SERVICE SPECIFICATION Agenda Item No. 8a Service Specification No. Service Atrial Fibrillation Audit patient reviews Commissioner Lead Caroline Davidson Period 1 st September to 31 st March 2017 Date of Review N/A 1. Introduction: 1.1 National/local context and evidence base Stroke is the fourth largest cause of death in the United Kingdom and is the leading cause of disability with 60% of stroke survivors leaving hospital with a disability1. It results in multiple and complex disabilities. The prevalence and burden of stroke is expected to increase in future decades due to the increasingly ageing population and the improvements in hyper-acute care resulting in the increased number of individuals surviving their stroke2. Atrial fibrillation is the most common sustained cardiac rhythm disorder 3 and is a significant risk for stroke. Despite recent guideline updates by NICE with extensive recommendations for anticoagulation management plus quality standards in AF (QS93) i 6 and extending AF QOF indicators for 2015/2016 the management of AF and stroke prevention still remains sub-optimal nationally and across NWL. Therefore in 2017/18 for the second wave of NHS Rightcare programme all 8 CCGs across NWL identified AF and Hypertension as a priority. NHS Operational Planning and Contracting Guidance for 2017-19 also stipulates demand reduction measures include medicines optimisation. AF is a major predisposing factor for stroke and accounts for 20% of all strokes 4, rising to one in three after the age of 80 years 5. Therefore managing AF is key to the prevention of stroke. AF is mostly only detected once a patient presents with serious complications such as stroke or heart failure. Public Health England estimates that over 17,000 people in NW London have undiagnosed AF and it is estimated that 170 AFrelated strokes, and 40 deaths, could be avoided each year through better management, including proactive medication management, earlier diagnosis and informed lifestyle changes. In NW London more than 6,260 people with AF who are at a high risk of having a stroke are not on any anti-coagulation treatment at all. The incidence of AF is age related. The risk of developing AF after the age of 40 is one in four and 30% in people aged over 85. 6 1 in 4 stroke survivors will experience a recurrent stroke within 5 years 7. Anticoagulation reduces stroke risk in patients with AF 8. NICE Guidance states that 84% of patients diagnosed with AF should be prescribed anticoagulants 9. The risk of stroke for patients not anticoagulated is 5.82%, for those on warfarin the risk is 2.09% and for those on DOACs it is 1.52% 9. Local Context 1) AF not risk assessed - QoF indicator AF006 requires that when patients are diagnosed with AF they should be risk assessed for stroke using the CHADS 2VASc> 2 tool which is done automatically in EMIS once the AF diagnosis is entered in the system. 2,777 patients on the QoF registers require risk assessment and it is estimated that 142 (5%) do not have a CHADS 2VASc> 2 score recorded. Audit tools developed to interrogate practice systems have found that AF diagnoses can be miscoded and therefore these patients are not flagged up for risk assessment and likely not being anticoagulated. A pilot 1
run by Metrohealth (refer to appendix 2) using the GRASP AF audit tool found 108 out of a register total of 1,861 patients that had tests or treatment indicating AF were not on the practice AF QoF registers. This represents an increase in the AF register of 6% on average across the 16 practices. Another pilot of 4 practices using the Oberoi ENHANCE SPAF (refer to appendix 3) tool found that 20 (4.5%) patients eligible had not been risk assessed so this indicates that the assumption in the GM modelling is correct. 2) Untreated - The QoF registers show that there are 3,191 patients eligible for anticoagulation of whom 886 (27.8%) are not being treated (including exceptions). 3) Drug therapy not optimized - The GM model indicates that there are 734 patients (30%) inadequately anticoagulated. The Oberoi pilot found 105 (24%) patients who needed their medicines reviewed. Practice variation There is significant variation between practices in the management of AF which cannot be explained practice demographics alone. Prevalence - reported prevalence of AF ranges between 0.2% and 2.24%. CCG prevalence 1.23%. Not Anticoagulated - variation from 80% to 10% QOF exception reporting varies between 0.03% and 65%. There is strong correlation between practices with high exception reporting and number of patients not anticoagulated. 