1. AF in the West Midlands: Prevalence, pathways and management Dr Indira Natarajan FRCP, Clinical Director for Stroke, West Midlands SCN & Senate Dr Orsolina Martino, Specialty Registrar in Public Health, PHE

2. West Midlands Strategic Clinical Network: Atrial Fibrillation Prevalence Tool CCG comparisons 25/02/2016 AF & Stroke Prevention in the West Midlands Atrial Fibrillation reported vs expected prevalence In 2014/2015 there were 98,780 people on the QOF register for AF across the West Midlands Reported prevalence ranges from 1.03% to 2.21% (average = 1.66%) Expected prevalence ranges from 1.77% to 3.09% (average = 2.52%) Reported and expected prevalence vary between and within CCGs

3. West Midlands Strategic Clinical Network: Atrial Fibrillation Prevalence Tool CCG comparisons 25/02/2016 AF & Stroke Prevention in the West Midlands How high risk patients (CHADs2>1) are treated In 2014/15 there were 56,672 patients recorded as high-risk (CHADs 2>1), including exceptions High-risk patients treated with oral anticoagulants range from 67.6% to 81.0% Exception reporting ranges from 10.4% to 17.5%

4. West Midlands Strategic Clinical Network: Atrial Fibrillation Prevalence Tool Risk comparison 25/02/2016 AF & Stroke Prevention in the West Midlands Numbers of high-risk patients, eligible for NOACs and strokes prevented based on CHADS2 (current), CHADS- VASC applied to current AF registers, and CHADS-VASC applied to expected prevalence Based on applying CHADS-VASC to current AF registers, an additional 27,503 patients would be identified as high-risk, an additional 23,378 would be eligible for NOACs, and an additional 632 strokes would be prevented Applying CHADS-VASC to estimated prevalence would result in a further 37,495 high-risk patients identified, 31,871 anticoagulated and 862 strokes prevented

5. West Midlands Strategic Clinical Network: Atrial Fibrillation Prevalence Tool Stroke admissions (primary diagnosis) with AF coded in addition (secondary & subsequent diagnosis) based on HES data 25/02/2016 AF & Stroke Prevention in the West Midlands Proportion of stroke admissions also coded with AF (HES data) The proportion of stroke admissions with a diagnosis of AF ranged from 23.5% to 35.2% (average = 29.2%)

6. West Midlands Strategic Clinical Network: Atrial Fibrillation Prevalence Tool Stroke admissions (primary diagnosis) with AF coded in addition (secondary & subsequent diagnosis) based on HES data 25/02/2016 AF & Stroke Prevention in the West Midlands Average length of stay for stroke admissions and stroke with AF admissions Length of stay for stroke with AF admissions ranged from 0.4 to 16.4 days (average = 8.4 days) This was generally higher than for stroke admissions overall (range 1.2 to 14.2 days, average = 7 days)

7. West Midlands Strategic Clinical Network: Atrial Fibrillation Prevalence Tool Key SSNAP indicators 25/02/2016 AF & Stroke Prevention in the West Midlands Proportion of SSNAP stroke arrivals with an AF diagnosis The proportion of SSNAP stroke arrivals with an AF diagnosis ranged from 10.3% to 25.5% (average = 19.0%)

8. West Midlands Strategic Clinical Network: Atrial Fibrillation Prevalence Tool Key SSNAP indicators 25/02/2016 AF & Stroke Prevention in the West Midlands Proportion of SSNAP stroke arrivals with an AF diagnosis who were NOT on anticoagulants at time of arrival The proportion of SSNAP stroke arrivals with an AF diagnosis who were NOT on anticoagulants ranged from 48.9% to 75.4% (average = 59.5%)

9. West Midlands Strategic Clinical Network: Atrial Fibrillation Prevalence Tool Key SSNAP indicators 25/02/2016 AF & Stroke Prevention in the West Midlands Proportion of SSNAP stroke arrivals with an AF diagnosis who were ONLY on antiplatelets at time of arrival The proportion of SSNAP stroke arrivals with an AF diagnosis who were ONLY on antiplatelets ranged from 18.8% to 50.8% (average = 32.7%)

10. West Midlands Strategic Clinical Network: Atrial Fibrillation Prevalence Tool Key SSNAP indicators 25/02/2016 AF & Stroke Prevention in the West Midlands Proportion of SSNAP stroke admissions where patients in atrial fibrillation on discharge are discharged on anticoagulants or with a plan to start anticoagulation The majority of patients in atrial fibrillation on discharge were discharged on anticoagulants, or with a plan to start anticoagulation (range 58.6% to 100% (average = 91.6%)

