Atrial Fibrillation A National View

Transcription

1 Atrial Fibrillation A National View Dr Matthew Fay General Practitioner Shipley West Yorkshire National Clinical Lead-NHS Improvement-Stroke

2 Acknowledgements Dr Campbell Cowan Dr Andreas Wolff Dr Arindam Kar Westcliffe Medical Practice

3 Costs associated with AF 12,500 strokes annually attributed to AF in UK DH estimates of costs of strokes attributable to AF Total cost 148 million in first year Hospital stay cost 103 million Post discharge care 45 million Cost per stroke 12,000

4 Costs attributable to treating AF Annual cost per patient 383 Costs per stroke averted 9,572 Additional costs due to major bleeds / patient Treatment saves money and pays for itself

5 David Nicholson has set the challenge of saving billion through efficiency savings from 2011 to The challenge to the NHS is how to make these savings whilst keeping quality as its organising principle Role of the centre Improve quality and make efficiency savings Quality improvements Efficiency savings The Department of Health s role is to help the NHS prepare to meet the QIPP challenge, in line with the four principles of change: - Co-production - Subsidiary - Clinical leadership - System Alignment 5

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7 Stroke prevention in AF Detection of AF Decision to anti-coagulate

8 Finding Atrial Fibrillation

9 Atrial Fibrillation Commonest sustained Arrhythmia Increasing in prevelence Very common Prevalence of 1.2% 600,000 case in England

10 PROJECTED AF PREVALENCE OLMSTED COUNTY DATA 12% observed increase in AF incidence between 1980 and 2000 Miyasaka et al, Circulation 2005; 114:119

11 Atrial Fibrillation Commonest sustained Arrhythmia Increasing in prevalence Very common Prevalence of 1.2% 600,000 case in England Really?

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13 Prevalence AF by practice

14 Direct Comparison

15 Fitzmaurice, D. A et al. BMJ 2007;335:383

16 Possible Solutions

17 Pulse Palpation at Flu Vaccination Essex Cardiac & Stroke Network Dr. Max Hickman, Chairman Colchester PBC Group PBC Business Case August 2008 LES agreed Sept

18 19

19 Investigations Cardiovascular examination ECG BP BMI Cholesterol, glucose, creatinine 20

20 Outcomes 37/43 practices in N E Essex Signed up to LES 34,201 patients screened in 6 weeks 3154 Patients found with irregular pulse (9.2%) 189 Patients found with AF (0.55%) 342 Patients found with other Arrhythmias (0.99%) including 2 in Complete H. Block! shane.gordon@nhs.net 21

21 The simple things in life AF screening in General Practice Dr Andreas Wolff

22 16% National AF Prevalence in 2008: 1.3% Whinfield Surgery AF prevalence 2008 = 1.32% Whinfield Surgery: patients aged 65 and over = 16%

23 Whinfield Surgery AF screening programme

24 Opportunistic computer prompted screening 5/08 5/ patients aged 65 years and older 1569 patients: pulse palpation 207 patients found with irregular pulse 130 patients with irregular pulse and no known AF 99 patients had ECGs 36 patients diagnosed with previously unknown AF ( +19 )

25 Key Facts 83.3% screened opportunistically 13% with irregular pulse 6.3% had ECGs 36% had AF on ECG Number needed to screen 43 Change in prevalence > 1.82% Prevalence of 65ys and older: 10.9%

26 Stroke Prevention

27 Anticoagulation is underused and suboptimal in high risk patients with atrial fibrillation who present with a stroke 5 year data Dr Maneesh Bhargava Dr Arindam Kar Dr Richard Perry Dr Diane Ames St Mary s Hospital Imperial College NHS Trust UK

28 Methods Retrospective analysis of 5 year stroke data from St Mary s Hospital Stroke Register ( ) n=1297 total ischaemic strokes Subjects of interest Pre existing AF or PAF High risk stratification according to NICE 2006 criteria No contraindications to anticoagulation

29 Data collected on Prior anticoagulant or antithrombotic use Admission INR for those on warfarin

30 Results 15% (187/1297) patients with ischaemic stroke were known to have AF or PAF.

31 Results Demographics Patients with ischaemic stroke and known AF (n=187)

32 Results High risk as per NICE guidelines: n=156/187 No documented contraindication to warfarin : n=131/156

33 N=59/131

34 High risk patients with no contra indication to warfarin : (n=131)

35 Results Warfarin treated patients (n=35/131): Sub therapeutic INR (<2.0): 69% (n=24/35) Overall only 8% (11/131) of eligible patients had therapeutic INR at time of stroke

36 Discharge outcomes were worse with AF...

37 Warfarin is underused Why? Patient factors Refusal, perceived inconvenience Responsibility associated with INR monitoring Inadequate knowledge Physician factors Over estimation of potential bleeding and falls risk Safety factors/monitoring

38 GRASP AF Tool Developed in Leeds 12 months in planning and developing Pilot results mirror National statistics (40-50% of patients who might benefit from warfarin are not receiving it MIQUEST based, CHART run identifies all AF patients and risk scores then using CHADS2

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40 Optimising anti coagulant management GRASP AF Initial experience Leeds and Surrey 40 50% of high risk patients not on warfarin But low conversion rates York Study 24 practices Approx 220,000 patients Supported by education package

41 AGE and CHADS 2 Score 2 or more and NOT prescribed warfarin WYCN June 2009

42 Attributable risk % strokes due to AF

43 Publications

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45 What about QOF

46 Existing AF QOF Allocation AF01 The practice can produce a register of patients with AF 5 AF02 The % of patients with AF diagnosed confirmed diagnosis with ECG or specialist 10 AF03 The % of patients with AF who are currently treated with anti coagulation drug therapy or an anti platelet therapy 13

47 Preventing More Strokes 3.17 The best way of improving the value for money of stroke care is by preventing strokes from occurring GPs play an important role in managing key risk factors associated with stroke since our previous report, GPs management of high blood pressure and atrial fibrillation within the Framework remains steady However, this data does not include patients who are not on GPs registers

48 3.19 Atrial fibrillation (AF) is a major risk factor for stroke. However, the current indicators for managing atrial fibrillation in the Qualityand Outcomes Framework reward practices for treating appropriate patients with any anticoagulation drug or anti-platelet therapy rather than specifically with warfarin.

49 3.20 NICE guidance recommends that the most effective treatment, for patients with atrial fibrillation poststroke, is with warfarin. However, only 24 per cent of stroke patients with the condition were discharged from hospital on warfarin in 2008, and only a further 9 per cent of patients were planned to receive it in future.

50 What could QoF Look Like AF01 The practice can produce a register of patients with AF AF02 % over 65yrs with a pulse check AF03 The % of patients with AF diagnosed with ECG or specialist confirmed diagnosis AF04 % AF with a risk assessment performed AF05 % at risk patients on oral anticoagulants

51 Food for thought 150,000 strokes per year in the UK per day 17 per hour Within the next four hours, 10 patients with AF will have suffered a stroke 8 would have been known to be high risk of stroke 6 should have been on warfarin 3 will go home 5 will end up in residential care The Stroke Association: Base on: Office of National Statistics Health Statistics Quarterly (12) Winter 2001 "Stroke incidence and risk factors in a population based cohort study. Scottish Stroke Care Audit 2005/2006. The Stroke Association estimate that 5,000 people per year have a stroke in Northern 2 will die... Ireland

52 We need to do better!

53 Thank you for your attention Question