GRASP-AF- The National Picture. Dr Richard Healicon National Improvement Lead Ian Robson Senior Analyst NHS Improvement February 2012

Transcription

1 GRASP-AF- The National Picture Dr Richard Healicon National Improvement Lead Ian Robson Senior Analyst NHS Improvement February 2012

2 Outline AF and stroke Objective Management of stroke risk Stroke risk algorithms NICE ESC guidelines GRASP-AF-practical demonstration GRASP-AF-data Variation in uptake Changes in national recorded prevalence of AF Changes in OAC use Summary Including future changes to QoF

3 Stroke is a frequent complication of AF Stroke is the leading complication of AF Patients with AF have a five-fold higher stroke risk than those without AF 1 AF doubles the risk of stroke when adjusted for other risk factors 2 Without preventive treatment, each year approximately 1 in 20 patients (5%) with AF will have a stroke 3 It is estimated that 15% of all strokes are caused by AF 5 and that 12,500 strokes per year in England are directly attributable to AF 6 1. NICE clinical guideline 36.June Available at accessed April 2010; 2. ACC/AHA/ESC guidelines: Fuster V et al. Circulation 2006;114:e & Eur Heart J 2006;27: ; 3. Atrial Fibrillation Investigators. Arch Intern Med 1994;154: ; 4. Carlson M. Medscape Cardiology. 2004;8; available at accessed Feb 2010; 5. Lip GYH, Lim HS. Lancet Neurol 2007;6:981-93; 6. NHS Improvement. June Available at accessed April 2010

4 Stroke is a serious complication of AF Stroke in AF is associated with a heavy burden of morbidity and mortality AF related stroke is usually more severe than stroke due to other causes 1 Compared with other stroke patients, those with AF are more likely to: Have cortical deficit (e.g. aphasia), severe limb weakness and diminished alertness, and be bedridden on admission 2 Have longer in-hospital stay with a lower rate of discharge to their own home 3 1. Savelieva I et al. Ann Med 2007;39:371 91; 2. Dulli DA et al. Neuroepidemiology 2003;22:118 23; 3. NICE clinical guideline 36.June Available at accessed April 2010; 4. Benjamin EJ et al. Circulation 1998;98:946 52

5 Objective: To reduce the number of strokes caused by AF Improved detection and diagnosis Raised awareness Promote opportunistic detection Ensure optimal treatment for those diagnosed with AF Improved assessment of risk- CHADS 2, CHA 2 DS 2 -VASc Appropriate management of risk- GRASP-AF Improve anticoagulation services

6 NICE guidance on stroke risk Patients with paroxysmal, persistent or permanent AF Determine stroke/thromboembolic risk 1 High risk Previous ischaemic stroke/tia or thromboembolic event Age 75 with hypertension, diabetes or vascular disease* Clinical evidence of valve disease, heart failure, or impaired LV function on echocardiography** Moderate risk Age 65 with no high risk factors Age <75 with hypertension, diabetes or vascular disease* Low risk Age <65 with no moderate or high risk factors Anticoagulation with warfarin Contraindications to warfarin? No Warfarin, target INR 2.5 (range 2.0 to 3.0) Yes Consider anticoagulation or aspirin 2 Aspirin 75 to 300 mg/day if no contraindications Reassess risk stratification whenever individual risk factors are reviewed

7 Stroke risk in AF: CHADS 2 CHADS 2 risk criteria Score Cardiac failure 1 Hypertension 1 Age >75 yrs 1 Diabetes mellitus 1 Stroke or TIA (previous history) 2

8 Stroke risk in AF: CHA 2 DS 2 VASc Congestive heart failure/left ventricular systolic dysfunction Score Hypertension 1 Age 75 2 Diabetes 1 Stroke / TIA 2 Vascular disease 1 Age Sex (female) 1 1

9 The GRASP-AF Tool- to improve the management of AF Identifies patients with atrial fibrillation Searches for co-morbidities and works out both a CHADS 2 and CHA 2 DS 2 -VASc score Searches for current medication- warfarin, aspirin or newer oral anticoagulant Searches for recorded reasons for NOT treating with warfarin Gives a simple alert for those at high risk and not on warfarin or newer oral anticoagulant

10 Ian Robson Senior Analyst, NHS Improvement Demonstration of GRASP-AF Live demonstration of CHART Online

11 CHART Online - downloads/uploads Total downloads Total uploads Aug Sept Oct Nov Dec Jan Feb Mar April May June July Aug Sept Oct Nov Dec

