Managing Stroke risk in AF: Are we fulfilling our potential?

Mel VarvelNHS Improving Quality

Marion KerrInsight Health Economics

October 2013

• Introduction- NHS Improving Quality• NHS Improving Quality’s role in stroke prevention• Management of stroke risk in AF• Tools to help: GRASP-AF and CHART Online• What the data is telling us about current management• Cost Effectiveness of primary prevention of AF-

related stroke• GRASPing the potential: The GRASP Suite• Summary

Outline

• Set up from 1 April 2013 and hosted by NHS England• Working to provide improvement and change

expertise to support improved health outcomes• Bringing together and building on the wealth of

knowledge, expertise and experience of all that has gone before:• National Cancer Action Team, National End of Life

Care Programme, NHS Diabetes and Kidney Care, NHS Improvement, NHS Institute for Innovation and Improvement.

Introducing NHS ImprovingQuality (NHS IQ)

Improvement programmes

NHS Health Check available to all adults

in England

Improved public awareness & early

diagnosis

GP engagement in the big killers: cancer, heart,

stroke, liver, resp

1. Preventing premature deaths

2. Long term conditions

4. Experience of care

3. Acute care

5. Safety

Evidence based tools

7 day integrated care pathways for frail elderly, end of

life, dementia

Primary care, diagnosis, enhanced

recovery, 7 days

Rural and remote services review

Children and young people’s transition to

adult services

Experience of care central to

commissioning & delivery

Developing an improvement system for safety across the

NHS

• Improved detection and diagnosis: Public awareness, case finding, risk management & access to care

• Optimal management of people diagnosed with chronic conditions

• Engagement with primary care (GPs and CCGs)

• Support for existing public health interventions and screening programmes

• Spread of existing and new audit tools in AF, COPD and HF to all GP practices, e.g. the GRASP Suite

Preventing premature death

• Stroke is the leading complication of AF• Patients with AF have a five-fold higher stroke risk

than those without AF1

• AF doubles the risk of stroke when adjusted for other risk factors2

• Without preventive treatment, each year approximately 1 in 20 patients (5%) with AF will have a stroke3

• It is estimated that 15% of all strokes are caused by AF5 and that 12,500 strokes per year in England are directly attributable to AF6

Stroke is a frequent complication of AF

1. NICE clinical guideline 36.June 2006. Available at http://www.nice.org.uk/guidance/CG36/?c=91497; accessed April 2010; 2. ACC/AHA/ESC guidelines: Fuster V et al. Circulation 2006;114:e257–354 & Eur Heart J 2006;27:1979–2030; 3. Atrial Fibrillation Investigators. Arch Intern Med 1994;154:1449–57; 4. Carlson M. Medscape Cardiology. 2004;8; available at http://cme.medscape.com; accessed Feb 2010; 5. Lip GYH, Lim HS. Lancet Neurol 2007;6:981-93; 6. NHS Improvement. June 2009. Available at http://www.improvement.nhs.uk/heart/Portals/0/documents2009/AF_Commissioning_Guide_v2.pdf; accessed April 2010

• 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 causes1

• 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 admission2

– Have longer in-hospital stay with a lower rate of discharge to their own home3

• The mortality rate for patients with AF is double that in people with normal heart rhythm4

Stroke is a serious complication of AF

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 2006. Available at http://www.nice.org.uk/guidance/CG36/?c=91497; accessed April 2010; 4. Benjamin EJ et al. Circulation 1998;98:946–52

CHADS2 risk criteria Score

Cardiac failure 1

Hypertension 1

Age >75 yrs 1

Diabetes mellitus 1

Stroke or TIA (previous history) 2

Stroke risk in AF: CHADS2

Stroke risk in AF: CHA2DS2VASc

Score

Congestive heart failure/left ventricular systolic dysfunction

1

Hypertension 1

Age ≥75 2

Diabetes 1

Stroke / TIA 2

Vascular disease 1

Age 65–74 1

Sex (female) 1

ESC Guidelines 2010

ESC Guidelines Focussed Update 2012

• Identifies patients with a history of atrial fibrillation

• Searches for co-morbidities and calculates a CHADS2 (and now CHA2DS2-VASc) score

