Making the Health Check work for you Atrial Fibrillation and the GRASP toolkit (Guidance on Risk Assessment and Stroke Prevention ) Dr. Indira Natarajan Consultant Stroke Physician University Hospital of North Staffordshire & Clinical lead for Stroke for the Heart and Stroke Network for Shropshire and Staffordshire
National Sentinel Audit Data
UHNS Acute Stroke Unit (ASU) 2001 2010 Outcome/ Result
One of the major risk factors for stroke Atrial fibrillation
Atrial fibrillation and Stroke 1200 Strokes / year at UHNS in 2011 15% of all Strokes are cardio embolic strokes secondary to AF AF Strokes lead to moderate and severe strokes AF still remains a treatable risk factor for preventing stroke
Atrial fibrillation facts. AF is the most common cardiac arrhythmia Prevalence of AF is increasing Risk of stroke persists in asymptomatic or paroxysmal AF DBG1778 Factors increasing stroke risk include: Previous stroke or transient ischaemic attack (TIA) Advancing age Heart failure Hypertension Diabetes mellitus Assessment of stroke risk is important to guide antithrombotic therapy
AF and associated stroke incur substantial healthcare costs 1 AF accounts for more than 1% of healthcare expenditure in the UK Total costs for treating the 12,500 strokes in England that are attributable to AF is 148 million in the first year DBG1778 The cost per stroke due to AF is estimated to be 11,900 in the first year after a stroke occurs Treating these patients with Warfarin could prevent 6,000 stokes nationally and save 4,000 lives each year (Nice 2006) 1. NHS Improvement. Commissioning for Stroke Prevention in Primary Care: The Role of Atrial Fibrillation. June 2009. Available at http://www.improvement.nhs.uk/heart/portals/0/ documents2009/af_commissioning_guide_v2.pdf; accessed April 2010
Risk Stratification Scores
Stroke severity increases costs Severe 4 5 34 809 Stroke severity* 3 2 12 323 18 281 DBG1778 0 1 10 530 Mild 0 5 10 15 20 25 30 35 40 Mean cost per patient over 18 months ( 1000) Data for 494 consecutive stroke patients in France; *10-day modified Rankin Scale Spieler JF et al. Cerebrovasc Dis 2002;13:132 41
AF and Stroke - An Audit 50 consecutive patients with AF 30 patients had moderate to severe strokes 9/ 50 were on warfarin ( 18%) 20/50 Known AF ( 40%) not on warfarin 32/50 (62%) Newly Diagnosed AF
GRASP AF Tool Kit Guidance on Risk Assessment and Stroke Prevention for Atrial Fibrillation
GRASP AF Tool The GRASP - AF tool will calculate their stroke risk using the validated CHADS2 scoring system this element of the toolkit now defaults to CHAD 2 S 2.VASc 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
National direction The National aim is to support 2000 GP practices from across the UK to implement the GRASP Toolkit by the end of March 2012 The GRASP toolkit has been redesigned from using CHADS2 to default to CHAD 2 S 2.VASc Staffordshire Heart and Stroke Network aims to increase the number of practices using the GRASP toolkit within Shropshire and Staffordshire from 12% to 25% by the end of March 2012.