2. Outcomes: 2.1 NHS Outcomes Framework Domains & Indicators Domain 1 Preventing people from dying prematurely X Domain 2 Enhancing quality of life for people with long-term X conditions Domain 3 Helping people to recover from episodes of ill-health or X following injury Domain 4 Ensuring people have a positive experience of care X Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm X 2.2 Local defined outcomes 1. To reduce the risk of stroke and premature death for patients with a diagnosis of AF ie. the avoidance of 64 strokes over 3 years. 2. To comply with NICE Guidelines for the drugs management of AF patients ie. 84% of high risk patients are on anticoagulants and patients who have been prescribed aspirin for AF are switched to anticoagulants. 3. Reduce practice variation in Hillingdon for the management of AF ie. Patients not anticoagulated - variation from 80% to 10% and QOF exception reporting varies between 0.03% and 65% (NICE guidance is max 15.79%). There is strong correlation between practices with high exception reporting and number of patients not anticoagulated. 3. Scope: The Atrial Fibrillation audit is a one off project that will bring practice registers up to date and ensure that AF patients are being medically optimized. Refer to appendix 1 for audit methodology. The audit searches are listed below and the contract only relates to patients highlighted from the searches as requiring review: 2
AF resolved Patients taking therapy suggestive of AF but no confirmed diagnosis Patients with coding suggestive of irregular pulse who may be suitable for screening Patients with no CHADS score or CHADS-VAC recorded Male patients CHADS2Vasc score =1 not anticoagulated Patients taking antiplatelet therapy no exception coding Patients with no current therapy or exception coding recorded Patients on anticoagulation that may need their treatment therapy optimised 3.1 Aims and objectives of service The purpose of the project is to find patients that require Risk assessment - ensure that the estimated 142 patients without a CHAD2DS2-VASc score of >2 are risk assessed. Of this cohort it is expected that 120 will be eligible for anticoagulation. Anticoagulation ensure anticoagulation of the 886 patients diagnosed with AF and not being treated and assessment of patients currently anticoagulated that might need review. 3.2 Service description/care pathway 3.3 Population covered The service is available to patients >18 (but mostly >40) with AF who are registered with a GP in Hillingdon. Acceptance criteria Patients who are identified by the audit searches as described in section 3 Scope. 3.5 Exclusion Criteria i. Patients under 18 years of age; ii. Patients registered with a GP outside of Hillingdon; iii. Patients who do not have the conditions explicitly referred to in the acceptance criteria. 3.6 Training, Skills and Experience The Service will be provided by a GP. 3.6 Equipment N/A 3.7 Interdependence with other services/providers The Provider will develop relationships with other providers in order to become an integral member of the Health and Social Care Community. 3
Hillingdon Clinical Commissioning Group (CCG); All Hillingdon general practices including GPs, practice nurses and healthcare assistants; networks Blood Pressure units at local acute hospitals; Third sector organisations; Hillingdon Borough Council; Service users as key stakeholders; Healthwatch; 3.8 Finance and Activity Recording Payment will be made for activity which is coded within EMIS using the code below and is subject to the Provider also delivering against the audit outcomes report provided by the CCG Pharmacist. Patients with AF will be coded as G5730 Patients with a Flutter or AF with flutter will be coded as G573 4. Service Delivery: The service is delivered by GPs who will review patients on the list provided by the CCG Pharmacist from the searches run in the audit. 