1. Reducing Death and Disability Sheila Glenn
Positive Strokes;
Reducing Death and Disability
Sheila Glenn
Instructions: Prepare a presentation for Module 2 at Yale University July 12-17th.
Submit to by July 3rd
Presentation should be 10 minutes and will include 10 minutes of Q&A, followed by written and in-person feedback from Yale faculty and your peers in the program.

2. Current State
Every year in England there are a significant number of premature deaths. A quarter of these are due to cardiovascular disease (CVD) Two thirds of premature deaths could be avoided through improved prevention, early detection and better treatment
One form of CVD is Atrial Fibrillation (AF). This is the most common heart arrhythmia and a known significant risk for stroke ( increasing both a stroke’s risk and severity)
However, despite strong evidence supporting the efficacy of anti-coagulants in preventing thromboembolism related to AF, it is estimated that almost half of all AF patients who would benefit from anti-coagulation are not receiving it
There is also a gap between the observed to expected number of patients with AF. In NHS Norwich CCG there is a 0.62 ratio of observed to expected AF prevalence. This suggests that 38% of patients expected to have AF have not been diagnosed. It is estimated that there are 1,896 people with undiagnosed AF in Norwich CCG.  

3. What’s the problem?
“The problem is….. preventable death or long term disability from Atrial Fibrillation related Strokes”
At Norfolk and Norwich University Hospitals
20.1% of patients had a diagnosis of atrial fibrillation prior to a stroke admission. Of these patients:
Only 40.5% were on anticoagulation medicine (national average 34.4%)
33.3% were on antiplatelet medication only (national average 36.1%)

4. What’s the Objective?
The number of AF related strokes in Norwich will decrease by 10% by December 2015

5. Root Cause Analysis

6. Which Strategy?
Stakeholder feedback suggested that a change in GP perception of risk , easy case finding and changes in prescribing behaviour would be a likely solutions to the problem statement. The following strategies were identified to enable this:

7. Implementation: Milestones
Business case signed off. April 15 (SG)
All practices’ download and analyse findings from GRASP AF and Warfarin Safety Tool (By end June 15)
Each practice identify an AF clinical al lead (By end of April 15)
Clinician attends the Medi-Bite AF learning event on the 21st May 2015 (SG)
Clinical case reviews take place in all practices (By end of Sept 15)
GP practices develop action plans (By end of October 15)
Norwich wide AF learning event (By Mid-November15)
Develop and agree a CCG wide AF action plan (By end Nov 15)

8. Success Factors
All practices will be able to identify all of their AF patients
All practices will have identified all patients with a potential of AF, these patients will all be assessed and started on treatment as appropriate
Use of NOACs will increase
AF related strokes presenting to the Norfolk and Norwich NHS Trust will decrease by 10% by December 2015 (Baseline May – December 2014 )
Decreased system cost associated with stroke

9. Personal Learning
Involving a wide range of stake-holders from the start was essential (This helped in analysis of the problem and a shared understanding of the potential solutions)
Using an educative, incentivised approach was impactful and effective
Identifying relevant clinical leaders with a passion in the area of stroke and AF had an emotional impact on motivation