1. The GM AHSN AF Landscape Tool: A shared public data platform to promote quality improvements and identify opportunities to prevent AF-related stroke in the devolved Greater Manchester health system
A Orlowski, GM AHSN, Manchester
D Heaton, Harvey Walsh Limited, Runcorn
J Macdonald, GM AHSN, Manchester

2. Stroke prevention in AF – A pathway of missed opportunities
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and estimates suggest its prevalence is increasing
If left untreated, AF increases the risk of stroke five-fold
AF-related strokes are often more severe with higher morbidity and mortality, but are also preventable with effective management
Public Health England (PHE) estimate the average cost/stroke at £24,000
Societal costs of stroke in the UK are estimated at £8bn/year
NICE Guidelines identified that over 50% of patients with known AF were not on effective medication
Better management of AF-related stroke could save the NHS £95 million a year
European Society of Cardiology. 2010;31: Lin H-J, et al. Stroke. 1996;27: Hart RG, et al. Ann Intern Med. 2007;146(12):857.

3. NICE CG180 (2014) – Improving stroke prevention in AF
NICE CG180 guidelines provide key markers of care and quality recommendations:
Offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account
Consider anticoagulation for men with a CHA2DS2-VASc of 1
Calculate time in therapeutic range (TTR) at each visit
Do not offer aspirin monotherapy
NICE CG180 Atrial Fibrillation: management.
Available from: nice.org.uk/guidance/cg180

4. Targets for improvement
NICE has called for CCGs to focus on preventing 8,000 strokes per year through better AF diagnosis and optimal anticoagulation
Two new CCG level indicators have been introduced to ensure patients are receiving NICE recommended treatments for their AF:
Proportion of patients with atrial fibrillation on anticoagulation admitted to hospital for stroke
Proportion of patients with atrial fibrillation not on anticoagulation admitted to hospital for stroke
PHE and the GM AHSN are collaborating to reach this goal. With the ambition to:
reduce 5,000 strokes in England over five years
reduce 365 strokes in GM in the next year – A Stroke a Day

5. Harnessing publicly available data
The opportunity:
Availability of national, regional and practice-level data on various aspects of care to:
Identify unwarranted variations in patient care, experience or outcomes
Provide a benchmark to enable the effective implementation of NICE CG180 guidelines
The challenge:
The AF care pathway spans primary and secondary care, emergency admissions and pharmacy
Variable access to different data sources at different time points, with no common view of the need or opportunity

6. The AF and AF-related Stroke Landscape Tool
Online shared evidence platform to stimulate improvements to the AF patient pathway using key public data sets:
Hospital Episode Statistics (HES)
Quality Outcomes Framework (QOF)
National Cardiovascular Intelligence Network (NCVIN)
Sentinel Stroke National Audit Programme (SSNAP)
GRASP-AF
Time in Therapeutic Range (TTR)
Baseline data are from 2015, across 13 CCGs, covering a population of 3,130,800
Hospital Episode Statistics (HES) – All admissions, outpatient appointments and A&E attendances at NHS hospitals in England
Quality Outcomes Framework (QOF) – Annual quality and outcomes reporting framework for GPs in England since 2004
National Cardiovascular Intelligence Network (NCVIN) – Public Health England calculated predicted AF prevalence data
Sentinel Stroke National Audit Programme (SSNAP) – Longitudinal audit of quality of care in stroke patients
GRASP-AF – An AF/coagulant prescribing audit tool created by NHS
Time in Therapeutic Range (TTR) – National quality standard to assess levels of therapeutic control
V1.0 launched in 2015 with V2.0 anticipated in 2017

8. CG180 and what the public data sets can show you
Progression to stroke
Review stroke risk when patients reach 65 years old
Review stroke and bleeding risks annually
HES
SSNAP
GRASP-AF
1.1 Diagnosis and assessment
Men are more commonly affected than women; increasing prevalence with age
Most common arrhythmia in people ≥ 75 years; 15% prevalence
NCVIN
QOF
1.4 Assessment of stroke and bleeding risks
Use CHA2DS2-VASc stroke risk score
Use the HAS-BLED to assess risk of bleeding
1.5 Interventions to prevent stroke
Consider OAC for men with a CHA2DS2-VASc of 1
Offer OAC to people with a CHA2DS2-VASc of >2
QOF AF004/5
1.5.1 Assessing anticoagulation control with VKA
Calculate TTR at each visit
Take into account factors that may contribute to poor control
Consider combination therapy
TTR
CG180
Guidance
Key Datasets

