Optimising detection and stroke prevention strategies in patients with Atrial Fibrillation in West Hampshire

Size: px

Start display at page:

Download "Optimising detection and stroke prevention strategies in patients with Atrial Fibrillation in West Hampshire"

Arnold Davidson
5 years ago
Views:

1 Optimising detection and stroke prevention strategies in patients with Atrial Fibrillation in West Hampshire Dr Chris Arden GP, Chandlers Ford GPSI Cardiology, Southampton West Hampshire CCG Cardiovascular Lead Friday 10 th November 2017 Nottingham

continued increase in the AF incidence) Olmsted County data, 2006

2 Projected Number of Patients With AF by 2050 MarketScan & Thomson Reuters Medicare databases, 2009 Olmsted County data, 2006 (assuming a continued increase in the AF incidence) Olmsted County data, 2006 (assuming no further increase in the AF incidence) ATRIA study data,

3 ANTICOAGULATION

4 How do we screen for AF?

2000 patients) via opportunistic screening utilising the NICE endorsed

5 Preventing stroke in West Hampshire We want to: improve the identification of asymptomatic/undiagnosed AF in WHCCG (an estimated 2000 patients) via opportunistic screening utilising the NICE endorsed WatchBP monitor; saving target - 30 strokes per year at a cost of 126k with zero investment.

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

7 National drivers

Preventing stroke in West Hampshire Strategy A collaborative plan involving WHCCG Long Term Conditions/GPs/Medicines

sessions/events Use of incentives/levers QOF/LES/QIPP Analysis/needs-gap evaluation/business case STEP 2

WatchBPTool Early adopter 3B Practices/wider roll-out WHCCG Reinforce educational sessions STEP 3 OPTIMISING

Warfarin Improving uptake of GRASP AF Tool + WPSAT/CHADS2VASC Uploading to National dataset Community Pharmacy

prescribing audit Introduction of AF/anticoagulation nurse?

8 Preventing stroke in West Hampshire Strategy A collaborative plan involving WHCCG Long Term Conditions/GPs/Medicines management and pharma STEP 1 PROACTIVE LEADERSHIP Awareness raising/public Health Audit 2012 Multi-level educational sessions/events Use of incentives/levers QOF/LES/QIPP Analysis/needs-gap evaluation/business case STEP 2 OPPORTUNISTIC SCREENING Screening programme targeting high risk asymptomatic patients Introduction of NICE endorsed WatchBPTool Early adopter 3B Practices/wider roll-out WHCCG Reinforce educational sessions STEP 3 OPTIMISING ANTICOAGULATION AND REPORTING Medicines Management LES Quality/Safety Intervention Anticoagulation education NOACS v Warfarin Improving uptake of GRASP AF Tool + WPSAT/CHADS2VASC Uploading to National dataset Community Pharmacy Interventions NICE KPIs STEP 4 EVALUATION/AUDIT Record monitor progress improvements via GRASP AF Increased NOAC prescribing audit Introduction of AF/anticoagulation nurse? Public Health Audit/participation in National trials Oxford + Southampton Review of anticoagulation provision/increasing INR self- testing opportunities/primary care community delivered cardiology services

9 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

10 Atrial fibrillation screening

11 Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting Honney R 1,2, Su F 1, Arden C 3, Pears R 2 & Roderick P 1 Background: Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed 1. Modified blood pressure devices, such as Microlife s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF 2. There is limited literature on the clinical impact of introducing such devices into UK general practice. Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol. Methods: This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity. Results: The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI= ). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI= ). significantly different between WHCCG (72.21%) and control (71.57%) practices (χ 2 =0.0456, p=0.831). The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually. The proportion of newly diagnosed high risk patients receiving anticoagulation was not Conclusions: Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme. References: 1 The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.public Health England; Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7): University of Southampton, Southampton. UK. 2 Hampshire County Council, Winchester. UK. 3 West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: r.honney@nhs.net

12 Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting Honney R 1,2, Su F 1, Arden C 3, Pears R 2 & Roderick P 1 Background: Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed 1. Modified blood pressure devices, such as Microlife s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF 2. There is limited literature on the clinical impact of introducing such devices into UK general practice. Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol. Methods: This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity. Results: The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI= ). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI= ). significantly different between WHCCG (72.21%) and control (71.57%) practices (χ 2 =0.0456, p=0.831). The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually. The proportion of newly diagnosed high risk patients receiving anticoagulation was not Conclusions: Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme. References: 1 The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.public Health England; Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7): University of Southampton, Southampton. UK. 2 Hampshire County Council, Winchester. UK. 3 West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: r.honney@nhs.net