• Searches for current medication- warfarin, aspirin or newer oral anticoagulant

• Searches for recorded reasons for NOT treating with OAC

• Gives a simple alert for those at high risk and not on warfarin or newer oral anticoagulant

GRASP-AF

GRASP-AF- dashboard view- CHADS2

GRASP-AF- datasheet

• Voluntary upload of GRASP-AF data to CHART online

• Web based benchmarking tool with a variety of comparative viewing options available:

• By clicking on specific areas in the displayed data it is possible to drill down from national level to individual practice level

• Secure and restricted access• For both front line staff and commissioners

CHART Online

CHART Online: Prevalence of AF

CHART Online: Use of OAC in High Risk Patients

• Data from end September 2013:

– Number of practices uploading data: 2,515

– Number of patients with AF: 318,039

– Prevalence of AF: 1.77%*

*GRASP-AF searches for history of AF and includes people coded as ‘AF resolved’

CHART Online data- uptake

CHART Online data- management

Of those 183,334 patients with a CHADS2≥2 in those 2,515 practices:

• 48.4% patients on oral anticoagulation (OAC) alone• 8.4% patients on OAC and aspirin• 34.5% patients on aspirin alone• 8.7% are not on either

Of those 79,082 patients not on OAC:

• 9.8% OAC declined• 3.6% contraindicated• 86.6% no reason given

Stroke risk in AF: CHADS2 and CHA2DS2VASc

• Data and audit can be a powerful driver for change• All GRASP tools are designed to generate

improvement in primary care and have proven QIPP value and alignment to QOF

• A number of conditions / diseases lend themselves to this approach

• GRASP can provide the focus for improvement work in HF, COPD and AF – preventing premature mortality, reducing admissions, promoting primary care management of chronic disease and improving quality of life for millions of people

The GRASP Suite

• About 3 million people have chronic obstructive pulmonary disease (COPD) in the UK

• Nearly 900,000 people in England and Wales are diagnosed as having COPD and an estimated 2 million people have COPD which remains undiagnosed

• Symptoms usually develop insidiously making it difficult to determine the true prevalence of the disease

• Most patients are not diagnosed until they are in their fifties

GRASP-COPD

• COPD is predominantly caused by smoking and is characterised by airflow obstruction that:

- is not fully reversible- does not change markedly over several months- is usually progressive in the long term

• The biggest caseload for primary care arises from respiratory conditions & it accounts for 12% of all emergency hospital admissions

• Over 1 in 3 patients admitted to hospital with COPD will be readmitted within 30 days and 1 in 10 dies within that period

• COPD costs the NHS more than £800 million each year, (equivalent to £1.3 million per 100,000 population.)

GRASP-COPD

GRASP-COPD dashboard

• Around 900,000 people in the UK have heart failure (HF)

• Like AF, the incidence and prevalence of HF increase steeply with age

• The prevalence of HF is expected to rise in future as a result of an ageing population, improved survival of people with CHD and more effective treatments

• HF has a poor prognosis: 30–40% of patients diagnosed with heart failure die within a year

• HF accounts for a total of 1 million inpatient bed-days – 2% of all NHS inpatient bed-days – and 5% of all emergency medical admissions to hospital

GRASP-Heart Failure (GRASP-HF)

• Good heart failure care reduces premature mortality, and improves quality of life

• Good heart failure care in primary care can reduce hospitalisations and save money for the NHS

GRASP-HF

Draft GRASP-HF dashboard

• Almost one third of GP practices in England using GRASP-AF and uploading data to CHART Online

• Still many high risk patients with AF are sub optimally managed

• Moving to ESC guidance (CHA2DS2-VASc) has the potential to save thousands more lives (and £s)

• NHS Improving Quality will continue to promote the use of GRASP-AF as part of a ‘suite’ of similar tools

• Primary care has a pivotal role to play in the call to action to reduce premature mortality; the GRASP suite will help

Summary

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