as a CCG priority. In 2012/13 the Fylde and Wyre CCG Practice Pharmacist Team, led by the Prescribing Support Manager, had worked on identifying and titrating up medication for people with heart failure. It seemed appropriate to continue this work and to add in AF, as many people have both conditions concurrently. The education and training element of the programme was presented to the CCG board and formally agreed. The project was then included in the CCG commissioning plan.
We carried out a baseline assessment of the AF registers and identified the numbers of people prescribed the different groups of drugs. These figures showed that there was the potential to reduce the risk of stroke by increasing the prescribing of anti-coagulants.
The population of Fylde and Wyre CCG is in the order of 150,000, with a higher than England average of people aged over 65. The prevalence of AF was already known to be high, so the focus was on optimising treatment, rather than increasing numbers of patients on the registers.
How did you implement the project
We developed an action plan which identified joint AF learning across primary and secondary care as a priority. We developed practice support materials to provide a unified approach.
Individual pharmacists then talked to each practice about the benefits to get their support for the project. All practices gave a commitment to data collection to ensure that outcomes were accurately measured. The data collection form was designed and completed by the practice pharmacist.
Consistency was achieved by having a protocol for the searches and data requests from the practice systems. We wanted to check that AF was not under-reported so utilised the AF Casefinder Miquest search software. This was easily run in general practice to find patients with AF who were not coded correctly and identify them as probable or possible AF patients.
Once the AF register was updated we ran the GRASP-AF tool through all the practice systems. This interrogated the records of patients on the AF register and identified their stroke risk (CHADS2VASC2) and antithrombotic therapy (antiplatelet, warfarin, NOAC or none). This helped practices identify and prioritise patients who were not being appropriately anticoagulated. These patients identified as not on an oral anticoagulant were invited to attend a clinic. These were organised in localities, for those practices happy to join together.
The Apodi AF clinics were designed and tailored to meet the CCGs requirements and excluded people already taking warfarin. They were held in the GP practices using spare capacity on a Saturday. The practices provided patient summaries and the clinics involved a nurse triage with education regarding both AF and stroke risk. The nurse carried out all necessary tests including blood pressure and pulse and calculated the relevant risk scores in clinics (CHADS2VASC2 and HASBLED). Each patient was then seen by a local cardiology consultant where they had the opportunity to discuss in detail the risks and benefits of anticoagulation with warfarin and NOACs. Time in clinic was approximately 45 minutes per patient.
Patients were asked to complete a satisfaction survey with PROMs. The main barrier we encountered was patients unwilling to start any oral anticoagulation therapy.
The main cost the project incurred was investment in NOACs, which are approximately £700 per patient higher than the prescribing of warfarin. This has put pressure on the prescribing budget, offset by disinvesting in other areas.
489 patients were invited to the clinics (after removal of vulnerable or inappropriate patients).
239 patients attended the 10 clinics.
There were 25 DNAs (i.e. approx. 2 per clinic).
48% of the patients who were invited attended the clinics.
- Number of patients on no anticoagulation therapy: Pre-clinics: 39 Post clinics: 14
- Number of patients on antiplatelet therapy only: Pre-clinics: 156 Post Clinics: 60
- Number of patients recommended NOAC anticoagulation: Pre-clinics: 0 Post clinics: 27
At the end of each clinic a list of recommendations was given to each participating GP practice. This included CHADs2VASC2 and HASBLED scores, which were then recorded on the patient record with a summary of the discussion with the patient.
A summary of the outcomes to date is below:
Feedback from nurses running the clinics
1. Most patients knew about what AF was and could define it sufficiently however many did not link it to stroke risk.
2. The patient education sessions supported knowledge around subjects such as vascular disease and stroke risk that can be hereditary.
3. Most patients enjoyed the group education and most added to the session providing their own examples of symptoms and sharing experiences which was reflected in the PROM report.
4. Many patients appreciated the discussions around diet and foods to be cautious of when taking warfarin.
5. There were a lot of positive comments on the basic language used to describe the heart pumping illustration and they found that useful.
6. Patients appreciated the support from the practice for managing this condition and time to ask questions with a dedicated nurse specialist.
Summary of PROMS
- 99% of patients found the experience beneficial.
- 85% of patients said they would attend a further AF clinic.
- 84% of patients said they found the education sessions useful.
- 74% of patients said they would find other education sessions useful.
- 93% of patients would recommend the AF clinic to others.
Data is still being collected across the participating practices but initial findings from 11 practices show that 36 additional patients have been added to AF registers from the casefinder software search and 40 additional people have been anticoagulated.
Key learning points
- Accurate AF registers mean that people are not missed
- Micquest searches made the data collection process efficient and accurate
- Low numbers are still significant in terms of stroke prevention
- Involving patients in decision making earlier in the process increases their willingness to consider and accept anticoagulation and takes into account adherence issues prior to prescribing.
- Clear records of the rationale for refusal of OAC treatment is helpful in following up and re-offering OAC treatment at a later date, including discussion of risk and benefit.
- Data to support QOF has been collected
- This managed approach has improved NOAC uptake from a patient safety perspective
- A unified team approach for the project, putting the evidence base into practice
- Clear agreement and protocols with the company carrying out the clinics
- Manual pulse checks should be undertaken in chronic disease clinics to support identification of AF.
Next steps: we are now planning to look at those patients who are not achieving time in therapeutic range on warfarin.
Yes. Apodi sponsored a small number of consultant-led clinics to the specification of the CCG. No funding was received directly.