Presentation on theme: "THE NATIONAL ANTICOAGULATION INITIATIVE Dr Andy Hughes Consultant Community Haematologist South West Essex Community Services and North East London Foundation."— Presentation transcript:
THE NATIONAL ANTICOAGULATION INITIATIVE Dr Andy Hughes Consultant Community Haematologist South West Essex Community Services and North East London Foundation Trust
~ 12,500 AF-related strokes/year in the UK High economic cost ~£600 million direct cost to NHS £800+million in “indirect” costs Incidence of AF set to double from one to two million by 2050
AF related strokes are bad! 25% mortality at 30 days. Significant disability. “A fate worse than death” burden on: Carers Family Society Health & social services
AF also associated with Increased incidence of dementia Bunch et al Heart Rhythm. 7(4):433. Increased incidence of silent cerebral infarcts 15% in AF patients with no prior h/o stroke Ezekowitz et al Circulation. 92(8):2178.
AF STROKES ARE PREVENTABLE 65% reduction in stroke 20% reduction in stroke Similar bleeding risk to Warfarin
GRASP-AF Guidance on Risk Assessment and Stroke Prevention for AF Total Patients with AF Patients with C2 >2 C2 >2 on OAC C2 >2 not on OAC C2 >2 on ASA C2 >2 No anti- thrombotic B/Wood - total 76,5111, B/Wood - % 1.9%61.5%58%42%32%10% National data* - % 1.77%57.5%56%43.6%35%8.7% *as of Jan 2013 C2 = CHADS2 score OAC = oral anticoagulant ASA = Aspirin 2 main risk factors with C2 Hypertension Age >75
Patients with AF & a previous stroke admitted with 2 nd stroke 57% on a VKA. Of these only1/3 rd have therapeutic INRs. 25% are only on an antiplatelet agent. 15% are not on any anti-thrombotic. WHAT’S MORE…..
Variation in the quality and safety of anticoagulation therapy across the country Variation across the country in the activities of anticoagulation services, because there is no standard service model or definition of an anticoagulation service A large proportion of people with AF are currently not receiving anticoagulation therapy in line with NICE guidance. Key issues in commissioning anticoagulation therapy NICE May 2013.
NATIONAL ANTICOAGULATION INITIATIVE CREATING A SYSTEM OF CARE SYSTEM Defines the outcome to be delivered to patients NETWORK Determines who delivers care to the patients PATHWAY Describes how the care is delivered
Common aim – stroke reduction in individuals with AF Shared: Objectives Criteria Standards Individual local service pathways Annual report on a standardised template published on The Initiatives website* The National Anticoagulation Initiative System *http://af-systems.yolasite.com
Promote stroke risk assessment of all known AF patients using CHADS2 (or CHADS-VASc). Increase the percentage of patients with CHADS2 scores of >2 on an OAC. Decrease the percentage of patients on APT. Measure the efficacy and safety of anticoagulation provided: Clinic TTR Percentage of patients with a TTR of >60% Critical INRs ( 5.0) Adverse events (bleeding or thrombosis) OBJECTIVES
ADDITIONAL OBJECTIVES 1/3 rd of individuals with AF are asymptomatic Case finding with opportunistic pulse taking (“Just a minute”) AF Service Integration
The National Initiative in Brentwood Nurse-led anticoagulant clinic ~850 active patients Nine practices Population ~76,000 ~1500 known AF patients
Doctors fear bleeding: Patients not put onto Warfarin. Undertreated. Patients fear stroke. “Houston, we have a problem…” EDUCATION
Educating colleagues and patients about AF is not just about sharing knowledge but about changing behaviour. “Knowledge is the enemy of disease.” Education, education, education………
How can we drive this forward? NHS Health Check implementation review and action plan July 2013 Initiative in preventing stroke & vascular dementia The National Anticoagulation Initiative is part of one of the working themes Public Health can be an important driver of: CCGs GPs Support of PHE will be important for the success of The Initiative.
THE NATIONAL INITIATIVE Brought together a group of innovators from different parts of the country Shared aim and agreed objectives Promote best practice Simple measurements of success, quality and safety Scalable national anticoagulation and stroke prevention programme Aim for national coverage within 5 years Reduce the high economic cost of AF-related stroke Reduce the burden on carers, family, society Reduce the demands on health and social services