Guidance on Risk Assessment and Stroke Prevention for Atrial Fibrillation (GRASP-AF) ALICE FOSTER HEAD PRESCRIBING ADVISER QIPP PRESCRIBING LEAD

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1 Guidance on Risk Assessment and Stroke Prevention for Atrial Fibrillation (GRASP-AF) ALICE FOSTER HEAD PRESCRIBING ADVISER QIPP PRESCRIBING LEAD

2 QIPP Improving Prescribing Installation of GRASP-AF in 106 NHS Devon practices by end of June 2011 Practices to be able to run first query July 2011 onwards AF prevalence in NHS Devon is 1.97% but up to 3.8% in some practices

3 Mid Devon Consortium AF prevalence Prescriber Name Total Patients Total Patients aged over 65 % patients over 65 Atrial Fibrillation Register 09/10 AF prevalence QOF 09/10 BAMPTON SURGERY 3,994 1, % % BLACKDOWN PRACTICE 7,270 1, % % BOW SURGERY 2, % % BRAMBLEHAIES SURGERY 6,430 1, % % CASTLE PLACE PRACTICE 15,096 2, % % CHAGFORD HEALTH CENTRE 3, % % CHERITON BISHOP SURGERY 4,641 1, % % CHIDDENBROOK SURGERY 7,271 1, % % CLARE HOUSE 10,461 2, % % COLLEGE SURGERY PARTNERSHIP 14,638 2, % % EXE VALLEY PRACTICE 1, % % HATHERLEIGH MEDICAL CENTRE 2, % % MID DEVON MEDICAL PRACTICE 4,824 1, % % MORETONHAMPSTEAD HEALTH CENTRE 3, % % NEWCOMBES SURGERY 6,905 1, % % NORTH TAWTON MEDICAL PRACTICE 2, % % OKEHAMPTON MEDICAL CENTRE 12,153 2, % % OKEMENT PRIMARY CARE CENTRE 222 1, % % SAMPFORD PEVERELL SURGERY 1, % % WYNDHAM HOUSE SURGERY 3, % %

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5 Background to GRASP-AF Query and risk stratification tool available for use with all GP clinical systems in England Developed collaboratively and piloted by the West Yorkshire Cardiovascular Network, the Leeds Arrhythmia team and PRIMIS+, as part of the AF in primary care national priority projects, made available nationally through NHS Improvement. This tool should be used as part of a systematic approach to the identification, diagnosis and optimal management of patients with AF to reduce their risk of stroke.

6 Stroke management and stroke prevention are major priority areas for the NHS. This has been identified as one of the recommended interventions on NHS Evidence - Quality and Productivity Priorities. Atrial fibrillation (AF) is a major cause of stroke, accounting for some 14% of all strokes. Atrial fibrillation also increases the risk and severity of stroke. Recognition and optimal treatment of AF is of particular importance as strokes due to AF are eminently preventable.

7 Prevalence rate in primary care is 1.2%, which equates to just over 600,000 patients in England have AF 12,500 strokes per year are thought to be directly attributable to AF The estimated total cost of maintaining one patient on warfarin for one year, including monitoring, is 383 The cost per stroke due to AF is estimated to be 11,900 in the first year after stroke occurrence NICE estimate that approximately 40% of patients in whom warfarin is indicated are not receiving it, amounting to some 166,000 patients nationally.

8 What does GRASP-AF do? Provides a set of MIQUEST queries to identify, for your practice, patients with a diagnosis of AF who are not on warfarin The GRASP - AF tool will calculate their stroke risk using the validated CHADS2 scoring system The tool will highlight patients with a CHADS2 score of 2 or more not receiving warfarin who would benefit from review to assess the issue of anti-coagulation The tool does not assess contraindications to warfarin, the decision whether or not to start warfarin remains a clinical one.

9 "Treating these patients with Warfarin could prevent 6,000 stokes nationally and save 4,000 lives each year (Nice 2006) The GRASP-AF toolkit will apply a CHADS2 stroke risk stratification score to your AF patients and identify those patients with AF at a high risk of stroke and not on warfarin. Experience has shown, after registering and downloading the GRASP-AF tool, this takes just a few minutes to run on the GP clinical system. Initial findings show that around five patients per GP benefit from being reviewed with a view to commencing warfarin.

