Alison Tennant MRPharmS MPH Head of Service Improvement and Quality Dudley CCG

Transcription

1 Alison Tennant MRPharmS MPH Head of Service Improvement and Quality Dudley CCG

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3 Commissioning is the set of linked activities required to assess the healthcare needs of a population, specify the services required to meet those needs within a strategic framework, secure those services, monitor and evaluate the outcomes Julie Woodin (2006) Healthcare Management Ed Walshe and Smith OUP

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5 Key clinical issues in providing an effective anticoagulation therapy service are: accurately identifying all patients with AF who require anticoagulation therapy in line with the NICE clinical guideline CG36 on AF according to the stroke risk stratification algorithm providing effective anticoagulation therapy providing a quality-assured service ensuring there is ongoing monitoring to reduce bleeding risk.

6 Disease areas: Atrial Fibrillation Thromboembolism Valvular Disease Patients with replacement valves Stroke MI

7 Older people Active In supported care Working population

8 Are the right patients on warfarin? High-risk/low-risk Need evidence of outcomes Reduction in events Patient compliance Patient satisfaction Safety Patient satisfaction Cost of service

9 All secondary care Mixed primary and secondary care NB NICE service standards

10 Capacity Patient access Patient self care New oral anticoagulants (NOAC)

11 Dabigatran etexilate is recommended as an option for the prevention of stroke and systemic embolism within its licensed indication, that is, in people with nonvalvular atrial fibrillation with one or more of the following risk factors: previous stroke, transient ischaemic attack or systemic embolism left ventricular ejection fraction below 40% symptomatic heart failure of New York Heart Association (NYHA) class 2 or above age 75 years or older age 65 years or older with one of the following: diabetes mellitus, coronary artery disease or hypertension. The decision about whether to start treatment with dabigatran etexilate should be made after an informed discussion between the clinician and the person about the risks and benefits of dabigatran etexilate compared with warfarin. For people who are taking warfarin, the potential risks and benefits of switching to dabigatran etexilate should be considered in light of their level of international normalised ratio (INR) control.

12 Dudley currently identified AF patients 5,823 patients on GP registers Currently 94.25% are currently treated with anticoagulation or anti-platelet therapy 4,607 with diagnosis of AF at local secondary care anti-coagulation clinic

13 48% of patients not on warfarin or not controlled by warfarin (yorkshire study) How many patients will prefer NOAC? How many will comply/tolerate?

14 5,823 patients 48% = 2795 patients 10% still not eligible as high risk = % not tolerant = 2013 Cost of 2 years of dabigatran = 3,232,878

15 Strokes prevented: - If could have taken warfarin (NNT = 25) Potentially prevent 81 strokes over 2 years NB: To prevent the same number with warfarin would have cost 885,720

16 Affordability of NOAC opportunity cost Information for patients on new drugs Sustainability of anti-coagulation services with lower numbers Assurance that acute trust has protocols to deal with bleeds Access to all make sure patients from all communities can access appropriate care

17 Opportunity cost is the cost of any activity measured in terms of the value of the next best alternative forgone (that is not chosen). It is the sacrifice related to the second best choice available to someone, or group, who has picked among several mutually exclusive choices

18 Need to ensure that good anticoagulation services are still in place for warfarin patients Need patients (and clinicians!) to understand the risks and benefits of new drugs Need mature debate about where the money will come from to fund new drugs