1. The practice will allow a CCG specialist pharmacist to review patient records looking at EMIS AF data and compare this with an approved audit tool. 2. The pharmacist will then review existing AF records to establish the list of patients with known AF (including those mis-coded) and not anti-coagulated. Following this appropriate clinical recommendations will be made to the practice 3. Identifying GPs with an interest in this area, and ensuring that they attend CCG provided training on how best to undertake the review and the use of the standard EMIS template that guides the GP through the review as well as providing an audit trail. 4. Coordinating review appointments between eligible patients or their carers and trained GPs. The review consultation will be face to face and last 15-20 minutes to discuss anti-coagulation therapies. 5. Referring the patient to the appropriate anticoagulation service to have a patient prescribing plan based on the agreed anticoagulant of the patient s choice. 6. The audit cycle will be repeated via the CCG specialist pharmacist as needed to ensure recommendations have been addressed 7. Eligible patients will be those identified by the searches in the audit and patients with a new diagnosis of AF within the time frame of the LIS 8. Working with the CCG to audit the contract in order to assess number of patients seen and with improved management of patients with AF (including anticoagulation) and understand the overall success of the contract. 5. Applicable Service Standards 5.1 Applicable national standards eg NICE, Royal College 4
Applicable national standards (eg NICE) 1. National Institute for Health and Care Excellence clinical guideline 180 Atrial fibrillation: the management of atrial fibrillation (2014). 2. Costing Report: atrial fibrillation. Implementing the NICE guideline on atrial fibrillation (CG180). National Institute of Health and Care Excellence (2014). 5.2 Applicable standards set out in Guidance and/or issued by a competent body (eg Royal Colleges) 1. NHS Digital Quality and Outcomes framework (QoF) 2015-16. http://content.digital.nhs.uk/article/2021/website- Search?productid=23378&q=quality+and+outcomes&sort=Relevance&size=10&page=1&area=both#to p 2. National cardiovascular intelligence network Cardiovascular intelligence packs. Public Health England. Accessed October 2015. http://www.yhpho.org.uk/resource/view.aspx?rid=207915 5.3 Applicable local standards Please see section 3. Applicable service category Practice(s) delivers their primary medical services contractual and statutory requirements. No unlifted, uncontested, related breaches in the last 12 months. Provider is CQC registered with no conditions, except in circumstances beyond the control of practices, such as the void position resulting from GP retirements; and the management of complaints. General Practice All Locally defined, service-specific requirements for providers Requirement Individuals will have access to relevant and comprehensive information, in the right formats, to inform choice and decision-making about their care. Providers will signpost patients to local services which could help them. Applicable service category All All 5
Information and services will be available for individuals who are able to self-manage their conditions or who need care plan support. Providers will consider whether working with other providers would increase the efficacy of the service (e.g. third sector, schools, libraries, religious organisations). Providers will demonstrate that they have identified any potentially hard to reach group (as defined by the JSNA) that exist within their target population, and have taken appropriate action to improve access to the service for these groups. All All All 6. Applicable CQUIN/Quality Goals 5.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D]) The Provider will submit the following quality information to the Commissioner. 7. Key Performance Indicators (KPIs): KPI Areas Baseline Indicative activity plan The patient list for each practice will be provided by the Pharmacist after the AF audit has been run. This is the indicative activity plan for the practice. KP 02 The number of AF patients not previously anticoagulated identified for anticoagulation KPI 03a All patients diagnosed with AF to have CHAD2DS2-VASc risk assessment KPI 03b 142 patients risk assessed and eligible for anticoagulation QoF figures show the number of patients that are expected to be picked up across Hillingdon are: 1. Not risk assessed 142 and eligible for anticoagulation 120. 2. Not anticoagulated 886 and eligible for anticoagulation 620. Breakdown by practice is shown in appendices: appendix 2 patients not risk assessed appendix 3 patients not anticoagulated Activity Reductions Across all of Hillingdon reduction of 64 nonelective admissions for AF related stroke over 3 years. Baseline 16/17 Stroke admissions to HASU = 407 6
