Pan London AF Improvement Programme

• Where to look

Sotiris Antoniou, Consultant Pharmacist

On behalf of Pan London Primary Care AF Improvement Programme

6th June 2016

A simplified view of the AF Pathway

1. Pre-Diagnosis

Populationscreening

Risk stratification

Case finding

Cross correlation withother registeredconditions

Contact & patientinvitation

Detect (Detect)

2. Diagnosis

Assessment

Electrocardiograms

Echocardiograms

Pulse checks

Correct

Catheter

Rhythm controlDC Cardioversion , Class1c (flecainide) or IIIantiarrhythmic drugs(amiodarone or sotalol)

Electrical / chemicalcardioversioni.e. pacemaker

Surgicalablation

Virtual clinics /Secondary caresupport

Left AtrialAppendage(LAA)

4. Treatment

Drugs /technology

Rate control (betablockers(Atenolol,bisoprolol) orrate limiting CCB(Diltiazem, verapamil)

Protect

3. Therapy

Behaviouralchange

Direct oralanticoagulant (DOAC’s)i.e. Rivaroxaban,Dabigatran, Apixaban,Edoxaban

“Don’t wait Anti-coagulate” i.eWarfarin

Perfect

5. Living with AF

Monitoring

INR devices

Patientactivation

Wearable heart monitor

Telehealth remotemonitoring

INRtesting

Medicationcompliance

3

Source: Stroke association: https://www.stroke.org.uk/professionals/af-page/af-page-%E2%80%93-ccgs-d

585

348

426

SSNAP 2014/15: Strokes and known AF

Anticoagulated Aspirin only No treatment

Why? - London picture

4Source: NCVIN 13-14 and QOF 14-15

-> 67,000 undiagnosed AF patients in London

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6

Prevalence data for practices in the CCG

7

8

Barnet – 760

Anticoagulation rates – untreated patients

9

10

Source: QOF 14-15AF 004 no exceptionsQOF Actual

Variation in anticoagulation rates for practices in the CCG

Anticoagulation rates

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Source: QOF 14-15AF 004 no exceptions

Could do better?

Best practice

-2000

-1500

-1000

-500

0

500

1000

1500

2000

2500

(£15,000,000)

(£10,000,000)

(£5,000,000)

£0

£5,000,000

£10,000,000

£15,000,000

£20,000,000

Yr1 Yr2 Yr3 Yr4 Yr5

5 year change in NHS and LA spend and strokes prevented

Total costs Total savings Budget impact (savings - cost) Strokes prevented

• Based on the NICE AF costing tool (2014) with thesame modelling assumptions

• 84.21% of AF population have CHADSVASC≥ 2

• Baseline demographic data from QOF 2014/15• Current and future treatment estimates from NICE

AF costing report 2014• 3 NOACS (not edoxaban) used in equal proportion• Cost of stroke £12,228 (NICE); major bleed cost

£1,173 (NICE)• Cost of long-term nursing care £6,880 does not

include all social care costs• Drug costs from MIMS 2015• Does not include other economic benefits• Does not include increase in AF incidence year-on-

year• Does not include additional patients

identified through screening

Modelling assumptions

Health and budget impact modelling – London

Stroke

sP

reven

ted

Savi

ngs

Co

sts

Benefits

• Prevent over 2000 strokes over 5 years• ~ 400 - 500 lives saved over 5 years• Net savings seen at year 3, and accumulative

net savings to health economy of ~ £3.5 millionover 5 years.

• Based on the NICE AF costing tool (2014) with thesame modelling assumptions

• 84.21% of AF population have CHADSVASC≥ 2

• Baseline demographic data from QOF 2014/15• Current and future treatment estimates from NICE

AF costing report 2014• 3 NOACS (not edoxaban) used in equal proportion• Cost of stroke £12,228 (NICE); major bleed cost

£1,173 (NICE)• Cost of long-term nursing care £6,880 does not

include all social care costs• Drug costs from MIMS 2015• Does not include other economic benefits• Does not include increase in AF incidence year-on-

year• Does not include additional patients

identified through screening

Modelling assumptions

Health and budget impact modelling – CCG

Stroke

sP

reven

ted

Savi

ngs

Co

sts

14

Where to look

• Data set in your delegate packs

• Locally available datasets on prescribing and INR• Warfarin Patient Safety Audit tool – PRIMIS members• http://www.nottingham.ac.uk/primis/index.aspx

• National cardiovascular intelligence network, CVD primary care intelligence pack -http://www.yhpho.org.uk/default.aspx?RID=182342

• NHS Right care – commissioning for value packs for CVD -http://www.rightcare.nhs.uk/index.php/commissioning-for-value/

• QOF 2014/15 - http://qof.hscic.gov.uk/

• Sentinel Stroke National Audit Programme Website (SSNAP) -https://www.strokeaudit.org/Newspress/SSNAP-Acute-Organisational-Audit-2014-Public-Repor.pdf

• Stroke association: https://www.stroke.org.uk/professionals/af-page/af-page-%E2%80%93-ccgs-d

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Key contacts for the programme are either through your local Academic Health Science Network or the London Strategic Clinical Network:

lauraspratling@nhs.net (Health Innovation Network AHSN, South London)

Shirlene.Oh@imperialcollegehealthpartners.com (Imperial AHSN, North West London)

Geraldine.Long@uclpartners.com (UCLPartners AHSN, North East and North Central London)

hcutting@nhs.net (Strategic Clinical Network)

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