AF Stroke from a PH perspective Greg Fell [email protected].
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Transcript of AF Stroke from a PH perspective Greg Fell [email protected].
Some important numbers as context
228 2,500
228 2,500
228 AF strokes per year in Bradford811 strokes in total.2,500 AF strokes in YH(1% and 10% of the England pop)
12,000 and 6,000
£12,000 and £6,000
The yr 1 and subsequent year costs of caring for stroke patients
The sub study of AF stroke – fits into a broader picture. c15% of
strokes are AF strokes.
Anticoagulation and AF stroke - “Dear NHS – must and can do better”
AF prevalence – its not something that is going to decline
QOF disease register and prevalence - Atrial Fibrillation
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
2006/07 2007/08 2008/09 2009/10 2010/11
Prev
alen
ce
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Patients on register
Total patients Prevalence Yorkshire & Humber prevalence
NB the age specific prevalence seen in GRASP AF dataset
13% growth in Bradford in last 5 years
New cases + finding existing cases
1.5% prevalence in YH.
85% of prevalent cases CHADS2 >=1
Long term trends in AF stroke (YH)
• To insert when I have the data
• Jon is getting me 10yr trend in AF stroke….
Dear NHS….. Must do better
Marked under use of a cheap and effective intervention that cuts stroke risk by c60%
This is not news.
“overuse” of anti platelet medicine
Dear NHS….. Must do better
Even in really high risk patients
34% anticoagulated
Community dwelling AF stroke survivors
N=3500.
NNT = 10-12
Here is the story of HOW to do better
We know a lot about individual clinical practice.
We know remarkably little about how “best” to improve population outcomes
Key features
• Data• Benchmark• Achievable benchmark of care for pop• Single side guidance for clinicians• Consistently applied to all• Small number of measured indicators• Regular feedback• Active support.• Seems to have achieved quite remarkable results –
• 43% controlled to 84% controlled (55 -64% in comparator)…..
And into AF
Where we started from
• 6,500 patients on AF register• AF substantially increases risk of stroke• Approx 2500 are on anticoagulation, significant more
should be. • Approx 50% of people that need the intention don't
receive it• Warfarin is and remains v effective in reducing risk of
stroke. • An “innovation” that is 50 years old.• Not without risk and thus needs to be used carefully
indicators
• % of AF patients (QOF) register with CHADS2 of 1 or more who are NOT receiving anticoagulation
• Time in therapeutic range achieved by INR monitoring providers
Aims:
“to ensure that at least 70% of patients with AF and a CHADS2 score of 1 or above are receiving Warfarin”
“for 80%* of those patients to achieve an INR in range*.”
The AF Quality Improvement Project
56 (of 80) practices actively participated in the project involved C330,000 population
Both hospital participated in the project trying to improve TTR in secondary care based Warfarin clinics.
Approach was simple• Clear quality standard• Measurable• Measure it – practice or provider level• Make data available and public• Achievable benchmark of care target for each
practice – what level are the 2nd quintile performers achieving
• Ten evidence based strategies were consistently applied to the practices that were participating to encourage improvement.
• Bespoke support and advice to practice and more widely - Q&A / Expert events / training / Practice visits / IT tools
• 1 year to 18 months.
Did it work?
AF QIP achievements
714 additional patients on Warfarin
31% relative improvement
If you believe the NNTs - 29 Strokes and 17 deaths preventedIf 29 avoided = approx 15% of AF Stroke
AF QIP achievements – against our target
65% of patients with CHADS2 ≥1 on Warfarin6% absolute improvement 31% relative.
Aim was 70%Remember only 2/3 of our units “played”
AF QIP practices – some achieved their own Target. Some didn’t.
Most got better though.AF QIP before / after across AFQIP practices
The best improvement was in the highest risk
INR didn’t change much over time.
Mean INR before the AFQIP = 76%*Mean INR after the AFQIP= 74% *p=0.1 no difference
*point prevalence
Large number of new patients added into INR clinics. Despite this – no change in % of tests in
Difference = 16% p>0.001 Difference = 9%
AF QIP practices vs. non AFQIP
Economic impact of AF QIPWas it worth it financially COST NEUTRAL V V V Worst case
This is highly simplisticCost of the intervention (warfarin +monitoring) £242 (NICE, 2012) *714= £172788Cost of the implementation –approximately= ~£100,000NHS cost of 29 strokes averted -29 *£13000=-£ 377000Total net savings = - £ 104212*
This should be interpreted with caution as it is based on the assumptions used in the NICE guidance. We will conduct a detailed analysis in the next 2months. To see what ACTUALLY did happen.
Equity – it is always practices in posh parts of town that participate
• Not here! No evidence of that. • Participation is across the board.• Thus hard to say this approach will increase
inequity
Where this project sits in the Scheme of “innovation”
We have “done” clean water
And vaccinations
And MRI and CT scanning / statins / Coronary artery bypass graft surgery and …..and ….. And…..and……
And warfarin is hardly innovative
But here is an important process innovation, that is cheap to implement and seems to make a difference at scale.
This is a model of “innovation” that seems to make a difference, and has traction, and is cheap
• Developing an effective model for QI in primary care
• One that primary care really engages with• cheap and simple to run, • Does rely on enthusiastic individuals with a
common goal.• There was consistently positive feedback from
practices and those that didn't initially participate are now requesting to do so.
Success factors?