Year 1 = 12 Years 2 and 3 = 26 Outcome Improvements HCCG PRESCRIBING IN LINE WITH NICE KPI 04. 84% patients with CHADS2VASc>2 are anticoagulated. KPI 05. 46.8% patients eligible for anticoagulation prescribed warfarin KPI 06. 35% patients eligible for anticoagulation prescribed DOAC NHS Business Services Authority. Medicines Optimisation CCG Dashboard. November 2016 available at https://apps.nhsbsa.nhs.uk/mod/atlasccgmedsop/atla s.html 8. Location of Provider Premises: The Service will be provided in the GP practice. All premises and equipment to be used must be subject to proper maintenance, the responsibility for the provision of suitable premises and equipment will be with the provider and must be relevant to the service, including as a minimum: 1. Premises must be DDA compliant; 2. Premises to enable safe and convenient patient access in relation to transport links; 3. Adequate seating to enable all patients to sit while waiting, including chairs for patients who have difficulty sitting low down. 4. WC and handwashing facilities should be provided; 5. Have access to interpretation and translation services; 6. Ensure that all premises and equipment to be used is subject to proper maintenance; 7. Decontamination and clinical waste disposal as appropriate; 8. Non-slip flooring; 9. Storage facilities for consumables. 9. Fee Level and Payment: The Provider will be paid according to the number of patients on their practice list as at 1 st September who are over 40. This is based on the evidence that 1 in 4 over 40s are at risk of developing AF. This is nonrecurrent funding. 7
10. Contract and Monitoring Arrangements: End of project comparison against the audit outcomes report provided to the practice by the AF pharmacist. APPENDIX 1 APPENDICES Audit Methodology (outcomes from this provide the practice indicative activity plan). Audit: Medicines Optimisation- Prevention of Stroke and Systemic Embolism in Atrial Fibrillation (AF) Background AF is an important cause of embolic stroke. Anticoagulation is recommended in patients with AF who are at increased stroke risk, unless the benefits of anticoagulation are outweighed by the bleeding risks. Aspirin alone is no longer recommended to reduce the risk of stroke in the AF population (NICE Guideline CG180: Atrial Fibrillation Clinical Guideline 180 June 2014). Key to reducing risk of AF-related stroke is: Early detection of AF in the population. Almost a third of people with AF are undiagnosed and untreated. These patients are at a high risk of premature death and disability Assessing risk of stroke using the CHA 2DS 2-VAS C score. The risk of stroke increases five-fold for people with AF irrespective of symptoms Assessing risk of bleeding risk using the HASBLED score. For most people with AF the benefits of anticoagulation outweigh the risk of bleeding. Initiation of anticoagulant therapies in patients at risk of stroke. Treatment with an oral anticoagulant medication reduces the risk of stroke in someone with AF by two-thirds. Everyone with AF who also has valvular heart disease should be offered anticoagulation- they do not need a formal risk score as stroke risk is high There is an opportunity for medicines optimisation for patients with AF in Hillingdon CCG, with the aim to increase the level of appropriate anticoagulation for patients with AF and improving outcomes for this group of patients. Review steps Four pilot GP practices in Hillingdon will be identified by the CCG to work with a Medicines Management Team (MMT) Pharmacist, with a named GP to lead at each practice. This project will be undertaken at the four GP practices in winter 2017. This project plan must be read in conjunction with the: 1. Hillingdon Cardiology Clinical Working Group AF guideline (Annex 1) 8
