1. Using the GRASP-AF tool to optimise anti-thrombotic therapy in patients with AF - the Plymouth experience
Paul Manson
Prescribing Adviser
March 2011

2. What are we trying to achieve?
Optimisation of anti-thrombotic therapy in patients with AF to reduce strokes.
Underuse of warfarin is well established
- need to change prescribing behaviour.
GRASP-AF provides a support tool to deliver this but still need to drive change.
Influencing prescribing is key.
Audit support
Benchmarking
Face to face engagement / GP education
Patient education (e.g Patient decision aids)
Incentives

3. Why is choice of anti-thrombotic important ?
Warfarin reduces stroke risk in AF by 64%
Aspirin reduces stroke risk in AF by 22%
Risk of major bleed with warfarin is slightly greater than with aspirin( 0.9% vs 0.6% p.a.)
If we switch 1000 AF patients with a high stroke risk (6% stroke risk p.a.) from aspirin to warfarin, we will prevent 24 extra strokes p.a. at the expense of 2 extra bleeds.
5% of patients change risk category each year

4. How does GRASP-AF help us?
Free data extraction tool which runs on all GP computer systems under CHART
Provides
High quality patient level data.
Practice summary data in a dashboard.
PCT access to data via CHART ONLINE

5. Patient level data

6. CHADS2 Summary Dashboard

7. PCT View of practice GRASP-AF Audits

8. What did we do in Plymouth?
Encouraged practices to run the GRASP-AF Audit tool as part of their annual CG audit requirements for 09/10
Practices were asked to:
run a baseline GRASP-AF data extraction
follow up patients with a CHADS2 score >1 not taking warfarin and not exception coded.
run a follow up GRASP-AF data extraction after 3 months and submit summary data from both data extractions to the PCT on a proforma provided.

9. Support for practices and PCT collation
PCT PRIMIS facilitator offered guidance and support for practices in delivering GRASP-AF data extractions and uploading to CHART online.
Guidance from PCT Cardiac Lead GP provided around the clinical evidence and issues regarding warfarin use.
Patient decision aids (

10. What happened?
36 out of 44 GP practices in NHS Plymouth ran the GRASP-AF audit
Detailed analysis of changes between baseline and follow up audit was possible in 32 practices (203,000 patients- 80% of PCT population)

11. Analysis of AF patients with CHADS2 score >1 for 32 practices analysed
Key
Taking warfarin
Not taking warfarin but coded as 'Warfarin declined'
Not taking warfarin but coded as ' Warfarin contraindicated '
Not taking warfarin and not exception coded
Follow up after mean 103.6
days (1,829 patients)
Baseline (1,811 patients)
315 patients (17.2%)
970 patients (53.5%)
669 patients (36.9%)
1020 patients (55.7%)
148 patients (8.1%%)
42 patients (2.3%%)
130 patients (7.1%)
346 patients (18.9%)
Small increase in warfarin prescribing in patients with a CHADS2 score >1 ( 53.5% to 55.7%)… 50 patients
Coding of exceptions to warfarin use (e.g. C/I or declined) were generally very poor at baseline but changed signficantly as a result of the audit.
Worryingly there were still 315 patients who should be considered for warfarin and not exception coded.

12. What went well?
The GRASP-AF audit tool ran well on GP systems with support from PCT PRIMIS facilitator.
Practice participation was good as result of linking audit to Clinical Governance payments.
Uploading of summary data by practices enabled remote PCT oversight.
Positive feedback from GPs in follow-up questionnaire

13. Questionnaire results (1)
1. Did your practice experience any technical problems in relation to using the GRASP-AF audit tool? (Number of answers 26)

14. Questionnaire results (2)
2. Has the practice’s clinical knowledge or attitude to using Warfarin in patients with AF at high stroke risk changed as a result of doing the audit? (Number of answers 27)

15. Questionnaire results (3)
3. Do the clinicians in the practice feel that further local training or support from the specialist services in the risk assessment of stroke risk in AF, or assessing the risks and benefits of different anti-thrombotics treatments would be beneficial? (Number of answers 26)

16. Questionnaire results (4)
4. Did the clinicians in the practice find the patient decision aids helpful is discussing risks and benefits with patients? (Number of answers 27)

17. What did not go so well?
The GRASP-AF tool includes patients who are ‘AF resolved’ following cardio-version.
When practices re-run the GRASP-AF tool, previous data is overwritten.
The smaller than anticipated increase in warfarin prescribing in high risk patients may be due to a number of factors:
Overstated concerns about the risks of warfarin and complexity of the prescribing decision.
Capacity issues by GPs – may take longer
Lack of ‘in-practice influence’ to change prescribing behaviour.

18. Recent follow up work
In December 2010 we did a further data extraction across all 42 Plymouth GP practices to track progress.
% warfarin prescribing in AF patients with a CHADS2 >1 was more than 3% higher in those practices who completed the 09/10 audit compared to those that did not (56.8% vs 53.6%)
Data for all 42 practices was uploaded to CHART ONLINE providing useful PCT level data.

19. Analysis PCT Level data from CHART ONLINE
Breakdown of CHADS2 scores across all 4,570 Plymouth
patients coded for AF
CHADS2 score = patients (16.1%)
CHADS2 score = ,229 patients (26.9%)
CHADS2 score = ,368 patients (29.9%)
CHADS2 score = patients (14.7%)
CHADS2 score = patients (8.9%)
CHADS2 score = patients (3.0%)
CHADS2 score = patients (0.4%)
57% patients have a CHADS2 score > 1

20. Analysis PCT Level data from CHART ONLINE
Possible annual stroke reduction in patients with CHADS2 score > 1

21. Thank you for listening Any questions?