9. How do you benchmark with fair comparisons?
HES
SSNAP
versus
QOF
GRASP-AF

10. Current incidence of stroke in the AF population
Current 2015 baseline assessments show that on average over one third of patients with known AF are still suffering from a stroke, many of which could have been avoided with effective management
Data set
RightCare
Comparator
GM Average
Highest CCG
Lowest CCG
QOF: Total number of strokes reported (per 100k)
1,821
1,771
2,108
924
HES: % Stroke in-patients with a history of AF
33%
39%
27%

11. CG180 and what the public data sets can show you
Progression to stroke
Review stroke risk when they reach 65
Review stroke and bleeding risks annually
HES
SSNAP
GRASP-AF
1.1 Diagnosis and assessment
Men are more commonly affected than women; increasing prevalence with age
Most common arrhythmia in people ≥ 75 years, with a 15% prevalence
NCVIN
QOF
1.4 Assessment of stroke and bleeding risks
Use CHA2DS2-VASc score stroke risk score
Use the HAS-BLED to assess risk of bleeding
1.5 Interventions to prevent stroke
Consider anticoagulation for men with a CHA2DS2-VASc of Offer anticoagulation to people with a CHA2DS2-VASc of >2
QOF AF004/5
1.5.1 Assessing anticoagulation control with VKA
Calculate time in therapeutic range (TTR) at each visit
Take into account factors that may contribute to poor control (e.g. adherence, illness)
Consider combination therapy
TTR
CG180
Guidance
HES
SSNAP
GRASP-AF
Key Datasets

12. Potentially missing AF diagnoses
PHE NCVIN expected prevalence rates indicate that almost one third of people with AF may be missing a diagnosis – over 21,000 people in the GM area alone
Data set
RightCare
Comparator
GM Average
Highest CCG*
Lowest CCG*
NCVIN: Expected incidence of AF (per 100k)
2282
2190
2112
1974
QOF (AF001): Reported incidence of AF (per 100k)
1565
1499
1199
1523
Expected (NCVIN) minus observed (QOF AF001) AF diagnosis (per 100k)
717
691
913
451
*All figures based on Expected (NCVIN) minus Observed (QOF) highest and lowest CCG

13. CG180 and what the public data sets can show you
AF prevalence
Men are more commonly affected than women; increasing prevalence with age
Most common arrhythmia in people ≥ 75 years, with a 15% prevalence
NCVIN
AF diagnosis
Perform manual pulse palpitation to assess for irregular pulse
Perform an ECG in all people in whom AF is suspected
Use the CHA2DS2-CASc to assess stroke risk
NCVIN vs QOF
Ideal management*
Offer coagulation to people with CHA2DS2-CASc score ≥ 2 (or 1 for men)
Use the HAS-BLED to assess risk of bleeding
Do not offer aspirin monotherapy
SSNAP
Treatment to target**
Calculate time in therapeutic range (TTR) at each visit
Take into account factors that may contribute to poor control (e.g. adherence, illness)
Consider combination therapy
QOF AF004/5
GRASP-AF
TTR
Progression to stroke
Review stroke risk when they reach 65
Review stroke and bleeding risks annually
HES
CG180
Guidance
Key Datasets
*e.g. anticoagulation recommended to the patient
** successful treatment to target, including adherence

14. Patients with AF not prescribed an anticoagulant before a stroke
A significant number of patients are not currently receiving an anticoagulant, with a high proportion then progressing to a stroke
Data set
RightCare
Comparator
GM Average
Highest CCG
Lowest CCG
GRASP-AF: Patients with AF not prescribed an anticoagulant
(%)
22%
31%
48%
SSNAP: Patients with AF not prescribed anticoagulant before stroke (%)
52%
57%
74%
44%

15. CG180 and what the public data sets can show you
Need
CG180 and what the public data sets can show you
AF prevalence
Men are more commonly affected than women; increasing prevalence with age
Most common arrhythmia in people ≥ 75 years, with a 15% prevalence
NCVIN
AF diagnosis
Perform manual pulse palpitation to assess for irregular pulse
Perform an ECG in all people in whom AF is suspected
Use the CHA2DS2-CASc to assess stroke risk
NCVIN vs QOF
Ideal management*
Offer coagulation to people with CHA2DS2-CASc score ≥ 2 (or 1 for men)
Use the HAS-BLED to assess risk of bleeding
Do not offer aspirin monotherapy
SSNAP
Treatment to target**
Calculate time in therapeutic range (TTR) at each visit
Take into account factors that may contribute to poor control (e.g. adherence, illness)
Consider combination therapy
QOF AF004/5
GRASP-AF
TTR
Progression to stroke
Review stroke risk when they reach 65
Review stroke and bleeding risks annually
HES
SSNAP
QOF AF004/5
GRASP-AF
Key Datasets
*e.g. anticoagulation recommended to the patient
** successful treatment to target, including adherence

