Dr Chris ArdenGP, Chandlers Ford GPSI Cardiology, SouthamptonWest Hampshire CCG Cardiovascular Lead

Friday 10th November 2017Nottingham

Optimising detection and stroke prevention strategies in patients with Atrial Fibrillation

in West Hampshire

Projected Number of Patients With AF by 2050

Olmsted County data, 2006 (assuming a continued increase in the AF incidence)

ATRIA study data, 2000

Olmsted County data, 2006 (assuming no further increase in the AF incidence)

MarketScan & Thomson Reuters Medicare databases, 2009

3.03

7.56

Chart1

1995199519951995

2000200020002000

2005200520052005

2010201020102010

2015201520152015

2020202020202020

2025202520252025

2030203020302030

2035203520352035

2040204020402040

2045204520452045

2050205020502050

ATRIA

Mayo no further increase in AF incidence

Mayo assuming a continued increase

Thomson Reuters

Year

Patients with atrial fibrillation (millions)

2.08

2.26

5.1

5.1

2.44

5.6

5.9

3.03

2.66

6.1

6.7

3.35

2.94

6.8

7.7

3.65

3.33

7.5

8.9

4.2

3.8

8.4

10.2

4.75

4.34

9.4

11.7

5.45

4.78

10.3

13.1

6

5.16

11.1

14.3

6.7

5.42

11.7

15.2

7.15

5.61

12.1

15.9

7.56

Sheet1

199520002005201020152020202520302035204020452050

ATRIA2.082.262.442.662.943.333.84.344.785.165.425.61

Mayo no further increase in AF incidence5.15.66.16.87.58.49.410.311.111.712.1

Mayo assuming a continued increase5.15.96.77.78.910.211.713.114.315.215.9

Thomson Reuters3.033.353.654.24.755.4566.77.157.56

www.escardio.org/guidelines

ANTICOAGULATION

http://www.escardio.org/guidelines

How do we screen for AF?

Preventing stroke in West Hampshire

We want to: improve the identification of asymptomatic/undiagnosed AF in WHCCG (an estimated

2000 patients) via opportunistic screening utilising the NICE endorsed WatchBP monitor; saving target - 30 strokes per

year at a cost of £126k with zero investment.

West Hampshire CCG 51 practices

546,000 population106,000 over 65s16,000 over 85s119,000 under 20

Ageing population

2,000undiagnosed

AF

12,000people with

AF

10,500AF high

risk stroke

Chart1

on OAC

no OAC

3,700 no OAC

6,800 on OAC

Hi risk AF

6800

3700

Sheet1

Hi risk AF

on OAC6800

no OAC3700

To resize chart data range, drag lower right corner of range.

National drivers

PROACTIVE LEADERSHIP•Awareness raising/Public Health Audit 2012•Multi-level educational sessions/events•Use of incentives/levers QOF/LES/QIPP•Analysis/needs-gap evaluation/business case

OPPORTUNISTIC SCREENING•Screening programme targeting high risk asymptomatic patients•Introduction of NICE endorsed WatchBPTool•Early adopter 3B Practices/wider roll-out WHCCG•Reinforce educational sessions

OPTIMISING ANTICOAGULATION AND REPORTING•Medicines Management LES – Quality/Safety Intervention•Anticoagulation education – NOACS v Warfarin•Improving uptake of GRASP – AF Tool + WPSAT/CHADS2VASC•Uploading to National dataset•Community Pharmacy Interventions•NICE KPIs

EVALUATION/AUDIT•Record monitor progress improvements via GRASP – AF•Increased NOAC prescribing audit•Introduction of AF/anticoagulation nurse?•Public Health Audit/participation in National trials Oxford + Southampton•Review of anticoagulation provision/increasing INR self- testing opportunities/primary care community delivered cardiology services

STEP 1

STEP 2

STEP 3

STEP 4

Preventing stroke in West Hampshire – StrategyA collaborative plan involving WHCCG Long Term Conditions/GPs/Medicines management and pharma

Optimising Care: The Plan

Identify undiagnosed AF using WatchBP tool

Identify and treat people not treated with OAC

Identify people on warfarin sub-optimally-controlled

Atrial fibrillation – screening

Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting

Honney R1,2, Su F1, Arden C3, Pears R2 & Roderick P1

Background:Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed1. Modified blood pressure devices, such as Microlife’s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF2. There is limited literature on the clinical impact of introducing such devices into UK general practice . Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol.

Results:The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI=1.02-1.56). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI=1.00-1.57).

The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually.

The proportion of newly diagnosed high risk patients receiving anticoagulation was not

significantly different between WHCCG (72.21%) and control (71.57%) practices (χ2=0.0456, p=0.831).

Conclusions:Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme.

Methods:This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity.

