1. AF Stroke from a PH perspective Greg Fell Greg.fell@bradford.gov.uk

2. Some important numbers as context

3. 2282,500

4. 228 AF strokes per year in Bradford 811 strokes in total. 2,500 AF strokes in YH (1% and 10% of the England pop)

5. 12,000 and 6,000

6. £12,000 and £6,000 The yr 1 and subsequent year costs of caring for stroke patients

7. The sub study of AF stroke – fits into a broader picture. c15% of strokes are AF strokes.

8. Anticoagulation and AF stroke - “Dear NHS – must and can do better”

9. AF prevalence – its not something that is going to decline NB the age specific prevalence seen in GRASP AF dataset 13% growth in Bradford in last 5 years New cases + finding existing cases 1.5% prevalence in YH. 85% of prevalent cases CHADS2 >=1

10. Long term trends in AF stroke (YH) To insert when I have the data Jon is getting me 10yr trend in AF stroke….

11. Dear NHS….. Must do better Marked under use of a cheap and effective intervention that cuts stroke risk by c60% This is not news. “overuse” of anti platelet medicine

12. Dear NHS….. Must do better Even in really high risk patients 34% anticoagulated Community dwelling AF stroke survivors N=3500. NNT = 10-12

13. Here is the story of HOW to do better

14. How to cut the AF stroke rate by 15% in a year. Greg.fell@bradford.gov.uk

15. We know a lot about individual clinical practice.

16. We know remarkably little about how “best” to improve population outcomes

17. Key features Data Benchmark Achievable benchmark of care for pop Single side guidance for clinicians Consistently applied to all Small number of measured indicators Regular feedback Active support. Seems to have achieved quite remarkable results – 43% controlled to 84% controlled (55 -64% in comparator)…..

18. And into AF

19. Where we started from 6,500 patients on AF register AF substantially increases risk of stroke Approx 2500 are on anticoagulation, significant more should be. Approx 50% of people that need the intention don't receive it Warfarin is and remains v effective in reducing risk of stroke. An “innovation” that is 50 years old. Not without risk and thus needs to be used carefully

20. indicators % of AF patients (QOF) register with CHADS2 of 1 or more who are NOT receiving anticoagulation Time in therapeutic range achieved by INR monitoring providers

21. Aims: “to ensure that at least 70% of patients with AF and a CHADS2 score of 1 or above are receiving Warfarin” “for 80%* of those patients to achieve an INR in range*.”

22. The AF Quality Improvement Project 56 (of 80) practices actively participated in the project involved C330,000 population Both hospital participated in the project trying to improve TTR in secondary care based Warfarin clinics.

23. Approach was simple Clear quality standard Measurable Measure it – practice or provider level Make data available and public Achievable benchmark of care target for each practice – what level are the 2 nd quintile performers achieving Ten evidence based strategies were consistently applied to the practices that were participating to encourage improvement. Bespoke support and advice to practice and more widely - Q&A / Expert events / training / Practice visits / IT tools 1 year to 18 months.

24. Did it work?

25. AF QIP achievements 714 additional patients on Warfarin 31% relative improvement If you believe the NNTs - 29 Strokes and 17 deaths prevented If 29 avoided = approx 15% of AF Stroke

26. AF QIP achievements – against our target 65% of patients with CHADS2 ≥1 on Warfarin 6% absolute improvement 31% relative. Aim was 70% Remember only 2/3 of our units “played”

27. AF QIP practices – some achieved their own Target. Some didn’t.

28. Most got better though. AF QIP before / after across AFQIP practices

29. The best improvement was in the highest risk

30. INR didn’t change much over time. Mean INR before the AFQIP = 76%* Mean INR after the AFQIP= 74% * p=0.1 no difference *point prevalence Large number of new patients added into INR clinics. Despite this – no change in % of tests in

31. Difference = 16% p>0.001 Difference = 9% AF QIP practices vs. non AFQIP

32. Economic impact of AF QIP Was it worth it financially COST NEUTRAL V V V Worst case This is highly simplistic Cost of the intervention (warfarin +monitoring) £242 (NICE, 2012) *714= £172788 Cost of the implementation –approximately= ~£100,000 NHS cost of 29 strokes averted -29 *£13000=-£ 377000 Total net savings = - £ 104212* This should be interpreted with caution as it is based on the assumptions used in the NICE guidance. We will conduct a detailed analysis in the next 2months. To see what ACTUALLY did happen.

33. Equity – it is always practices in posh parts of town that participate Not here! No evidence of that. Participation is across the board. Thus hard to say this approach will increase inequity

34. Where this project sits in the Scheme of “innovation” We have “done” clean water And vaccinations And MRI and CT scanning / statins / Coronary artery bypass graft surgery and …..and ….. And…..and…… And warfarin is hardly innovative But here is an important process innovation, that is cheap to implement and seems to make a difference at scale.

35. This is a model of “innovation” that seems to make a difference, and has traction, and is cheap Developing an effective model for QI in primary care One that primary care really engages with cheap and simple to run, Does rely on enthusiastic individuals with a common goal. There was consistently positive feedback from practices and those that didn't initially participate are now requesting to do so.

