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 silent cerebral infarcts 15% in AF patients with no prior h/o stroke Ezekowitz et al. 1995. Circulation. 92(8):2178. Increased incidence of dementia Bunch et al. 2010. Heart Rhythm. 7(4):433.

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 with C2 >2 C2 >2 on OAC C2 >2 not on ASA C2 >2 No anti- thrombotic B/Wood - total 76,511 1,480 911 532 381 293 88 - % 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

WHAT’S MORE….. Patients with AF & a previous stroke admitted with 2nd stroke 57% on a VKA. Of these only1/3rd have therapeutic INRs. 25% are only on an antiplatelet agent. 15% are not on any anti-thrombotic.

Key issues in commissioning anticoagulation therapy NICE May 2013. 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.

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

The National Anticoagulation Initiative System 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* *http://af-systems.yolasite.com

OBJECTIVES 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 (<1.5 and >5.0) Adverse events (bleeding or thrombosis)

ADDITIONAL OBJECTIVES 1/3rd of individuals with AF are asymptomatic Case finding with opportunistic pulse taking (“Just a minute”) Service Integration AF

The National Initiative in Brentwood Nurse-led anticoagulant clinic ~850 active patients Nine practices Population ~76,000 ~1500 known AF patients

“Houston, we have a problem…” Doctors fear bleeding: Patients not put onto Warfarin. Undertreated. EDUCATION Patients fear stroke.

Education, education, education……… Educating colleagues and patients about AF is not just about sharing knowledge but about changing behaviour. “Knowledge is the enemy of disease.”

How can we drive this forward? 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. NHS Health Check implementation review and action plan July 2013

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