11. West Midlands Strategic Clinical Network: Atrial Fibrillation Prevalence Tool Key SSNAP indicators 25/02/2016 AF & Stroke Prevention in the West Midlands Numbers of SSNAP stroke arrivals with an AF diagnosis, January 2014 to September 2015 Numbers of stroke admissions have fluctuated but remained broadly similar regionally and nationally over the last 18 months The proportion of stroke admissions with AF also fluctuated, accounting for approximately 20% both regionally and nationally over the 18-month period

12. Summary of West Midlands data Approximately a third of patients with AF across the region (estimated at 44,638 in total) are not reported This is 4,005 fewer than in 2013/14, reflecting some improvement Based on 2014/15 estimates, approximately 49,081 additional patients are eligible for NOACS This could potentially prevent 1,326 strokes across the region Potential cost savings range from £13.3M to £53.1M on average – ranging from £130-£520K in Wye Forest CCG to £900K-£3.6M in Sandwell & West Birmingham CCG 25/02/2016 AF & Stroke Prevention in the West Midlands

13. AF care pathways in the West Midlands Diagnosis and management of AF varies across the region - in some areas, AF is managed entirely or mainly in primary care Patients may be diagnosed in primary care using ECG facilities on site, or in secondary care Anticoagulation therapy may be determined by the GP, or in anticoagulation clinics in community or secondary care settings Monitoring may also be done in primary or secondary care settings, depending on what is prescribed and the needs of the patient Tools such as GRASP-AF, HAS-BLED and Keele University’s decision support tool can help GPs find and manage cases appropriately 25/02/2016 AF & Stroke Prevention in the West Midlands

14. Local examples 25/02/2016 AF & Stroke Prevention in the West Midlands In Coventry & Rugby initial diagnoses are made in a range of settings, including GP and other primary care centres. Patients diagnosed with AF will be referred to secondary care to see an AC nurse or haematologist; they may be referred to a consultant if they are a high-risk case or to review unstable INR on a regular basis. In Birmingham South & Central AF is managed primarily in primary care. Patients are diagnosed via ECG in some practices, or in community-led centres – some go to hospital. Following diagnosis they are assessed in community- based anticoagulation clinics. South Worcestershire used consultation and education to develop tools and strategies to meet stretched targets for detecting arrhythmia and starting/monitoring anticoagulation. AF is diagnosed and managed in primary care, with complex cases managed in secondary care. Walsall CCG has in-house ECG recording in 80-90% of practices. Patients are diagnosed in the surgery, and most will also be managed in primary care (where controlled/ stable) – more complex or uncertain cases are referred to secondary care. Telford & Wrekin has a Locally Enhanced Service (LES) for AF developed in line with NICE guidance, and patients are managed in primary care by their GP. All patients with an AF diagnosis are reviewed annually.

15. What works well… Sharing information with GPs to show the value of improving AF diagnosis and management Training and support in the use of data and tools Counselling for patients in specialist clinics to help them understand their diagnosis and available options Using targets to measure and demonstrate improvement 25/02/2016 AF & Stroke Prevention in the West Midlands

16. …and some of the challenges Attending clinics in secondary care can be time consuming for patients, with little flexibility Managing rising demand in the population, particularly among smaller practices GP capacity to keep on top of interpretation and training Variations in quality of data recording Recent changes to AF targets 25/02/2016 AF & Stroke Prevention in the West Midlands

17. Patients, pathways and public health – what are the issues? Difficulty accessing services is a major barrier to patients receiving timely and appropriate care The doctor-patient relationship is a key factor in attending appointments and adhering to treatment Differences in groups of patients less likely to access/receive the treatment they need widens health inequalities As with any preventative action, it can be difficult to demonstrate the benefits – and the harms of NOT doing it are only seen when it is too late 25/02/2016 AF & Stroke Prevention in the West Midlands

18. The bigger picture 25/02/2016 AF & Stroke Prevention in the West Midlands

19. The public health impact of stroke Stroke is both a cause and consequence of health and social inequalities, impacting directly and indirectly on individuals, families and communities. People from the most deprived areas are twice as likely as those from the most affluent areas to have a stroke, and three times as likely to die from it. Over half of all stroke survivors are left with a disability, and over a third require help with everyday activities. A report produced by the Stroke Association in 2012 showed that: – 69% of stroke survivors aged 25-59 were unable to return to work, and 65% reported a decrease in household income; – 58% reported an increase in household expenses, including heating bills, transport costs, care services and home adaptations; – 63% were living in fuel poverty, and 40% had to cut back on food. In the UK, the economic costs of stroke to society are around £9 billion per year, including the costs of health and social care, informal care, loss of productivity and benefit payments. 1 25/02/2016 AF & Stroke Prevention in the West Midlands