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STROKE PREVENTION SERVICES QUALITY AND SAFETY INDICATORS IN A CHANGING CONTEXT David Patterson MD FRCP FRSPH Professor of Cardiovascular Medicine Consultant.

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Presentation on theme: "STROKE PREVENTION SERVICES QUALITY AND SAFETY INDICATORS IN A CHANGING CONTEXT David Patterson MD FRCP FRSPH Professor of Cardiovascular Medicine Consultant."— Presentation transcript:

1 STROKE PREVENTION SERVICES QUALITY AND SAFETY INDICATORS IN A CHANGING CONTEXT David Patterson MD FRCP FRSPH Professor of Cardiovascular Medicine Consultant Cardiologist Department of Cardiovascular Medicine, Whittington Health CHIME, University College London Helicon Health, Chief Executive

2 HeartBeat/HeliconHeart - Seamless anticoagulation and stroke prevention services across north London building on 20 years of world-leading research on electronic health records Good European Health Record years of international research on the requirements, design, implementation, sharing and protection of electronic health records Leading a global open source EHR Foundation Leading the development of European and International EHR standards implementation of an ISO EN conformant EHR server with a suite of cardiovascular web applications Set up and seed funded by UCL in 2012 Key partners CHIME and Whittington Health HeartBeat Anticoagulation management and advisory system HeliconHeart is a unique package of clinical services comprising: - Web software - Clinically useful Electronic Health Record, standards-based - Decision support – which drugs to use, how and when - Collaboration tools - Education - Governance & data analytics

3 NICE AF GUIDELINES 2014 Key priorities for implementation: Personalised package of care and information Referral for specialised management Assessment of stroke and bleeding risks Interventions to prevent stroke Rate and rhythm control

4 2014 ATRIAL FIBRILLATION AWARE WEEK 24 TH NOVEMBER - 29 TH NOVEMBER The aims of the AF Aware week are simple: AF - Detect, Protect, Correct:  Detect: Opportunistic Screening has been shown to increase detection of AF  Protect: Identification and treating patients with AF at an early stage will deliver significant health and cost benefits  Correct: Early detection, diagnosis and appropriate medical management leads to fewer appointments & admissions, saving individuals long-term ill health The All-Party Parliament Group on AF (APGAF) has played a key role in helping to establish that AF should, in both policy and clinical domains, be considered a discrete entity within “the family of cardiovascular disease”. APGAF meets again tomorrow to explore the still existing barriers for patients to gain access to the optimal treatment.

5 WHAT ARE THE REASONS FOR OFFERING ANTICOAGULANT AND STROKE PREVENTION TREATMENT TO PATIENTS ? “Anticoagulation therapy is required for people with different conditions, who are identified in a range of settings and, in the case of deep venous thrombosis and pulmonary embolism, require urgent intervention.” NICE 2013 Based on epidemiological data and other information, it is concluded that the number of adults aged 18 or over in England who require anticoagulation therapy and may need access to an anticoagulation therapy service include: ConditionAnticoagulation therapy service Atrial fibrillation (CHADS 2 score=1)226,000 Atrial fibrillation (CHADS 2 score>1)476,000 VTE including PE and DVT125,000 Others155,000 “Therefore, it is suggested that the indicative rate for people needing anticoagulation therapy is up to 2.4% or 2400 per 100,000 of the population aged 18 years or over” NICE 2013

6 ARE WE IDENTIFYING ALL THE PATIENTS WITH AF WHO SHOULD BE ANTICOAGULATED? ATRIAL FIBRILLATION IS A MAJOR PREVENTABLE CAUSE OF STROKE National data obtained from GRASP-AF show that only 66% of high risk patients are managed using oral anticoagulation (May 2014 – 33% of all practices in England) This is in spite National Guidelines from National Institute for Health and Care Excellence and the European Society of Cardiology promoting their use

7 RAISING AWARENESS – IDENTIFYING PATIENTS WITH AF The Atrial Fibrillation Association (AFA) and the Stroke Association have undertaken awareness-raising events: Know your pulseEducational events Opportunistic is cost-effective Flu vaccination programme Surgery pre-assessment Eye appointments Pharmacy visit Supermarket visit Pub visits? Opportunistic or screening programme?

8 NICE (2013) SUPPORT FOR COMMISSIONING: ANTICOAGULATION THERAPY NICE GUIDELINES FOR AF (2014) There is such an intimate relationship between AF and other manifestations of CV Disease (The Family of Cardiovascular Disease) and to anticoagulant and prevention services for strokes It is an essential step to identify patients with AF and direct appropriate patients to anticoagulant and stroke prevention therapy in order to reduce the incidence of stroke. ATRIAL FIBRILLATION Hypertension Raised lipids Coronary artery disease HEART FAILURE Hypertension Coronary artery disease Raised lipids ANTICOAGULATION Monitoring Frequent visits PST & PSM options

9 WHY ARE WE HERE? Cardiovascular disease (CVD) is the biggest killer in the UK Costs of CVD are massive Strokes are avoidable with preventive treatment Wide variations in quality and safety Strokes are very costly to the patient and society Poor clinician and patient education of UK population have CVD ONS 2011 >11% £19b BHF 2014Stroke Association ,000 Strokes/year UK Not on effective therapy to reduce strokes NICE UK 44% £23k Saving from each stroke prevented NAO 2010 No. 1 risk “Not all staff have the required work competencies” NPSA Risk of Anticoagulation, 2006