13 Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting Honney R 1,2, Su F 1, Arden C 3, Pears R 2 & Roderick P 1 Background: Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed 1. Modified blood pressure devices, such as Microlife s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF 2. There is limited literature on the clinical impact of introducing such devices into UK general practice. Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol. Methods: This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity. Results: The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI= ). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI= ). significantly different between WHCCG (72.21%) and control (71.57%) practices (χ 2 =0.0456, p=0.831). The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually. The proportion of newly diagnosed high risk patients receiving anticoagulation was not Conclusions: Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme. References: 1 The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.public Health England; Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7): University of Southampton, Southampton. UK. 2 Hampshire County Council, Winchester. UK. 3 West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: r.honney@nhs.net

Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting Honney R 1,2, Su F 1, Arden C 3, Pears R 2 & Roderick P 1 Background: Atrial fibrillation (AF) is a

14 Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting Honney R 1,2, Su F 1, Arden C 3, Pears R 2 & Roderick P 1 Background: Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed 1. Modified blood pressure devices, such as Microlife s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF 2. There is limited literature on the clinical impact of introducing such devices into UK general practice. Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol. Methods: This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity. Results: The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI= ). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI= ). significantly different between WHCCG (72.21%) and control (71.57%) practices (χ 2 =0.0456, p=0.831). The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually. The proportion of newly diagnosed high risk patients receiving anticoagulation was not Conclusions: Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme. References: 1 The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.public Health England; Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7): University of Southampton, Southampton. UK. 2 Hampshire County Council, Winchester. UK. 3 West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: r.honney@nhs.net

15 Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting Honney R 1,2, Su F 1, Arden C 3, Pears R 2 & Roderick P 1 References: 1 The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.public Health England; Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7): University of Southampton, Southampton. UK. 2 Hampshire County Council, Winchester. UK. 3 West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: r.honney@nhs.net

16 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

17 GRASP AF An automated tool to identify patients at high risk of stroke in AF and not on adequate thromboprophylaxis, using existing GP data Delivered by PRIMIS+ and available via your Cardiac Network.

18 Audit of Atrial Fibrillation & CHADS2-VASc Scores Classic View Select Risk Score Practice: CHADS2-VASc CHA2DS2-VASc Total Practice Population Total Percent No. with Atrial Fibrillation Age >= 65 yrs with AF NB: Handling of anticoagulant exclusions Age range AF prevalence (%) by age band AF prevalence (%) Percentage Risk profile for thrombo-embolism 0 1 >1 CHA2DS2-VASc score HF or LVD Hypertension Age >=75 Diabetes Stroke or TIA Vasc disease Age Risk factors in patients with AF CHA2DS2-VASc score Breakdown of anticoagulant & antiplatelet use by CHA2DS2-VASc score > Anticoagulant Both Antiplatelet None Sex = Female 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% Percentage Percentage Anticoagulant use in high risk patients On anticoagulant (121 patients) Not on anticoagulant (73 patients) Strokes expected annually in the 73 high risk untreated 2.9 Percentage Score or review in last 15 mths CHADS2 AF review HELP OVERVIEW PODCAST PRIMIS+ 2011

19 Optimising Care: GRASP AF Total number of expected strokes annually Sep Mar Sept Sep Mar Sept Sep Mar Sept

20 Optimising Care: WPSAT Apr % Mar % Sept % Apr 15 59% Mar 16 67% Sept 16 67%

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

22 Optimising Care: The Results WatchBP GRASP AF Before No OAC On OAC 2071 more OAC 39 expected strokes avoided

23 Number of reported strokes across WHCCG

24 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)

Optimising detection and stroke prevention strategies in patients with Atrial Fibrillation in West Hampshire

Optimising detection and stroke prevention strategies in patients with Atrial Fibrillation in West Hampshire Dr Chris Arden GP, Chandlers Ford GPSI Cardiology, Southampton West Hampshire CCG Cardiovascular