West Hampshire clinical commissioning group (CCG) saw an opportunity to save 52 lives from atrial fibrillation-related stroke by optimising oral anticoagulation treatment. One fifth of West Hampshire CCG population are aged over 65 years. In 2014, we had 2,000 undiagnosed atrial fibrillation (AF) patients and 10,500 people with AF at high risk of stroke, of which 3,700 weren’t receiving effective oral anticoagulation treatment for AF-related stroke prevention. People with AF are five times more likely to suffer from a stroke. Half of AF-related stroke patients die within a year, many of these strokes being preventable. With the prevalence of AF increasing and an ageing population, doing nothing wasn’t an option.
We worked with more than 350 GPs across 51 practices to identify undiagnosed AF patients and optimise oral coagulation treatment for stroke prevention. We decided to use a three-pronged approach: the WatchBP tool to identify undiagnosed people with AF, GRASP AF quality improvement tool developed by PRIMIS to identify and treat those who were not receiving oral anticoagulation treatment and PRIMIS Warfarin Patient Safety Audit Tool (WPSAT) to identify and optimise the treatment of those poorly-controlled on warfarin. First, the audit tools identified patients at high-risk of strokes in every practice. Then the results were fed back to the GPs. The medicines optimisation team provided training to GPs and patients to change their mind-sets and behaviours. Finally, the medicines optimisation incentive scheme was implemented.
By the end of September 2016 – two years after running the first set of GRASP AF audit – our tool audit WatchBP identified 19 new AF cases in five pilot sites in the first five months. There were 2,071 additional high-risk patients receiving oral anticoagulation therapy and 10,17 fewer patients being prescribed antiplatelets monotherapy. The total number of patients on oral anticoagulant rose from two third to three quarter. This means that 39 expected strokes were avoided. With regards to WPSAT, 3000 patients poorly controlled on warfarin were reviewed. The CCG average for the percentage of people well-controlled on warfarin rose by 8% and there were 52 fewer ischaemic strokes in West Hampshire in 2016 overall compared with the same period the previous year.
We had a massive ambition but were a CCG in financial turnaround and had zero budget. However, many people and organisations, such as the Wessex Academic Health Science Network (Wessex AHSN) and Public Health England (PHE), gave us their support and goodwill. Early on in the work, GP practices suspected that we wanted to performance manage them by using PRIMIS audit tools. This changed over time when they realised it was genuine health improvement work. We found that getting educational messages across about aspirin and other antiplatelets was ineffective for AF stroke prevention. Again, this became easier with time, as those messages were shared widely. We had technical difficulties with the PRIMIS audit tools in the practice including the staff, systems and the hardware availability. Some clinicians were reluctant to start oral anticoagulation in high-risk patients with difficulties with frailty and based on benefit and risk scenarios. There was a difference of clinical opinion amongst the local specialists about the value of combined oral anticoagulation and antiplatelets therapies, especially the local cardiac surgeons who were out of step with European guidelines. We had a large number of patients who required improvement work and a lack of clinical time to review them. To start oral anticoagulation, you need a 30-minute appointment not a standard GP 10-minute appointment. It was difficult to keep the momentum going after several years of incentivising practices to do the work as part of the medicines optimisation incentive scheme. Some felt we had 'already done' work on this area and wanted us to move on to other therapeutic areas requiring improvement.
Our intention is to continue AF improvement work in the foreseeable future. We still have too many patients arriving in hospital with AF-related strokes who are not anti-coagulated. We’re about to roll out another batch of AliveCor devices to practices with assistance from Wessex ASHN. We’re continuing to review the dose/indication and clinical picture for all patients on DOACs to ensure they are being used safely with minimum harm. Many patients are started on the wrong dose of DOAC, often by secondary care, too low or too high a dose for their age and renal function.
CCG comment ‘The fact that this project has led to an actual reduction in the number of partients having a stroke is really impressive. ‘The availability of the PRIMIS quality improvement tools, combined with a rigorous project methodology and clinical champions contributed to the success of this project.’