We identified patients in each practice with AF who were not treated according to the NICE guidance for Atrial fibrillation management (CG180).We then designed a template for practice systems, with links to the NICE Patient Decision Aid. The template has 3 steps for decision making: discussing the risk of stroke with the patient; deciding whether to take an anticoagulant or not; selection and initiation of an anticoagulant.
This example was originally submitted to demsontrate implementationm of NICE CG180. This guidance has been updated and replaced by NG196. This example continues to align generally with the updated guidance. The updated guideline should be referred to if replicating any aspect of this example.
Aims and objectives
To reduce the risk of stroke in susceptible patients, by ensuring that AF is treated according to patient preference. To support greater patient involvement in selecting treatment options for AF, by promoting the use of the NICE PDA.
Reasons for implementing your project
Our baseline showed that 1,759 patients were untreated for the risk of stroke in AF, or were on aspirin rather than an anticoagulant (Ref Dr Tim Evans, Head of Health Intelligence (Stroke) at PHE). The lists of these patients were reported to our practices, and the AF template was made available on their clinical systems (SystmOne, EMIS Web and Vision). Dr Rizwan Syed, a Solihull GP with an interest in Cardiology, was asked to support the development of the template (by Minesh Parbat, Pharmacist).
How did you implement the project
A Protected Learning Time event was staged, with a presentation by a GP with experience in treating AF (Dr R Thorns, GPwSI in CVD, Dudley CCG), to remind GPs about the issues involved, and to guide them through the use of the template.
This AF project was put into the local contract, to ensure engagement. Some practices initiated anticoagulation themselves, but others referred their patients to the secondary care Anticoagulation clinic. Practice pharmacists supported the project, and the number of patients reviewed, or not reviewed, was fed back to practices throughout 2015/16.
The full NICE PDA document can be seen as unwieldy, so we split it up according to CHADSVASc score, and linked the template to a smaller document for each score.
The project incurred costs: the prescribing of DOACs has increased by £339,257 on the previous year, or +95%, which compares with +61.8% for England (figures from Keele University, Centre for Medicines Optimisation: Dec-15 data).
The gross number of untreated patients in Solihull CCG at baseline was 1,759. To date, AF reviews have been conducted for 1,116 of these patients.
The outcome, in terms of reduced risk of stroke, is difficult to quantify, but admissions for cerebrovascular disease fell from the period April to December 2014, to the same period in 2015. This fall could, at least in part, be a result of this project. There could be a financial benefit to CCG in the long term, the prospect of which helped to establish the support of finance for this project.
Key learning points
To achieve maximum impact and impetus, this type of project is best implemented as early as possible in the financial year.
The template design can be problematic, and so enlisting the support of a CSU Practice System facilitator would be helpful.
Specifically for SystmOne: the template doesn't allow the GP to go back to the patient's record part way through, which can be a problem.