1. Welcome Add date Add speaker Chair Mohammed Khalil Senior Commissioning Manager SWB CCG Atrial Fibrillation Project A Structured Programme For Primary Care

2. Introduction Sandwell and West Birmingham CCG has a population of 549,398 registered patients CCG footprint covers Sandwell and West Birmingham patients – older population in Sandwell and younger in Birmingham Significant gap in Atrial Fibrillation actual to expected prevalence – Estimated prevalence gap in 2014/15 of 4,000 patients with undiagnosed atrial fibrillation

3. Back Ground - AF Identification Opportunistic screening through pulse checks for over 65s – Improved detection through targeted screening (e.g. flu clinics) – Increase in prevalence from 0.98 to 1.1% – Estimated prevalence gap from 2013/14 to 2014/15 reduced by 185 Leaning from ICOF locality 2014/15 – APODI integrated clinics

4. Project Development Interface Clinical Services (ICS) - independent pharmacist-led clinical service provider Funding through Bayer PLC Developed bespoke model with ICS, included learning from APODI project Iterative process to tailor project to CCG requirements

5. Business Case Implementation of NICE guidance CG 180 - treatment of untreated already diagnosed AF patients and those that are exception coded, a total of 1,127 patients (Cardiovascular Intelligence Pack, Public Health England, March 2015) Prevent 36 strokes - Using the average treatment cost of a stroke CCG of £6,909, it is anticipated that direct treatment cost savings of £249,169 would be generated Reduced prescribing cost - Warfarin will be used as first line and NOAC prescribing will be monitored to ensure it is clinically appropriate

6. Project Aims To identify and project actual disease burden of AF within the CCG through prevalence register validation To support practices in the therapeutic management of stroke risk in AF patients in accordance with risk profile incorporating HAS- BLED, current national and local guidelines, local formularies, and practice preferences Include local consultant haematologists/cardiologists, to deliver specialist anticoagulation clinic services within primary care Educational support to practice staff and patients to help with the understanding of their condition and therapeutic management

7. Project Aims Installation of ICS toolkit, to systematically scan AF registers to facilitate benchmarking performance against national data Assist the practice in the achievement of Quality and Outcome Indicator targets for AF, in line with the indicator changes of the QOF 2015/16 parameters- risk stratified against CHA2DS2-VASc and all patients currently treated with an antiplatelet will need to be reassessed for anticoagulant Adoption and integration of NICE CG 180 guidelines into practice work streams Reduction in number of strokes with Atrial Fibrillation as their cause Management of treatment cost for Atrial Fibrillation by ensuring only those patients from whom Warfarin is not effective are prescribed the new NOACs anticoagulants

8. Project Components Therapy Review. A clinical pharmacist delivering a therapy review through individual assessment of all patients with atrial fibrillation, using clinical system software and professional knowledge. Pharmacist Led Anticoagulation Education, Transition Support and Adherence Clinic. Support practices with the burden of transitioning patients to non VKA oral anticoagulants (NOACs) through a pragmatic review of those patients on aspirin or time within therapeutic range of less than 65%.

9. Project Components Consultant-led anticoagulation assessment clinics. For complex clinical cases and using a local consultant Anticoagulation educational support for healthcare professionals. training specifically designed to support practice clinicians in the appropriate management of AF patients, ensuring best practice and optimising treatment outcomes. External Evaluation and validation of the project. Independent evaluation to ensure the CCG can capture learning and make recommendations going forward.

10. Patient Journey ON OAC PATIENT WITH AF (CHA 2 DS 2 - VASc>1) NO OAC VKA PATIENT – ASSESS TIME IN RANGE NON VKA PATIENT ASSESS COMPLIANCE COMPONENT 1 CINICAL NOTES REVIEW (DEEP DIVE) RECOMMENDATION LEAD GP AUTHORISATION TO MANAGE INTERVENTION COMPONENT 2 – PHARMACIST LED CLINIC: DISCUSSION WITH PATIENT INITIATION / TRANSITION TO APPROPRIATE THERAPY COMPONENT 3 – CONSULTANT LED CLINIC DISCUSSION WITH PATIENT INITIATION / TRANSITION TO APPROPRIATE THERAPY Sub-Optimal Control (TTR) Poor Compliance Invite Complex patients Optimal Management PROVISION OF EDUCATIONAL INFORMATION PROVISION OF EDUCATIONAL SESSIONS DECREASED VARIATION IN CARE INCREASED ORAL ANTICOAGULANT USE PROMS DATA FROM CLINICS REDUCED STROKES

11. Practice Engagement To contact book practices in following agreement to engage in audit. Email confirmation sent out to confirm date and time. Clinical pharmacist to contact practice manager prior to review to ensure that review is good to go ahead and arrange logins, room availability etc. Clinical protocol to be signed and dated by lead GP and Practice Manager prior to commencing clinical audit Practice to arrange for INR data prior to review. (If yellow book then to contact patients to bring yellow book in and copies to be made.) On morning of review, clinical pharmacist to meet GP and PM to introduce project. Pharmacist will require access to quiet room with computer terminal and printer. Meet with GP during the day to discuss which patients should be invited in to pharmacist and consultant clinics. (GP authorisation required to invite any patients in). If component 1 not completed within 1 day, clinical pharmacist to arrange convenient day(s) to complete Following GP authorisation, patients invited into hub clinic for discussion with either clinical pharmacist or consultant Outcomes from pharmacist & consultant clinics fed back to GP and actioned by ICS/GP/Consultant.

12. Governance Each practice sign’s an agreement with ICS which includes data sharing Individual practice and lead authorising clinician retains control over process at all times – All interventions require individual sign off under direction of a clinician – All ICS personnel undertaking therapy reviews will adhere to: Detailed clinical audit protocol Strict governance protocol National and local guidelines on management of AF

13. Project Roll-out Project started in January 2016 and will be delivered separately to each locality network First locality will allow opportunity for learning for subsequent roll-out Initial feedback for SHA locality of 32 practices – 21 practices signed up – 620 patients reviewed to date – 164 to be invited to pharmacist clinics (TTR<65% or no anticoagulant's) – 51 patients on AF treatment not on AF register

14. Things to consider Early on identify clinical champion to support the development of project Tailor the project to suit local needs i.e. education for practice staff, consultant input Use the locality network to engage with practices Regular meetings to track progress to ensure practices are signing-up and issues are picked up and addressed

15. Expected Project Outcomes CCG level - reducing AF related strokes disability/death, associated saving on treatment cost, pragmatic approach to prescribing Practice level – improving AF identification /stratification and anticoagulation GP level - audit/appraisal/revalidation

16. Questions?