2. Hillingdon CCG guideline: Direct Oral Anticoagulants (DOACs) for the Prevention of Stroke and Systemic Embolism in Non-Valvular Atrial Fibrillation (NVAF) (Appendix 2) Objectives Validate the AF register Assess patients with AF, paroxysmal AF and atrial flutter for anticoagulation Optimise anticoagulation therapy to ensure maximum reduction in stroke risk with minimum risk of bleeding 1. Validating the AF Register Following application of the Enhance SPAF tool the following search groups will be categorised: o Patients with AF resolved recorded o Patients with codes specifically related to AF QQF indicators, with no confirmed AF diagnosis o Patients taking therapy suggestive of AF, with no confirmed AF diagnosis on EMISS WEB o Patients with coding suggestive of AF, with no confirmed AF diagnosis The MMT Pharmacist will check the notes of all patients identified in the categories above with possible missing diagnosis of AF Patients with AF will be coded as G5730 Patients with a Flutter or AF with flutter will be coded as G573 A comparison of the number of patients coded as AF for each practice will be made against the prevalence of patients identified as AF by the MMT Pharmacist 2. Assessing Patients with AF, Paroxysmal AF and Atrial Flutter for Anticoagulation When the AF registration has been validated, AF diagnosis confirmed and the AF read code added where appropriate, the search will be re-run to ensure all AF patients are included The re-running of the Enhance SPAF tool will identify the following patients: o On AF register and on warfarin in the last 6 months with INR uncontrolled recorded or INR values out of range o On AF register and on antiplatelet only in the last 6 months with CHA 2DS 2-VAS C 2 o On AF register and exception coded to warfarin excluding patients previously on a DOAC or not indicated for warfarin o On AF register and requires CHA 2DS 2-VAS C score and HASBLED score Following the search a comparative description of anticoagulation/ antiplatelet medication regimes across the 4 practices will be recorded. The different regimes will be denominated to: o Warfarin alone o DOAC alone o Single antiplatelet o Dual antiplatelet o Single antiplatelet and anticoagulation o Triple therapy- 2 antiplatelets and an anticoagulant o Nil 3. Optimising Anticoagulation Therapy to Ensure Maximum Reduction in Stroke Risk with Minimum Risk of Bleeding 3a MMT Pharmacist Review All patients on the practice AF register will be reviewed by the MMT Pharmacist in March 2017. Patients will be split into the following categories: 9
Patient group AF patients already prescribed warfarin alone AF patients already prescribed a DOAC alone AF patients prescribed no anticoagulation or antiplatelet treatment AF patients prescribed antiplatelet treatment alone AF patients prescribed combined anticoagulation and antiplatelet treatment Comment Is this the correct decision for the patient? Is warfarin control adequate has time in therapeutic range been assessed? Is this the correct decision for the patient? Is the dosage prescribed in line with manufacturers recommendations? All patients to be reviewed All patients to be reviewed Check if patients are taking antiplatelet treatment for other indications e.g. myocardial infarction All patients to be reviewed Check if patients are taking antiplatelet treatment for other indications e.g. myocardial infarction For patients with AF, paroxysmal AF and atrial flutter not prescribed any oral anticoagulant an assessment of the individual patient s stroke risk and bleeding risk will be assessed using the CHA 2DS 2-VAS C and HASBLED scores. A breakdown of the current anticoagulation/ antiplatelet medication regimes and the number of patients for GP review following the analysis of patients by the MMT Pharmacist is required to show a comparison between the respective GP Practices. The MMT Pharmacist will: o o o o o Consider anticoagulation for men with a CHA 2DS 2-VASc score of 1 and offer anticoagulation to people with a CHA 2DS 2-VASc score of 2 or above, taking bleeding risk into account Review need for anticoagulation and the quality of anticoagulation