CARDIOLOGY
Clinical review prevents thousands of strokes
A review by Interface Clinical Services of 135,000 patients with atrial fibrillation (AF) at more than a 1,000 GP practices led to over 25,000 medical interventions, which is believed to have prevented hundreds of strokes and saved the NHS millions of pounds. This article examines the work that’s being done.
Atrial fibrillation (AF) is the most common form of cardiac arrhythmia, affecting more than one million people in the UK. The abnormal rhythm prevents the heart from pumping effectively allowing blood to pool in the upper chambers called the atria. This pooling can result in the formation of a clot which can break loose and cause a stroke. Patients with AF are five times more likely to have a stroke, and when a stroke is related to AF there are increased levels of mortality, morbidity, disability, and longer hospital stays. Around 7,000 strokes and 2,000 deaths could be prevented every year through effective detection of AF, and protection with the right anticoagulant drugs. Multiple audits across the UK have confirmed that anticoagulant medications used to reduce the risk of AF-related stroke are under-prescribed.1 Professor Mark Baker, NICE’s (National Institute for Health and Care Excellence) director of clinical practice, has commented on the importance of stroke prevention for AF patients, saying: “We know that AF increases the risk of strokes by up to five times. It’s estimated that the condition causes around 12,500 strokes each year. We also know that around 7,000 strokes and 2,000 premature deaths could be avoided every year through effective detection and protection with anticoagulant drugs that prevent blood clots forming.”2 In response to the growing need for effective stroke prevention practices for AF patients in primary care, the NHS has partnered with clinical pharmacists from Interface Clinical Services to carry out a long term-clinical review aimed at increasing stroke prevention for atrial fibrillation patients. The review is still ongoing, but so far has assessed nearly 280,000 patients in over 2,000 GP practices across the UK. It has resulted in over 50,000 medical interventions, and is believed to have prevented more than 1,800 strokes. Funding for the review came from industry sponsorship.
Assessing the risk of strokes
Mike Drakard: “This was one of the largest projects we have undertaken.”
Mike Drakard, CEO of Interface Clinical
Services, whose pharmacists worked with the GPs on this review service, said: “This was one of the largest projects we have undertaken and based on NICE’s figures we believe that this review has prevented more than 1,800 strokes and over 500 deaths. The average cost of treating a stroke, rehabilitation and community support is at least £24,855,3
therefore, conservatively
we estimate a saving of over £45 million for the NHS as a whole.” The service initially began by identifying patients at 2,148 GP surgeries across the UK who had been diagnosed with AF or had clinical markers associated with AF. Patients where the diagnosis was not clear were excluded and flagged for further examination by the practice. This left 278,829 patients – representing approximately 24% of the UK AF population. Each of these patients were then assessed using the new CHA2DS2-VASc scoring system, as recommended by NICE and The European Society of Cardiology, which estimates the risk of stroke by scoring factors such as: congestive heart failure, hypertension, over 75, diabetes, stroke/mini stroke, gender, and vascular disease.
28 I
WWW.CLINICALSERVICESJOURNAL.COM
Following the stroke risk assessment, just over 21,000 patients were classified as low risk with no action required. The remaining 257,194 patients who were found to be at high-risk of stroke, were assessed for current stroke prevention therapy. The assessment process divided these patients into two groups: those who were on oral anticoagulant therapy, 181,767; and those who were not, 75,427. The 181,767 patients on oral anticoagulant therapy were further divided into two categories: those on a VKA (vitamin K antagonist) anticoagulant, and those on a non-VKA anticoagulant. VKAs are a group of substances that reduce blood clotting by blocking the action of vitamin K. The non-VKA anticoagulants are the new class of anticoagulants often referred to as NOACs, and include dabigatran, rivaroxaban, apixaban and edoxaban, which work on specific sites in the clotting cascade, by inhibiting clotting factors. The 75,427 patients who were not on any anticoagulant therapy were divided into those requiring VKA anticoagulant treatment, 21,827, and those requiring non-VKA anticoagulant treatment, 8,113.
Each patient was then clinically assessed, both those on anticoagulant therapy and those who were not, in line with NICE clinical guidelines, Quality and Outcomes Framework (QOF) criteria and practice specification. Those patients who were identified as requiring an intervention were asked to come for a consultation with their GP. The GP in consultation with the patient then made the decision on the best treatment for that patient going forward. Key results of the service were:
l Of the 75,427 patients who were not taking any type of oral anticoagulants, 21,827 were prescribed VKA therapy, and 8,113 were prescribed one of the new non-VKA anticoagulant drugs.
l Of the 181,767 patients already on oral anticoagulant medication 15,684 moved from VKA therapy to the new NOAC
SEPTEMBER 2017
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72
