Atrial fibrillation (AF) is one of the most common forms of abnormal heart rhythm and a major cause of stroke.
The abnormal rhythm prevents the heart from pumping effectively allowing blood to pool in the upper chambers called the atria. This pooling can result in the formation of a clot which can break loose and cause a stroke.
Professor Mark Baker, Director of Clinical Practice at the National Institute for Health and Care Excellence (NICE), commenting on the AF NICE guidance, said: “We know that AF increases the risk of strokes by up to five times. It’s estimated that the condition causes around 12,500 strokes each year. We also know that around 7,000 strokes and 2,000 premature deaths could be avoided every year through effective detection and protection with anticoagulant drugs that prevent blood clots forming.”1
Mike Drakard CEO of Interface Clinical Services, whose organisation worked with the GPs on this review service, said: “This was one of the largest projects we have undertaken and based on NICE’s figures we believe that this review has prevented more than 800 strokes and over 200 deaths. The average cost of treating a stroke, rehabilitation and community support is at least £24,855,2 therefore, conservatively we estimate a saving of over £20 million for the NHS as a whole.”
The service initially identified patients at 1028 GP surgeries across the UK who had been diagnosed with AF or had clinical markers associated with AF. Patients where the diagnosis was not clear were excluded and listed for further examination by the practice.
This left 135,203 patients – representing approximately 12% of the UK AF population. Each of these patients were then assessed using the new CHA2DS2-VASc scoring system, as recommended by NICE and The European Society of Cardiology, which scores factors such as: congestive heart failure, hypertension, over 75, diabetes, stroke/ mini stroke, gender, and vascular disease.
Just under 10,000 of these patients were classified as low risk with no action required. The balance of 125,782 patients, who fell into the moderate and high-risk category, were then assessed for current stroke prevention therapy.
The assessment procedure divided these patients into two groups. Those who were on oral anticoagulant therapy – 89,455 and those who were not – 36,237.
The 89,455 patients on oral therapy were further divided into two categories, those on a VKA – vitamin K antagonist – anticoagulant and those on a non VKA anticoagulant. VKAs are a group of substances that reduce blood clotting by blocking the action of vitamin K. The non VKA anticoagulants are the new anticoagulants often referred to as NOACs and include dabigatran, rivaroxaban, apixaban and edoxaban, which work on specific sites in the clotting cascade, by inhibiting clotting factors.
Each patient was then clinically assessed – both those on anticoagulant therapy and those who were not – in line with NICE clinical guidelines, Quality and Outcomes Framework (QOF) criteria and practice specification. Those patients who were identified as requiring an intervention were asked to come for a consultation with their GP.
The GP in consultation with the patient then made the decision on the best treatment for that patient going forward.
Key results of the service were:
Of the 36,327 patients who were not taking any type of oral anticoagulants – 12,516 were prescribed VKA therapy and 4189 were prescribed the new non-VKA anticoagulant drugs.
Of the 89,455 patients already on oral anticoagulant medication – 8774 moved from VKA to the new anticoagulant drugs and 2,743 on the new anticoagulant drugs had their dose adjusted or were taken off the drug due to clinical issues.
Those patients who were not taking their drugs regularly were sent letters to encourage adherence.
The review also highlighted patients who needed secondary care referrals to a haematologist.
Interface Clinical Services work closely with GPs and practice staff to identify patients at risk of an AF related stroke. Interface pharmacists provide the practice with valuable resource enabling GPs to deliver the best outcomes for patients and ensure they receive the appropriate preventative care.
Interface have more than 70 pharmacists helping GPs, practice managers, administrators, and commissioners manage long-term conditions, improve patient care and maximise QOF outcomes. To date, Interface have worked in 3470 primary care practices throughout the UK, helping to improve the quality of prescribing for millions of people.
Dr John Wearne, a GP from Cheshire who took part in the review commented “This exercise has been hugely beneficial to patients at our practice. The Interface pharmacist analysed the data and identified the patients that we should review together. I found their input invaluable as we would never have had the time or resources to undertake a review of such complexity which ultimately has such a significant effect for our patients. The industry support which made this possible is the type of industry partnership which really is beneficial in delivering high class, patient centric care.”
Professor Trevor Jones who was previously R&D director of Welcome, Director General of the ABPI and who continues to provide healthcare advice to both the NHS and the pharma industry commented. “These types of partnerships between the NHS and industry are invaluable. Interface’s role in providing highly trained pharmacists to provide independent advice to GPs can only help in the uptake of new NICE approved medicines. This benefits the patient and in this case saves millions of pounds for the NHS.”
Mike Farrar who was CEO of the NHS Confed and worked in the NHS as a senior manager for more than 20 years commented, “This type of exercise is great for patients and the NHS in terms of outcomes and savings. As long as the data and prescribing decision is always under the control of the GP, these types of partnerships should be encouraged.”
Research in this area indicates that if the NHS can target their resource to ensure patients with the greatest need get the best care and medication early in their disease it will have the best effect in achieving improved outcomes.
- National Audit Office. “Progress in improving stroke care, Report on the findings from our modelling of stroke care provision” (February 2010). NAO Report (HC 291 2009–2010). www.nao.org.uk/wp-content/uploads/2010/02/0910291_modelling.pdf.