for people who are taking an anticoagulant Review the anticoagulation control in people taking vitamin K antagonists (warfarin) Review patients prescribed a DOAC whether the dosage is appropriate against clinical parameters such as renal function, manufacturers recommendations (according to weight and age), and concurrent drug therapy. A renal function check will be recommended if a recent result (as a minimum within last 12 months) is not available. Assess patients currently prescribed antiplatelet therapy for preventing AF related strokes (not for other indications). In the past, aspirin had been considered an alternative to anticoagulant therapy in AF patients unable to take warfarin, however it is substantially less effective than anticoagulation. Combination antiplatelet therapy, aspirin with clopidogrel, is more effective for preventing AF related strokes than aspirin alone, but is still less effective than oral anticoagulation, and associated with a bleeding risk similar to that of anticoagulation. Combination antiplatelet therapy is not routinely recommended for preventing AF related strokes (Specialist Pharmacy Service: Medicines Optimisation in Atrial Fibrillation the first stop for professional advice). The MMT Pharmacist will give their comments and recommendations to the named GP by 31 st March 2017 Data relevant to the GP including weight, renal function, other relevant medication or medical history that could affect the choice of anticoagulation will be provided. 10
3b GP Review The named GP at the respective practices will co-ordinate a practice review of the recommendations made by the MMT Pharmacist. The MMT Pharmacist would further help facilitate the named GP with reviewing patients if requested. Where they consider appropriate, the GP practice will implement changes suggested by the MMT Pharmacist to improve the uptake and safety of anticoagulation in their AF patients. The named GP will feedback final outcomes and implementations by 14 th April 2017. The status of GP reviews at 14 th April 2017 will be described. The choice of anticoagulation will be left to the GP to discuss with the patient using the NICE Patient Decision Aid and will be based on patient clinical features (e.g. significant renal impairment, drug interactions or extremes of bodyweight) and preferences. Anticoagulation may be with apixaban, dabigatran, edoxaban, rivaroxaban or warfarin, dependent licensed indication. Dual (single antiplatelet + anticoagulation) or Triple (dual antiplatelet therapy + anticoagulation) therapy: For all patients on dual or triple therapy a rationale and duration should be clearly documented. If continuing dual or single antiplatelet therapy with anticoagulation beyond 1 year this should be confirmed with a cardiologist (Specialist Pharmacy Service: Medicines Optimisation in Atrial Fibrillation the first stop for professional advice https://www.sps.nhs.uk/wpcontent/uploads/2016/10/medicines-optimisation-in-af-vs1-oct-2016-1.pdf). The most common indication for dual antiplatelet therapy + anticoagulation will be patients with atrial fibrillation/ flutter who have undergone coronary artery stenting. In all cases rationale and duration of treatment the use for triple therapy must be defined by a cardiologist and should be aspirin + clopidogrel (and not ticagrelor or prasugrel) + anticoagulation. 11
APPENDIX 2 BASELINE DATA FROM QoF - PATIENTS REQUIRING RISK ASSESSMENTS Practice code Practice name Number of patients not risk assessed Exceptions Possible no of reviews 9 6 15 2 2 4 17 4 21 4 4 8 2 0 2 1 1 2 8 3 11 0 4 4 2 0 2 1 1 2 4 3 7 7 0 7 2 0 2 3 1 4 4 0 4 2 2 4 2 1 3 2 1 3 2 0 2 12
8 0 8 1 0 1 1 0 1 1 0 1 1 0 1 3 0 3 3 1 4 1 1 2 1 0 1 5 0 5 1 0 1 100 42 142 13
APPENDIX 3 BASELINE DATA FROM QoF - PATIENTS POSSIBLY ELIGIBLE FOR ANTICOAGULATION Practice code Practice name Number of patients not anticoagulated Exceptions Possible no of reviews 35 14 49 5 5 10 24 9 33 22 10 32 29 27 56 31 8 39 11 6 17 20 17 37 8 20 28 37 35 72 10 3 13 22 36 58 9 3 12 14 3 17 16 9 25 13 11 24 5 6 11 5 13 18 7 21 28 6 6 12 13 10 23 29 7 36 14 15 29 5 1 6 23 9 32 14
6 3 9 27 1 28 4 2 6 4 7 11 1 2 3 2 0 2 0 8 8 3 2 5 1 3 4 13 8 21 2 5 7 4 1 5 1 4 5 7 1 8 1 4 5 4 0 4 11 3 14 12 4 16 1 1 2 1 4 5 518 368 886 15