1. Saving Lives from AF-related Stroke in West Hampshire CCG Optimising oral anticoagulation in AF
Liz Corteville, Medicines Optimisation
Cardiovascular Lead Pharmacist, West Hampshire CCG
Primary Care Pharmacists Association –
Symposium 17th January 2017

2. Atrial fibrillation Very common in the elderly On the increase
AF can lead to life-threatening health problems
Especially, stroke
Stroke prevention is with OAC
Reduce risk of stroke by 70%
Aspirin /antiplatelet monotherapy no longer indicated for stroke prevention in AF (NICE)

3. 1/3 of patients with AF will have a stroke
Atrial fibrillation
Patients with AF are 5-6 times more likely to suffer a stroke than patients who do not have AF.
AF related strokes are more severe and are more likely to be fatal.
1/3 of patients with AF will have a stroke
It’s crucial to identify patients with AF in the community (often asymptomatic).

4. 2,000 undiagnosed AF 12,000 10,500 West Hampshire CCG 51 practices
546,000 population
106,000 over 65s
16,000 over 85s
119,000 under 20
12,000
people with AF
Ageing population
10,500
AF high risk stroke

5. Optimising Care: The Plan
Identify undiagnosed AF using WatchBP tool
Identify and treat people not treated with OAC
Identify people on warfarin sub-optimally-controlled

6. Optimising Care: The Patient at the Centre
Saving lives for people and families
Saving time and money for the NHS

7. Optimising Care: The Method
Audit tools identified patients at high risk of stroke
Results to GPs & continuous feedback on improvement
Education and training was delivered
Medicines Optimisation Incentive Scheme
identification, feedback, education = continuous health improvement

8. Optimising Care: Collaborative Approach
350 GPs
and their teams
Donald

9. Optimising Care: GRASP AF
Total number of expected strokes annually
Number of high risk patients prescribed anti-platelets
Sep 14
167
Mar 16
129
Sept 16
128
Sep 14
2510
Mar 16
1651
Sept 16
1493
Number of high risk patients taking OAC
Sept 16
7987
Mar 16
7524
Sep 14
5916

10. Optimising Care: WPSAT
Average % of warfarin patients with a TTR less than 40%
Average % of warfarin patients with a TTR over 65%
Apr %
Mar 16
8.4%
Sept 16
7.7%
Mar 16
67%
Sept 16
67%
Apr 15
59%

11. Optimising Care: The Results19
new cases AF diagnosed
WatchBP
GRASP AF
39 expected strokes avoided
2071
more OAC

12. Optimising Care: The Results
3000 people
poorly-controlled on warfarin reviewed
WPSAT

13. Number of reported strokes across WHCCG

14. Optimising Care: Paying for Improvements
£1.7 million saved in 15/16
Mike
Dr Chris
Neil
£1.5 million extra spent on DOACs for AF

15. Optimising Care: What next?
WatchBP to AliveCor
Review 1500 high-risk patients receiving antiplatelet monotherapy
Review 1500 high-risk patients not receiving OAC or those poorly-controlled on warfarin
Getting improvement work embedded into routine clinical practice (including care home residents)

16. Optimising Care: DOACs and Frailty
DOACs have many advantages; fixed dosing, steady pharmacokinetics, lack of coagulation monitoring
But compliance and adherence are crucial, as short half-life
Falls risk often over-stated as reason for with-holding treatment
Intracranial haemorrhage: DOACs better than warfarin in frequent fallers
Low body weight common in frail elderly; caution dosing
Overall, in elderly patients with polypharmacy DOACs fewer interactions than warfarin
However, each DOAC has own set of drug interactions
Applying to Care Home population

17. Optimising Care: Making DOACs safer
Carry out full risk-benefit analysis including medication review before commencement/ annually on continued use
Review regularly (NICE – annually; EHRA 1/12 after initiation then every 3/12)
Care with correct dosage (under- and over- dosage) and ordering frequency
Use creatinine clearance to calculate renal function (not eGFR) – might need switch to warfarin
Always check co-prescribing DOAC and antiplatelet agents are specialist approved
Check for drug interactions
Check no duplication of anticoagulant (switch protocol)
Educate patients/carers/ home staff re what bleeding looks like

18. Optimising Care: Reporting Bleeds
Prolonged nosebleeds (over 10 minutes)
Blood in vomit
Blood in sputum
Passing blood in urine or faeces
Passing black faeces
Severe (larger than palm of hand) or spontaneous bruising
Unusual headaches
In women heavy or increased menstrual/vaginal loss
Involved in major trauma

19. Prioritising patients for review – Polypharmacy Prioritisation Tool

20. Prioritising patients for review – filter for e. g
Prioritising patients for review – filter for e.g. OAC, antiplatelets, digoxin and low eGFR

21. Optimising Care: Patient-centred
Getting OAC improvement work embedded into care homes
Challenges are similar for residents as for general population
frailty; safety; training (reporting bleeds); adherence
To conclude
I’m pleased to have been able to share with you
A POWERFUL
REPRODUCIBLE
COLLABORATIVE
Way of carrying out
HEALTH IMPROVEMENT
To the benefit of PATIENTS and the NHS