12 GRASP uploads to CHART online Persistent gap between downloads and uploads Intend to continue with voluntary upload of data Strategy to increase the uploading of data- More information on downloading the tool List of benefits Clarification about security Automated reminders after 3 month period if no subsequent upload

13 Benefits to GPs of uploading Convenient access to their data from any computer. To be able to benchmark their practice against other practices, PCTs, networks and national data Regular uploads will allow them to track their changes and improvements in AF management, and how these changes relate to current best practice guidelines By better management of stroke risk in AF, they will contribute to a reduction in AF related strokes They will contribute to a data set which will help their local CCG commission appropriate services, plan drug budgets etc

14 Benefits to GPs of uploading They will contribute to a data set which will facilitate greater cooperation and joint working between GPs, local commissioners and providers, which will be useful in the future when CCGs will undertake these functions. They will be contributing to one of the largest AF databases in the world. They will be contributing to a national data set which will help plan and commission services more efficiently and which will help the development of future clinical guidelines

15 Clarification about security Only anonymised patient level data is uploaded and that this is transmitted and stored securely. Viewing the data in CHART Online is restricted to those people registered on the PRIMIS+ Profile Centre who are validated by either PRIMIS+ or NHS Improvement. The only persons authorised in this category are: authorised staff from practices who have contributed data; PRIMIS+ facilitators; PRIMIS+ staff and NHS Improvement staff, and other users working in connection with GRASP AF and validated by NHS Improvement. Users who are validated by PRIMIS+ or NHS Improvement will only be able to view a Practice's national code if given specific permission by the Practice.

16 North West London Birmingham, Sandwell and Solihull NEYNL North Central London South East London Coventry and Warwick Uploads by network Sussex WYCN Hereford and Worcester Black Country South Central Dorset Kent Surrey Shrops and Staffs North East London South West London Anglia Essex East Midlands North Trent Beds and Herts Cheshire and Merseyside network NECVN Cumbria and Lancs Peninsula AGWS Greater Manchester and Cheshire

17 Top ten PCTs PCT Number of practices that have uploaded Number of Practices In PCT Percentage of practices that have uploaded Blackpool PCT North Staffordshire PCT Plymouth PCT Oldham PCT Gateshead PCT Gloucestershire PCT County Durham PCT Darlington PCT East Lancs PCT Bury Primary Care Trust

18 Prevalence of AF Data to date: Number of practices uploading data: 1567 Number of patients with AF: 199,816 Total list size: 11,225,618 Prevalence of AF: 1.78%

19 WYCN CHART Online- warfarin prescribing First upload (%) Latest upload (%) Beds and Herts Essex North East London North West London South West London NECVN Cumbria and Lancs Cheshire and Merseyside Greater Manchester and Cheshire South Central Kent Surrey Sussex AGWS Dorset Peninsula Black Country Hereford and Worcs Shrops and Staffs NEYNL North Trent network Anglia % on warfarin

20 Summary Large number of GP practices using GRASP-AF and uploading the data to CHART Online Probably the largest AF related database in the world GRASP-AF data is revising (upwards) the estimate of the national prevalence of AF Still large variation in uploads of GRASP across the networks GRASP-AF is improving the way stroke risk in AF is managed, but changes are small Anticipate an impact from the future QoF changes

21 Future- Changes to QoF RETIRED AF4: The percentage of patients with Atrial Fibrillation diagnosed after 1 April 2008 with ECG or specialist confirmed diagnosis

22 Future- Changes to QoF NEW AF5: The percentage of patients with Atrial Fibrillation in whom stroke risk has been assessed using the CHADS2 risk stratification scoring system in the preceding 15 months

23 Future- Changes to QoF REPLACE AF3 AF6: In those patients with Atrial Fibrillation in whom there is a record of a CHADS2 score of 1, the percentage of patients who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy AF7: In those patients with Atrial Fibrillation in whom there is a record of a CHADS2 score of greater than 1, the percentage of patients who are currently treated with anti-coagulation drug therapy

24 GRASP-AF- New Guidance and Support New user guides: Downloading, installing and setting up Running GRASP Understanding results Uploading to CHART On-line Using CHART On-line Common issues and solutions Can be found at

25 GRASP-AF- New Guidance and Support support: Support for practices, networks and other organisations working with GRASP-AF Contact with your query