10 POPULATION ATTRIBUTABLE RISK The contribution each risk factor makes to overall stroke prevalence can be calculated as a population attributable risk (PAR). In England: PAR of smoking 13.3% PAR of hypertension34.8% 50% of the risk of stroke can be “preventable” by controlling these 2 risk factors. There is logic in managing these risk factors at the same time as the risks attributable to atrial fibrillation (heart rhythm and rate control and oral anticoagulation)

11 IMPACT OF HELICON AF & STROKE PACKAGE Strokes/year strokes saved Before With Helicon’s AF& Stroke package Estimated cost saving: £592,000 Total population: 320,000 >60y: 57,290 An Urban CCG “The cost of stroke could be cut by 20% with better management of atrial fibrillation.” NICE 2006

12 UNIQUE ONLINE SOLUTION FOR SHARED CARE Electronic Health Record An online care record shared across all venues of care Clinical Decision Support Integrated tools for better diagnosis, risk assessment & treatment Clinical Governance Analytics Robust analytics enables multi-site comparison Clinician & Patient Education Patients are equipped for self- care and clinicians are kept up to date with accredited learning

13 EDUCATION The patientThe clinician It has features for the patient, together with their carer or family member that include:  Only comprehensive on-line resource to support the self-testing patient  Assessment tools to assess competencies  More value on expansion to self- management (inclusion of dosing support)  Retain support of local practitioner for skills-based training  Resource that patient can share with their practitioner to facilitate consultations  User can select different levels of information based on learning needs  Produced and supported by experts in field Part of the course for the clinician is to study the course for the patient.  Offer both skills and knowledge based education with assessments of both  In addition to the clinical knowledge base we offer very practical support in terms of service delivery, clinical governance and patient-centred consultations  User can select different levels of information based on learning needs  Supported by experts in field  UCL branding  Forum to allow interaction with fellow students and mentors / tutors  Not a stand-alone product.  Forum for alumni to help continue their education and to share experiences

14 THE INVOLVEMENT OF THE PATIENT AND CARER

15 CASE STUDY COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUST (CDDFT) In June 2013, 200 patients taking warfarin were identified and recruited for an INR self-testing study Within 6 months of the study starting, 70% of patients had increased their time in therapeutic range (TTR) by over 20%. The average increase was 15%. Financially, INR self-testing was cost neutral when all CCG costs were included such as the reduction in adverse events. Self- testing also freed up clinic capacity. Patients loved the service - every patient in the study said they would recommend it Average TTR across all 200 patients, before & after study 6 months before study59.7% 3 months before study59.0% 3 months after study71.9% 6 months after study74.7%

16 PATIENT SELF-TESTING AND/OR SELF-MANAGING THE CONTROL OF THE INR  FINGER PRICK TESTING WITH COAGUCHEK  COMMUNICATION WITH HCP: Grace concludes: “I get comfort from knowing that, thanks to HeliconHeart, all my clinicians have access to a single electronic health record for me. I also like playing an active role in my treatment and I find I worry less about my AF.” ADDRESSING THE CO-MORBIDITIES OF AF  BLOOD PRESSURE & PULSE/HEART RATE  SMOKING  ACTIVITY/EXERCISE/DANCE  WEIGHT MEASUREMENT (PARTICULARLY FOR HEART FAILURE MANAGEMENT) SUPPORTED BY  ON-LINE EDUCATION  LOCAL HEALTH CARE PROFESSIONAL WITH ACCESS TO EHR AND ADVISORY SYSTEMS  STRONG CLINICAL GOVERNANCE IVR Web App

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19 STROKE PREVENTION SERVICES WARFARIN CLINIC VISIT

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21 COMMUNITY BASED STROKE PREVENTION SERVICES IN ROMIRE STROKE PREVENTION IN PATIENTS WITH ATRIAL FIBRILLATION PERIOD – TOTAL NUMBER OF PATIENTS SUSTAINING A STROKE IN ROMIRE : 236 Data from National Sentinel Stroke Audit THOSE THAT HAD AF THOSE THAT NOW HAVE AF AF PREVIOUSLY DIAGNOSED PROPORTION ON AN OAC AT TIME OF STROKE PROPORTION NOW ON AN ORAL ANTICOAGULANT % 100% 40% QUALITY OF SERVICE VKA CONTROL TTR > 70 TTR > 60 65% 81% NUMBER TAKING A NOAC 5 THOSE THAT HAD AF AND SMOKEDPROPORTION WHO HAD A SMOKING INTERVENTION 20 15% THOSE THAT HAD RECOGNISED HYPERTENSION PROPORTION TAKING HYPOTENSIVE AGENTS 40% PROPORTION WHOSE BP WAS WELL CONTROLLED 30 % EXERCISE/ACTIVITYPROPORTION TAKING EXERCISE > 5 TIMES PER WEEK 20% PROPORTION WHO ARE SEDENTERY 45%

22 PREVENTION OF STROKE NEW OPPORTUNITIES The expanded HeliconHeart package that results from our new strategic partnership with InHealthCare, is an integrated, web-based solution for stroke prevention, which makes it easier for busy healthcare professionals to plan and manage AF, oral anticoagulation and stroke prevention services. It is also designed for patients who wish to play a more active role in managing their condition. THE PACKAGE FEATURES:  Real-time electronic health record (EHR) shared with clinical colleagues and patient  Anticoagulant & AF advisory systems  Interoperability with existing GP systems and other clinical systems  Affordable patient self-monitoring, using BP monitor and Roche’s Coaguchek  Hosted on NHS spine via N3  Education for clinicians  Education for patients

23 KEEP IN TOUCH To discuss today’s presentation or any matters arising please me at I will be on the Roche stand between 3 and 4 this afternoon To find out more about Helicon Health’s unique package of stroke prevention services, go to


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