10 What is a CHADS2 score? CHADS2 assigns one point each for Congestive heart failure Hypertension Age 75 or older Diabetes mellitus and two points for a previous Stroke (S2) or transient ischemic attack Patients with AF with a CHADS2 score of 2 or more should be treated with warfarin

11 Annual stroke risk if not on anticoagulants Points Annual Stroke Risk 0 1.9% 1 2.8% 2 4.0% 3 5.9% 4 8.5% % %

12 GRASP AF (ATRIAL FIBRILLATION) CHOOSE ANOTHER LIBRARY ATRIAL FIBRILLATION HOME ATRIAL FIBRILLATION & CHADS SCORE WARFARIN NO PERCENT Total No of Patients currently registered with Practice 5342 Total No of Patients with Atrial Fibrillation / Flutter % % of practice population aged 65+ with Atrial Fibrillation / Flutter 6.12% Risk Profile for Thromboembolism NO PERCENT CHADS2 Score = % CHADS2 Score = % CHADS2 Score > % TOTAL %

13 GRASP AF (ATRIAL FIBRILLATION) CHOOSE ANOTHER LIBRARY ATRIAL FIBRILLATION HOME ATRIAL FIBRILLATION & CHADS SCORE WARFARIN Warfarin use in high risk patients (CHADS2 > 1) NO PERCENT Patients on warfarin % Patients not on warfarin % % of practice population aged 65+ with Atrial Fibrillation / Flutter 6.12% Patients on warfarin and anti-platelet agents in CHADS2 groups None Anti-platelet Warfarin Both CHADS2 Score = CHADS2 Score = CHADS2 Score >

14 Line by line list of all patients with atrial fibrillation Those with CHADS2 score greater than 1 and not on warfarin highlighted in red Filters to find specific groups of patients Graphs including view of warfarin use, reasons for not prescribing, against CHADS2 score

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18 Making a difference After running the GRASP-AF tool, upload your data to CHART-Online which will enable you to save your initial baseline position. Following review for optimal therapy, further uploads will demonstrate progress to reducing risk of stroke in patients with AF within your practice and enable you to anonymously compare your results online with other practices, PCTs, Cardiac and Stroke Networks and SHAs. Run the GRASP-AF tool on an annual basis as an active CHADS2 risk stratification review for your AF patients to support the management of stroke prevention.

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22 How will this be done in NHS Devon? 1. Each GP practice nominates a PRIMIS+ contact practice manager, admin staff or IT 2. PRIMIS+ contact registers on PRIMIS+ Profile Centre This gives Level 1 access to PRIMIS+ 3. Once registered practice provides name, and practice code of PRIMIS+ contact to Rachel Browse at NHS Devon prescribing. 4. PRIMIS+ will upgrade practice user to Level 2.

23 5. NHS Devon IT engineers will contact practice to come and install CHART and GRASP-AF software, map folders, set up Excel security on one desktop PC in the practice. Check that software runs correctly 6. Practice can then run query and save results to main practice shared drive. 7. Software can be installed on more than one PC but once query is run the data is on the shared drive so can be easily accessed

24 8. GP s will then be able to see results from query and review patients identified. 9. Uploaded data is anonymised but gives practice and PCT comparable information. 10.Guidance and information will be provided from the Peninsula Heart and Stroke Network 11.After 6-12 months the query can be run again to identify the change

25 What will this cost each practice?

26 The software is NHS and is free to download for those registered with PRIMIS+. IT support will be given by NHS Devon. Guidance and supporting information from the Peninsula Heart and Stroke Network Supported by NHS Devon prescribing team pharmacists and technicians

27 NO FINANCIAL COST TO PRACTICE BUT SIGNIFICANT POTENTIAL PATIENT BENEFIT WITH REDUCED RISK OF STROKE

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29 SAFER PRESCRIBING CHOOSE ANOTHER LIBRARY SAFER PRESCRIBING HOME POSSIBLE INAPPROPRIATE DRUG FOR AGE POSSIBLE INAPPROPRIATE PRESCRIBING POSSIBLE OVERLOOKED SAFETY INFORMATION POSSIBLE INADEQUATE MONITORING PART 1 POSSIBLE OVERLOOKED LABORATORY TESTS POSSIBLE INADEQUATE MONITORING PART 2 The Safer Prescribing Library allows practices to examine their current prescribing to identify issues or even systems which might need attention.