36. Success factors? clear measurable indicators work of local GPs and other clinicians in making this happen. Collaboration of a wide range of parts of the system (provider and commissioner) and with strong PH and clinical leadership live data to ensure some “competition” between practices, live Q&A with experts, a clear approach to peer facilitation, recognising that practices had as much to teach each other as “experts” had to teach them

37. Dear NHS…. HAVE DONE better. subsequent data analysis – 25 less AF strokes per year It is a challenge that CAN be addressed. We have proved this.

38. So…… Its important People die People are disabled and their families are made miserable It is costly AND relatively common It is preventable The track record of the NHS in this is … lamentable…. Dear NHS……..

39. Any questions? Greg.fell@bradford.gov.uk

40. Postcript – reflections. This is work in progress

41. Additional slides – more detail

42. approach was similar to that advocated by world leaders in quality and safety (Provonost) explicitly focused on some of the reasons why existing and well publicised guidelines are under implemented. directly addressed areas where there is disagreement, we simplified guidelines so as they influence decisions at the point of care, disrupted the status quo by providing comparative performance data. We relentlessly focused on population based care, as opposed to focusing on individual clinicians and the patient / clinician interaction.

43. The intervention – in detail a specifically assembled team two indicators, established a method for extracting data out of primary care clinical information systems in a way that all practices that choose to participate can see all other practices achievement. We set a target number of patients to be considered for anticoagulation in each practice, based on the Achievable Benchmark of Care method. For the system as a whole, defined as all participating practices in Bradford, our aim was to ensure that at least 70% of patients with AF and a CHADS2 score of ≥1 are receiving anticoagulation, and for 80%* of those patients to achieve an INR in range. 18 month period (time to change!) ten simple but evidence based strategies (AHRQ / IHI) to encourage and incentivise achievement the target in each practice. –provision of bespoke support and advice to practices and more widely –Q&A –Expert events –training –Practice visits –IT tools and templates to standardise the approach to anticoagulation decisions in general practice and bring evidence to the point of clinical decision making. –Updated audit at intervals – to see progress

44. Success factors in implementation strong clinical and PH Leadership. visible and LOCALLY credible opinion formers and leaders to lead Ruthless and meticulous implementation A small number of locally agreed high impact and measurable indicators a clear approach to peer facilitation, recognising that practices had as much to teach each other as “experts” had to teach them Benchmark live data on achievements against those indicators across all participating practices. This encourages competition within a system on quality metrics – striving to be the best. Single side guidance for clinicians, broader suite of tools embedded in primary care IT system to enable better and more standardised practice. Applied to large population over long time period. Regular feedback on achievement – with data and softer messages. Active evidence based strategies were consistently applied to the practices that were participating to encourage improvement simply hard work and sustained implementation of evidence based clinical behaviour change strategies.

45. Practice visits – key intervention Each practice gets 2 visits. As part of the practice meeting (in between clinics - time restricted) involve multiple staff groups GP, PN, HCA. More staff involved, more likely to have a speedy up take of templates etc. Ensuring data recording is consistent is one of the biggest battles, we want our indicators to be as sensitive and specific as possible and consistent methods of recording reduce false positive/negatives appearing in any searches produced. ask for who updates their clinical tree to come along. This is normally a data clerk and usually not the kind of staff member they readily let out to meetings (GPs have the monopoly on PLT still) Running the searches with them, discussing difficult patients etc makes the QIP real and allows tasks/recalls etc to be done whilst I am there e.g. can we task the nurse to add a BP check to that patients appointment next week? Or that patient is due in for a review, could we ask the secretary to send out a letter inviting them in? The subsequent follow up visit could be pooled, as we won’t have time for all the first visits at this rate I think this would be a wise economy of scale suggestion.

46. Examples of the tools

48. Spread - it is critical. one of the greatest challenges spread, both to broader geography and to other clinical areas Constancy of purpose is important. The NHS needs to be clear in their expectations as to this improvement being the norm and that it cannot wait out this "flavour of the month". important to have a realistic understanding of change fatigue and how much process improvement the organization can do at once. Here we deliberately focused on “the masses” rather than the “best performers”. Often an assumption is made that "if you improve the leading edge, the rest will follow“, or if you “target the laggards, it will bring up the trail”. whilst this might be true - this approach will not achieve population shift at the same level as setting achievable targets for mass improvement. a visual display of performance of the system really helped motivate change, especially where there is real time shift that can spur further action. creation of half-life type goals rather than finite targets will be important in sustaining long term improvement. This will embed the notion that the system does not become complacent once a target has been achieved.

49. getting others on board. Tactics for bringing along those who have not yet adopted the change The "we didn’t invent it and we think our idea is better" syndrome we are all guilty of this Get the vital few on board (the majority will follow) - key opinion leaders. The remainder will need to be managed. This is the aproach taken, seemingly very successfully, by pharma companies. Strong network of KOLs. Understand what prevents the remaining few from coming on board. Qualitatively. How does it feel to them Use KOLs and quickly find a success story. Measure and spread the word. Some of the most effective champions are the ones who are former hold outs. Use leadership to force the issue. Be straightforward and ask, "Do you know something that we don't? If you do, we need to understand it“ emphasise the importance of patients expectations and demand Imagine a scenario of all AF patients knew that aspirin had limited to zero net benefit and demanded anticoagulation from their doctor. Patients need to know what to demand.