16. CG180 and what the public data sets can show you
AF prevalence
Men are more commonly affected than women; increasing prevalence with age
Most common arrhythmia in people ≥ 75 years, with a 15% prevalence
NCVIN
AF diagnosis
Perform manual pulse palpitation to assess for irregular pulse
Perform an ECG in all people in whom AF is suspected
Use the CHA2DS2-CASc to assess stroke risk
NCVIN vs QOF
Ideal management*
Offer coagulation to people with CHA2DS2-CASc score ≥ 2 (or 1 for men)
Use the HAS-BLED to assess risk of bleeding
Do not offer aspirin monotherapy
SSNAP
Treatment to target**
Calculate time in therapeutic range (TTR) at each visit
Take into account factors that may contribute to poor control (e.g. adherence, illness)
Consider combination therapy
QOF AF004/5
GRASP-AF
TTR
Progression to stroke
Review stroke risk when they reach 65
Review stroke and bleeding risks annually
HES
CG180
Guidance
SSNAP
QOF AF004/5
GRASP-AF
Key Datasets
*e.g. anticoagulation recommended to the patient
** successful treatment to target, including adherence

17. Even known AF, treated patients are not always receiving optimal care
QOF AF004 + AF005: 3764 patients not treated to target and 3307 exception reported in the GM area – totaling 7071 patients potentially inadequately managed
Data set
RightCare
Comparator
GM Average
Highest CCG
Lowest CCG
QOF (AF004*): Treated patients not to target (per 100k)
112
159 76
QOF (AF004): Treated patients exception reported (per 100k)
109 86
140 46
QOF (AF005**): Treated patients not to target (per 100k) 5 9 54
QOF (AF005): Treated patients exception reported (per 100k) 20 19 43 7
*AF004 = CHADS2>1
**AF005 = CHADS2=1

18. CG180 and what the public data sets can show you
AF prevalence
Men are more commonly affected than women; increasing prevalence with age
Most common arrhythmia in people ≥ 75 years, with a 15% prevalence
NCVIN
AF diagnosis
Perform manual pulse palpitation to assess for irregular pulse
Perform an ECG in all people in whom AF is suspected
Use the CHA2DS2-CASc to assess stroke risk
NCVIN vs QOF
Ideal management*
Offer coagulation to people with CHA2DS2-CASc score ≥ 2 (or 1 for men)
Use the HAS-BLED to assess risk of bleeding
Do not offer aspirin monotherapy
SSNAP
Treatment to target**
Calculate time in therapeutic range (TTR) at each visit
Take into account factors that may contribute to poor control (e.g. adherence, illness)
Consider combination therapy
QOF AF004/5
GRASP-AF
TTR
Progression to stroke
Review stroke risk when they reach 65
Review stroke and bleeding risks annually
HES
CG180
Guidance
Key Datasets
*e.g. anticoagulation recommended to the patient
** successful treatment to target, including adherence

19. 2015 benchmarks: key findings
There is a significant opportunity to reduce the progression to stroke in patients with known AF
In some regions the number of people with known AF not prescribed an anticoagulant before a stroke was as high as 74%
Even treated patients are not always optimally managed
Up to 20% of patient with a CHADS2>1 (AF004) are not to target
Up to 27% of patients with a CHADS2=1 (AF005) are not to target
NICE estimates that up to 470,000 adults with AF have not been diagnosed and therefore are not receiving appropriate advice to reduce their risk of stroke
Over 21,000 people could have a missing diagnosis in GM alone

20. Future perspectives
GM is the first region in England to gain control of its health and social care budgets
In this new landscape the AF Landscape Tool…
helps us to identify regional variations and address inequalities in care
helps our members to answer the question: “Where are we now?” pinpointing where local resources can be directed most effectively
provides vital information to build business cases for improvements in the AF patient pathway
We are partnered with PHE’s AF stroke prevention programme, and three more AHSNs have recently adopted the landscape tool
QOF AF reports using CHA2DS2-VASc scores are due in October
Kent, Surrey and Sussex (KSS); North West Coast (NWC); Imperial College Health Partners

21. Any Questions?