Audit “ a critical systematic analysis of the quality of medical care – including outcomes use of resources and quality of life for the patient”

BASILDON ANTICOAGULANT SERVICE 1989Consultant and Clinical Assistants seeing patients in clinic Prothrombin time measured by MLSO x patients – 3 weekly clinics In control - 50% No patient selection or education

BASILDON ANTICOAGULANT SERVICE 2002 Nurses see the patient in clinic, on ward and at home Automated analyser interfaced to computer NPT as required 2,400 patients New patients seen, others by request

Benchmarking exercises If same algorithm - what makes the difference ? Manual intervention Patient selection

% Time in Range Comparison for April 2002 Run, Site 11 and Range 2.50 This chart shows the time in range for all sites in ascending order. The bar below the line shows the time below range; the bar above the line shows the time above range. Your site is highlighted in red. The numbers of patients for each site are shown at the bottom of the chart. % Time in Range

PATIENT SELECTION The ideal patient: is co-operative can read has no other illnesses or drugs remembers what you tell them doesn’t worry is stable and temperate in their habits

Patient selection SPAF, etc. highly selective Beyth – multi-component intervention – 9% of older patients randomised Can we generalise from such a selected group?

RISK FACTORS FOR THROMBOSIS IN AF – SPAF 3 independent clinical predictors RR CCF2.6 MultivarateHypertension2.2 PH of thrombo embolism2.1 Event rate - % pa Age < Univariate > Age as a multivariate risk featureRR = 1.2

RISK FACTORS FOR VTE Cancer31% CCF24% Fracture10% MI 8% Obesity 4%

Male Patients Female Patients >80 Incidence rate per 100,000 Age years

The results are sometimes embarrassing Evidence based medicine Like teenage sex Everyone thinks everyone else is doing it Those doing it have enthusiasm rather than expertise Old people disapprove of it

THE EVIDENCE BASE INCEPTION-COHORT PROSPECTVE COLLABORATIVE STUDY ITALIAN STUDY ON COMPLICATIONS OF ORAL ANTICOAGULANT TREATMENT (ISCOAT) Palaretti Lancet p patients in 34 clinics followed for one year AGE < AGE > Died 102 Died AC comp. 5

ANTICOAGULANT CONTROL 51566INRs Mean interval 15 days Multivarcate Risk Ratios All ranges %controlbelowabove All patients patients with bleeding RR Relative Risk Factors age > arterial disease 1.7 INR > Timing – 1 st 90 days 2.5

STUDY OBJECTIVES To identify complication of anticoagulant therapy 1.As a basis for improved practice – cf published works 1.To identify patients who would benefit from other treatments

Study Methods Review of 1 year’s patients –2,400 1/4/01 – 31/3/02 search of PAS for events - Bleeding + thromboses according to ICD codes Thrombosis DVT,PE TIA Search of blood bank needs for episodes GP + FHSA records for conformation/missing patients

G45 TIA I26 PE I60 CVA (thrombosis) I80 DVT K25 Gastric ulcer K26 Duodenal Ulcer K27 Peptic ulcer – site unspecified K92 GI He N2 Recurrent and persistent haematuria R4 Epitaxis R31 Haematuria R58 NOS

Basildon results LIH Target on DAWN Thromboses5 Bleeds INR on admission 29/39

>12  INR for complications

Outcome: Recovered and continued warfarin85% Recovered and stopped 9% Died 6% Death related to AC 0%

Co-morbidities Cancer18% Arthritis3% Heart failure – not stated

Local cause: Yes29% Peptic ulcer 6% Ca. Colon 3% Bladder lesion 6% Bronchitis 3% Ca. Bronchus 6%

INTERACTING DRUGS Yes32% Simvastatin15% Aspirin10% Amioderone 6% Diclofenac 3% Prednisolone 3%

ANTICOAGULANT CONTROL % in control below above All ranges ISCOAT Basildon

INCIDENCE OF BLEEDING P.A. Fatal % Major % Minor % Levin – experimental studies ’ Londfield review of similar studies ’ Palaretti – prospective cohort study ’ Watts + Clark retrospective

Have we captured all the events ? Do clinicians report events to us ? Review of patients terminated in study period = 252 No. who have had blood transfusions = 13 2 Haemorrhagic deaths G.U. warfarin stopped 3/12 prior to fatal bleed post-op switched to IV heparin

PAS identifies admission and ICD code PAS identifies death Out of hospital death not necessarily referred ? Outcomes  Check GP records  FHSA statistics

Follow-up of DNAs All DNAs get a reminder letter If 3 DNAs – letter from EJW to patient and GP 35 patient disappeared 10 ‘disappeared’ patients attended post i.e. persistent poor attendees

What can DAWN tell us about our worst patients ? Worst – out of range 90% of the time 197 results from 24 patients i.e. 1% of our patient population provide the 10% worst results  Improve patient selection Palaretti changed 11% to anti-platelet R, Basildon < 1%

What should we do with the Awkward Squad ? Educate Stop warfarin – alternativesaspirin aspirin + dipyridamole New R, pentasachoride DTIs Agatroban Ximelagatran Clinical review and explain risks of stopping ? Give all patients an annual review

Fibrinogen Thrombin Melagatran (429,5 Da) exosite 1 (fibrinogen) exosite 2 (heparin) active site

NEWER ANTITHROMBOTICS WILL BE EXPENSIVE They will be cost effect for : Housebound patients Poorly controlled patients Patients on interacting drugs ? Discharge to GP now

CONCLUSION : This audit has shown a lower incidence of major and fatal bleeding than in previously reported studies. The retrospective nature of the data collection means some cases of non-fatal bleeding and some thromboses may not have been identified. Robust systems of data capture are required Fatal episodes can be identified through FHSA records

The Future

Technological Trends INTERNET World-wide Intranet or “NHSnet” Video Voice Image Telemedicine Notebooks Palmtops Mobile Phones Web Enabled TV Computer Telephony

Citrix Possibilities Seamless Connectivity

A Possible New Model Pharmacies Acute Hospitals Community e.g.Nurses PCGs GPs Dentists NHSNet or IntraNet Features Security Browser 24 hoursModem Admin Dawn AC Web Edition Needs a link for audit data collection

BASILDON ANTICOAGULANT SERVICE ? 2003 as all patients to have (or be offered) a clinical review patients treated inappropriately to be terminated problems patients to be offered alternative R,