1. Stoke On Trent CCG – Atrial Fibrillation Service AF Nurse in GP Practice Interfacing Primary and Secondary Care for AF Stroke Prevention Jodie Williams – Atrial Fibrillation Nurse Specialist BA Hons in Specialist Practice Nurse Prescriber Secretary for CLOT (Clinical Leaders of Thrombosis)

2. My Role Qualified in 2003 Acute Stroke Unit – Stroke Emergency Assessment Team

3. Impact Devastation & Impact – Patients & Relatives Approx. 30% of acute stroke admissions attributable to AF

4. CCG - 52 GP Practices

5. Locally – Stoke on Trent Prevalence according to QOF (Jan 2013/2014) is 1.67% National Average is 1.57% Potentially underestimated by 2,800 69.6% of patients are treated with Oral Anticoagulation (OAC) Strive for 85% of high risk patients to be treated and managed effectively

6. Strokes due to AF 1.5% patients in their fifties 2.8% patients in their sixties 18.8%of patients in their seventies 23.9% of patients in their eighties = approx. 140 strokes every year

7. Prevention For 37 high risk patients treated with OAC we can expect to prevent one stroke in primary care If we treat 85% of high risk patients with OAC that means – 23 strokes could be prevented each year

8. Cost - Locally The NICE Costing Report (2014) estimated in the first year after stroke it costs £12,244 rising to a possible £40,000 140 strokes – Local Health Economy could spend up to 5.6 million on treatment, rehabilitation and long term care Prevent 23 strokes – Potential to save £281,244 - £920,000

9. AF Nurse within the CCG WHY? Improve outcomes for patients with AF Provide education and Support for GPs

10. The Interface Primary Care Secondary Care Specialised Care

11. For Each Patient…. Renal Function / Creatinine Clearence Continuation of Antiplatelets Other Medication – Herbal Remedies NSAIDS Listen to the Patient

12. HOW?

13. Where are we now? 5 GP Practices have had the AF registers reviewed, patients reviewed and treatment complete Currently working with 8 GP Practices to review registers and patients

14. Results (DEC 2015) Patient demographic Total number of patient reviewed 1413 Total number of patient treated 310 Average age 75.2 Gender (Male: Female) 54%: 46%

15. CHA2DS2-VASc Scores All of the 1413 patients have their CHA2DS2-VASc scores assessed. 84.1% of the patients have CHA2DS2- VASc scores of 2 or above

16. HAS-BLED Scores All of the 1413 patients have their HAS- BLED score assessed 68.8% has a HAS-BLED score of 2 or above

17. Treatment before review 1312 patients had their treatment before the review recorded 258 (19.7%) were not treated at all 211 (16.1%) were treated with Aspirin 670 (51.1%) were treated with Warfarin

18. Warfarin Patients For patients treated with Warfarin, 591 have INR information available Time in therapeutic range <65%29.1% Time in therapeutic range ≥65%70.9% Average TTR recorded78.1%

19. Treatment Change 310 patients had their treatment changed following review-These patients were put on Warfarin, NOAC or were not treated. None of these patients were prescribed Aspirin

21. Treatment after review 1150 patients had their treatment after review recorded 208 (18.1%) are not treated at all 53 (4.6%) are treated with Aspirin 630 (54.8%) are treated with Warfarin 247 (21.5%) are treated with NOAC

23. Treatment comparison – before and after the review

24. Currently 310 Patients have been managed and commenced on anticoagulation and effectively managed

25. This means… A potential of 8.5 major debilitating strokes have been prevented in 15 months Potential cost saving between £ 101,150 - £374,000 to the LHE

26. Outcomes for Primary and Secondary Care Reduced Patient / Carer Burden, Cost Effective Passion and Dedication as a Team Education and support for GP’s and the Public Public Awareness

27. Where can we improve? Detection and awareness Education for nurses and doctors Reluctance and trust in prescribing Public awareness – Cost, Reluctance

28. AF Related Stroke 12,500 AF Related Strokes every year 1:2 will die within the first year from an AF related stroke 32% of these patients will die within 30 days. AFA. ABPI March 2014

29. NICE Guidelines 180 2014 Using CHA 2 DS 2 VASc to Determine Need for Anticoagulation ◊Do not offer stroke prevention therapy to people aged <65 with AF and no other risk factors other than their sex ◊Consider Anticoagulation for men with CHA 2 DS 2 VASc score of 1 ◊Offer Anticoagulation to people with CHA 2 DS 2 VASc score of >2, taking bleeding risk into account

30. HASBLED Score

31. Stroke Bleeding Aim: reducing the risk of thrombotic events with an acceptable increase in bleeding complications BALANCING RISK Fang MC. Ann Intern Med 2011;155:636–7.

32. Assessing Anticoagulation Control with VKAs Calculate the person’s Time in Therapeutic Range (TTR) at each visit When calculating TTR: ◊Use a validated method of measurement such as the Rosendaal method for computer-assisted dosing or proportion of tests in range for manual dosing ◊Exclude measurements taken during the first 6 weeks of treatment ◊Calculate TTR over a maintenance period of at least 6 months [new 2014]

33. Assessing Anticoagulation Control with VKAs Reassess anticoagulation for a person with poor anticoagulation control shown by any of the following: ◊2 INRs >5 or 1 INR >8 in past 6 months ◊2 INRs <1.5 in past 6 months ◊TTR less than 65% [new 2014] If poor anticoagulation control cannot be improved, evaluate the risks and benefits of alternative stroke prevention strategies and discuss these with the person [new 2014].

34. Anticoagulation for Stroke Prevention ◊ Do not withhold Anticoagulation solely because the person is at risk of having a fall [new 2014] ◊ Discuss the options for Anticoagulation with the person and base the choice on their clinical features and preferences Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation [new 2014]

35. Thank you!!