1University of Southampton, Southampton. UK. 2Hampshire County Council, Winchester. UK. 3West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: r.honney@nhs.net

References: 1The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.Public HealthEngland; 2013. 2Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7):1046-8.

mailto:r.honney@nhs.net

Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting

Honney R1,2, Su F1, Arden C3, Pears R2 & Roderick P1

Background:Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed1. Modified blood pressure devices, such as Microlife’s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF2. There is limited literature on the clinical impact of introducing such devices into UK general practice . Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol.

Results:The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI=1.02-1.56). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI=1.00-1.57).

The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually.

The proportion of newly diagnosed high risk patients receiving anticoagulation was not

significantly different between WHCCG (72.21%) and control (71.57%) practices (χ2=0.0456, p=0.831).

Conclusions:Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme.

Methods:This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity.

1University of Southampton, Southampton. UK. 2Hampshire County Council, Winchester. UK. 3West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: r.honney@nhs.net

References: 1The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.Public HealthEngland; 2013. 2Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7):1046-8.

mailto:r.honney@nhs.net

Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting

Honney R1,2, Su F1, Arden C3, Pears R2 & Roderick P1

Background:Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed1. Modified blood pressure devices, such as Microlife’s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF2. There is limited literature on the clinical impact of introducing such devices into UK general practice . Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol.

Results:The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI=1.02-1.56). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI=1.00-1.57).

The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually.

The proportion of newly diagnosed high risk patients receiving anticoagulation was not

significantly different between WHCCG (72.21%) and control (71.57%) practices (χ2=0.0456, p=0.831).

Conclusions:Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme.

Methods:This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity.

1University of Southampton, Southampton. UK. 2Hampshire County Council, Winchester. UK. 3West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: r.honney@nhs.net

References: 1The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.Public HealthEngland; 2013. 2Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7):1046-8.

mailto:r.honney@nhs.net

Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting

Honney R1,2, Su F1, Arden C3, Pears R2 & Roderick P1

Background:Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed1. Modified blood pressure devices, such as Microlife’s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF2. There is limited literature on the clinical impact of introducing such devices into UK general practice . Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol.

Results:The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI=1.02-1.56). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI=1.00-1.57).

The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually.

The proportion of newly diagnosed high risk patients receiving anticoagulation was not

significantly different between WHCCG (72.21%) and control (71.57%) practices (χ2=0.0456, p=0.831).

Conclusions:Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme.

Methods:This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity.

1University of Southampton, Southampton. UK. 2Hampshire County Council, Winchester. UK. 3West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: r.honney@nhs.net

References: 1The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.Public HealthEngland; 2013. 2Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7):1046-8.

mailto:r.honney@nhs.net

Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting

Honney R1,2, Su F1, Arden C3, Pears R2 & Roderick P1

1University of Southampton, Southampton. UK. 2Hampshire County Council, Winchester. UK. 3West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: r.honney@nhs.net

References: 1The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.Public HealthEngland; 2013. 2Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7):1046-8.

mailto:r.honney@nhs.net

Optimising Care: The Method

Audit tools identified patients at high risk of

stroke

Results to GPs & continuous feedback on

improvement

Education and training was

delivered

Medicines Optimisation

Incentive Scheme

identification, feedback, education = continuous health improvement

GRASP – AFAn automated tool to identify patients at high

risk of stroke in AF and not on adequate thromboprophylaxis, using existing GP data

Delivered by PRIMIS+ and available via your Cardiac Network.

Audit of Atrial Fibrillation & CHADS2-VASc ScoresClassic View

Total PercentNo. with Atrial Fibrillation 236 1.56Age >= 65 yrs with AF 203 7.62

HELPOVERVIEWPODCAST

NB: Handling of anticoagulant exclusions

©PRIMIS+ 2011

in the 73 high risk untreated

2.9

Select Risk ScorePractice:

Strokes expected annually

Total Practice Population 15148

AF prevalence (%) by age band

0.0 5.0 10.0 15.0 20.0

85+75-8465-7450-6430-490-29

Age

rang

e

AF prevalence (%)

Risk profile for thrombo-embolism

0

20

40

60

80

100

0 1 >1CHA2DS2-VASc score

Perc

enta

ge

Risk factors in patients with AF

0% 20% 40% 60% 80%

Sex = Female

Age 65-74

Vasc disease

Stroke or TIA

Diabetes

Age >=75

Hypertension

HF or LVD

Breakdown of anticoagulant & antiplatelet use by CHA2DS2-VASc score

108

13

4

13

1

0

55

10

3

18

4

7

0% 20% 40% 60% 80% 100%

>1

1

0CH

A2DS

2-VA

Sc s

core

Percentage

Anticoagulant

Both

Antiplatelet

None

Anticoagulant use in high risk patients

020406080

100

On anticoagulant(121 patients)

Not on anticoagulant(73 patients)