• clear measurable indicators• work of local GPs and other clinicians in making this
happen.• Collaboration of a wide range of parts of the system
(provider and commissioner) and with strong PH and clinical leadership
• live data to ensure some “competition” between practices,
• live Q&A with experts, • a clear approach to peer facilitation, recognising that
practices had as much to teach each other as “experts” had to teach them
Dear NHS…. HAVE DONE better.
subsequent data analysis – 25 less AF strokes per year
It is a challenge that CAN be addressed. We have proved this.
So……
• Its important• People die• People are disabled and their families are made
miserable• It is costly AND relatively common• It is preventable• The track record of the NHS in this is …
lamentable….• Dear NHS……..
Postcript – reflections.
This is work in progress
Additional slides – more detail
• approach was similar to that advocated by world leaders in quality and safety (Provonost)
• explicitly focused on some of the reasons why existing and well publicised guidelines are under implemented.
• directly addressed areas where there is disagreement, we simplified guidelines so as they influence decisions at the point of care,
• disrupted the status quo by providing comparative performance data.
• We relentlessly focused on population based care, as opposed to focusing on individual clinicians and the patient / clinician interaction.
The intervention – in detail• a specifically assembled team • two indicators, • established a method for extracting data out of primary care clinical information systems in
a way that all practices that choose to participate can see all other practices achievement. • We set a target number of patients to be considered for anticoagulation in each practice,
based on the Achievable Benchmark of Care method. • For the system as a whole, defined as all participating practices in Bradford, our aim was to
ensure that at least 70% of patients with AF and a CHADS2 score of ≥1 are receiving anticoagulation,
• and for 80%* of those patients to achieve an INR in range. • 18 month period (time to change!)• ten simple but evidence based strategies (AHRQ / IHI) to encourage and incentivise
achievement the target in each practice. – provision of bespoke support and advice to practices and more widely – Q&A – Expert events – training – Practice visits – IT tools and templates to standardise the approach to anticoagulation decisions in
general practice and bring evidence to the point of clinical decision making. – Updated audit at intervals – to see progress
Success factors in implementation
• strong clinical and PH Leadership. visible and LOCALLY credible opinion formers and leaders to lead
• Ruthless and meticulous implementation• A small number of locally agreed high impact and measurable indicators • a clear approach to peer facilitation, recognising that practices had as much
to teach each other as “experts” had to teach them • Benchmark live data on achievements against those indicators across all
participating practices. This encourages competition within a system on quality metrics – striving to be the best.
• Single side guidance for clinicians, broader suite of tools embedded in primary care IT system to enable better and more standardised practice. Applied to large population over long time period.
• Regular feedback on achievement – with data and softer messages.Active evidence based strategies were consistently applied to the practices that were participating to encourage improvement
• simply hard work and sustained implementation of evidence based clinical behaviour change strategies.
Practice visits – key intervention• Each practice gets 2 visits. • As part of the practice meeting (in between clinics - time restricted)• involve multiple staff groups GP, PN, HCA. More staff involved, more likely
to have a speedy up take of templates etc. • Ensuring data recording is consistent is one of the biggest battles, we want
our indicators to be as sensitive and specific as possible and consistent methods of recording reduce false positive/negatives appearing in any searches produced.
• ask for who updates their clinical tree to come along. This is normally a data clerk and usually not the kind of staff member they readily let out to meetings (GPs have the monopoly on PLT still)
• Running the searches with them, discussing difficult patients etc makes the QIP real and allows tasks/recalls etc to be done whilst I am there e.g. can we task the nurse to add a BP check to that patients appointment next week? Or that patient is due in for a review, could we ask the secretary to send out a letter inviting them in?
• The subsequent follow up visit could be pooled, as we won’t have time for all the first visits at this rate I think this would be a wise economy of scale suggestion.
Examples of the tools
Spread - it is critical. • one of the greatest challenges • spread, both to broader geography and to other clinical areas• Constancy of purpose is important. • The NHS needs to be clear in their expectations as to this improvement being
the norm and that it cannot wait out this "flavour of the month". • important to have a realistic understanding of change fatigue and how much
process improvement the organization can do at once. • Here we deliberately focused on “the masses” rather than the “best
performers”. • Often an assumption is made that "if you improve the leading edge, the rest
will follow“, or if you “target the laggards, it will bring up the trail”. • whilst this might be true - this approach will not achieve population shift at the
same level as setting achievable targets for mass improvement.• a visual display of performance of the system really helped motivate change,
especially where there is real time shift that can spur further action.• creation of half-life type goals rather than finite targets will be important in
sustaining long term improvement. • This will embed the notion that the system does not become complacent once
a target has been achieved.
getting others on board. Tactics for bringing along those who have not
yet adopted the change• The "we didn’t invent it and we think our idea is better" syndrome
we are all guilty of this• Get the vital few on board (the majority will follow) - key opinion leaders.• The remainder will need to be managed. This is the aproach taken,
seemingly very successfully, by pharma companies. Strong network of KOLs.
• Understand what prevents the remaining few from coming on board. Qualitatively. How does it feel to them
• Use KOLs and quickly find a success story. Measure and spread the word. Some of the most effective champions are the ones who are former hold outs.
• Use leadership to force the issue. Be straightforward and ask, "Do you know something that we don't? If you do, we need to understand it“
• emphasise the importance of patients expectations and demand • Imagine a scenario of all AF patients knew that aspirin had limited to zero
net benefit and demanded anticoagulation from their doctor. • Patients need to know what to demand.