Uploading Data Quality Facilitators in each locality can upload GRASP AF Tool kit They can also help in uploading the data to CHART online so that we can benchmark local practice
Audit of Atrial Fibrillation and CHADS2 Scores Please click on the Web Upload icon to send in your data Classic View Select Risk Score Practice: Total Practice Population 5368 Total Percent No. with Atrial Fibrillation 95 1.77 Age >= 65 yrs with AF 77 6.17 Age range AF prevalence (%) by age band 0-29 30-49 50-64 65-74 75-84 85+ 0.0 5.0 10.0 15.0 Percentage 100 80 60 40 20 0 Risk profile for thrombo-embolism 0 1 >1 NB: Handling of anticoagulant exclusions AF prevalence (%) CHADS2 score Risk factors in patients with AF Breakdown of anticoagulant & antiplatelet use by CHADS score Heart Failure Hypertension Age >=75 Diabetes Stroke or TIA CHADS2 score 0 1 >1 1 7 2 2 0 2 2 9 2 22 39 7 Anticoagulant Both Antiplatelet None 0% 50% 100% 0% 20% 40% 60% 80% 100% Percentage Percentage 100 80 60 40 20 0 Anticoagulant use in high risk patients On anticoagulant (9 patients) Not on anticoagulant (48 patients) This dashboard w as developed by PRIMIS+ for use w ith CHART Strokes expected annually in the 48 high risk untreated 3.2 (95% CI 2.4 to 4.2) Percentage 100 80 60 40 20 0 Score or review in last 15 mths CHADS2 AF review HELP OVERVIEW PODCAST PRIMIS+ 2011
Audit of Atrial Fibrillation and CHA2DS2-VASc Scores Please click on the Web Upload icon to send in your data Classic View Select Risk Score Practice: Total Practice Population 5368 Total Percent No. with Atrial Fibrillation 95 1.77 Age >= 65 yrs with AF 77 6.17 Age range AF prevalence (%) by age band 0-29 30-49 50-64 65-74 75-84 85+ 0.0 5.0 10.0 15.0 Percentage 100 80 60 40 20 0 Risk profile for thrombo-embolism 0 1 >1 NB: Handling of anticoagulant exclusions AF prevalence (%) CHA2DS2-VASc score Risk factors in patients with AF Breakdown of anticoagulant & antiplatelet use by CHA2DS2-VASc score HF or LVD Hypertension Age >=75 Diabetes Stroke or TIA Vasc disease Age 65-74 CHA2DS2-VASc score 0 1 >1 1 1 8 3 1 9 2 1 1 61 5 2 Anticoagulant Both Antiplat elet None Sex = Female 0% 20% 40% 60% 80% 100% 0% 50% 100% Percentage Percentage 100 80 60 40 20 0 Anticoagulant use in high risk patients On anticoagulant (11 patients) Not on anticoagulant (70 patients) This dashboard w as developed by PRIMIS+ for use w ith CHART Strokes expected annually in the 70 high risk untreated 3.5 Percentage 100 80 60 40 20 0 Score or review in last 15 mths CHADS2 AF review HELP OVERVIEW PODCAST PRIMIS+ 2011
So far. 1350 out of 8000 GP practices across the UK are using the toolkit, the aim is to encourage 2000 GP practices to implement the GRASP toolkit by the end of March 2012
Locally. 12% of GP practices across Shropshire and Staffordshire are using GRASP the toolkit at present, this was confirmed by the National team in December 2011 predominately these are within North Staffordshire
AF Stroke Strategy Locally we have helped in developing a network wide AF Strategy for both : Primary Care and Secondary Care The use of GRASP tool kit within North Staffs PCT - more people with AF are now taking anticoagulants therefore, prevention of strokes have occurred.
Regional Commissioning Framework One of the key ambitions is to improve quality and safety in primary care SHA Cluster Board have agreed 4 key objectives and one of the key objectives: Is to Improve management of patients taking warfarin by uploading the GRASP tool KIT this objective can be achieved
Developments Meetings are being arranged with CCG Chairs/Managers to discuss the implementation of the GRASP toolkit Atrial Fibrillation training days have taken place in June and November 2011 working with Staffordshire University. Further developments expected regarding the new anticoagulants Numbers of GP practices across the network using the GRASP toolkit have been identified by linking with the national team Links have been made with Data Quality Facilitators across the network to assist with implementation PRIMIS has been contacted to include AF within its web page, this has been achieved, CHART online now demonstrates AF Personally championing the need for Stroke Prevention secondary to AF
In Summary. The Shropshire and Staffordshire Heart and Stroke Network aims to increase the number of practices using the GRASP toolkit within Shropshire and Staffordshire from 12% to 25% by the end of March 2012. This will be achieved by working closely with the new GP Commissioning Consortia and promoting the adoption of the system at GP protected learning time events, training opportunities provided by the network focusing on Atrial Fibrillation and sharing national information from the NHS Improvement team with GP s across the network. Awareness raising will increase the uptake of the system and should increase the anticipation of reaching a target of 25% of all GP practices across Shropshire and Staffordshire using the GRASP toolkit.
Thank You