Perc

enta

ge

Score or review in last 15 mths

0

20

40

60

80

100

CHADS2 AF review

Perc

enta

ge

CHA2DS2-VAScCHADS2-VASc

Optimising Care: GRASP AFTotal number of expected strokes annually

Sep 14

167Mar 16

129Sept 16

128

Sep 14

2510Mar 16

1651Sept 16

1493

Mar 16

7524Sept 16

7987Sep 14

5916

Optimising Care: WPSAT

Apr 15 8.6%

Mar 168.4%

Sept 167.7%

Apr 15

59%Mar 16

67%Sept 16

67%

Optimising Care: The Results

3000 people poorly-controlled on warfarin reviewed

WPSAT

Chart1

Before

After

% warfarin TTR>65%

% patients taking warfarin well-controlled

59

67

Sheet1

% warfarin TTR>65%

Before59

After67

To resize chart data range, drag lower right corner of range.

Optimising Care: The Results

39 expected strokes avoided

Before

On OAC

No OAC

2071more OAC

WatchBP

GRASP AF

Chart1

On OAC

No OAC

On OAC

No OAC

Mar-16

After

74.3

25.7

Sheet1

Sep-14Mar-16

On OAC64.5On OAC74.3

No OAC35.5No OAC25.7

To resize chart data range, drag lower right corner of range.

Sheet1

Sep-14

Mar-16

Number of reported strokes across WHCCG

Chart1

42064

42095

42125

42156

42186

42217

42248

42278

42309

42339

42370

42401

42430

42461

42491

42522

42552

42583

42614

42644

42675

42705

42736

42767

42795

52 actual strokes saved

Month

Number of Strokes - 12 Month Rolling Average

Number of Reported Strokes - 12 Month Rolling Average

92.0833333333

91.3333333333

91.6666666667

91.8333333333

91.6666666667

90.25

89.0833333333

88.4166666667

87.5833333333

87.0833333333

86.8333333333

86.9166666667

87.6666666667

88.8333333333

87.25

87.75

86.9166666667

88.1666666667

87.4166666667

Data

HHFT - BNHHFTHHFT - RHCHSHFTRBCHUHSTOTALRolling 12 Month AverageChange compared to same Month in Previous YearFinancial Year Total

Apr-140417133293

May-140389103087

Jun-142338133591

Jul-143317173694

Aug-143286173488

Sep-140418153397

Oct-1413821744102

Nov-143417113395

Dec-141278144090

Jan-15130964995

Feb-150308133687

Mar-151297113886921,105

Apr-15133520258491-9

May-150265174391924

Jun-151408103493922

Jul-15040711349292-2

Aug-15117317337190-17

Sep-151311113278389-14

Oct-15136518349488-8

Nov-15134613318588-10

Dec-150321010328487-6

Jan-16031417409287-3

Feb-161339153088871

Mar-1614371331958891,052

Apr-1614581034988914

May-16024617257287-19

Jun-160346213899886

Jul-1612876408287-10

Aug-1682731038868815

Sep-1602589327487-9

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Chart Monthly

41730

41760

41791

41821

41852

41883

41913

41944

41974

42005

42036

42064

42095

42125

42156

42186

42217

42248

42278

42309

42339

42370

42401

42430

42461

42491

42522

42552

42583

42614

42644

42675

42705

42736

42767

42795

Month

Number of Strokes

Number of Reported Strokes - HHFT, UHSFT, SHFT, RBCHFT

93

87

91

94

88

97

102

95

90

95

87

86

84

91

93

92

71

83

94

85

84

92

88

95

98

72

99

82

86

74

Chart - 12 Month Average

42064

42095

42125

42156

42186

42217

42248

42278

42309

42339

42370

42401

42430

42461

42491

42522

42552

42583

42614

42644

42675

42705

42736

42767

42795

Month

Number of Strokes - 12 Month Rolling Average

Number of Reported Strokes - 12 Month Rolling Average

92.0833333333

91.3333333333

91.6666666667

91.8333333333

91.6666666667

90.25

89.0833333333

88.4166666667

87.5833333333

87.0833333333

86.8333333333

86.9166666667

87.6666666667

88.8333333333

87.25

87.75

86.9166666667

88.1666666667

87.4166666667

Optimising Care: What next?

WatchBP to AliveCor

Review 1500 high-risk patients receiving antiplatelet monotherapy

Review 1500 high-risk patients not receiving OAC or those poorly-controlled on warfarin

Getting improvement work embedded into routine clinical practice (including care home residents)

Slide Number 1Slide Number 2Slide Number 3How do we screen for AF?Preventing stroke in West HampshireSlide Number 6National driversSlide Number 8Optimising Care: The PlanAtrial fibrillation – screeningSlide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Optimising Care: The MethodSlide Number 17Slide Number 18Optimising Care: GRASP AFOptimising Care: WPSATOptimising Care: The ResultsOptimising Care: The ResultsNumber of reported strokes across WHCCGOptimising Care: What next?