A consultant‐led anticoagulation review of all patients in one clinical commissioning group to prevent atrial fibrillation related stroke

Abstract

Objective Ensuring patients with Atrial fibrillation (AF) are appropriately anticoagulated across NHS Bedfordshire Clinical Commissioning Group (BCCG) with the primary goal of reducing AF‐related strokes. Methods With Inspira Health, BCCG adopted the Primary Care Atrial Fibrillation (PCAF) Service which is led by Consultant Cardiologists. PCAF uses retrospective clinical audit to identify patients who require prospective face‐to‐face review on the need for anticoagulation. Results 34 GP practices participated covering a 376 311 population (80% of BCCG). 12 573 patients’ medical records were audited. The initial AF register was 7301 patients (AF prevalence 1.9%) and an additional 265 patients were identified through AF casefinder resulting in an AF prevalence of 2.0%. From 7566 patients with AF, 5831 were already on anticoagulants (77.1%), with 50.5% (n = 2947) on VKA medications and 49.5% (n = 2884) on direct oral anticoagulants (DOACs). Of the DOAC patients, 595 (20.6%) required dosage review or up to date blood tests. Case notes were reviewed for 1735 patients not on anticoagulation, with 901 (51.9%) patients deemed not eligible for anticoagulation. This left 834 (48.1%) patients who were eligible for, but not on, anticoagulation. A further 407 (13.8%) patients currently taking VKA medications were deemed sup‐optimal with regards to INR control with TTR < 65%. In total 1241 patients were invited for review by a Consultant Cardiologist at their local GP practice, with an attendance rate of 90%. From all face to face and virtual consultations, 908 patients had anticoagulants prescribed, changed, management of INRs improved or were in the process of being anticoagulated at the time of follow‐up. From this we would expect 36.3 AF related strokes prevented and a cost saving to the NHS of £470 200 per year. Conclusion Through comprehensive audit, BCCG have been able to ensure that patients with AF are appropriately anticoagulated in 80% of their catchment population. This has improved anticoagulation to prevent AF‐related stroke.

Association of conflicting information from healthcare providers and poor shared decision making with suboptimal adherence in direct oral anticoagulant treatment: A cross-sectional study in patients with atrial fibrillation

“…OR 3.92; 95 % CI 1.06À14.48) were more prone to be less adherent. Previous studies have described that addressing knowledge deficits concerning AF and the treatment with anticoagulants, can be vital in ensuring an increased patient satisfaction and consequently a good adherence rate [2,[34][35][36]. This is also in line with a study by Vaanholt et al, who conducted focus groups with AF patients across Europe [37].…”

“…It highlights the importance of adequate patient education, involvement of family members, pre-specified follow-up schedules, involving a local pharmacist if possible, use of technical aids (medication boxes, phone apps, reminder systems) and electronic monitoring if poor adherence is suspected. EHRA also suggests that all AF patients should receive individualized information, specific to their needs, condition and treatment, and repeated over time [19,34,36]. Moreover, HCPs should also be continuously educated, especially in rapid evolving fields and related new therapies to avoid conflicting information.…”

Primary care heart failure service identifies a missed cohort of heart failure patients with reduced ejection fraction

“…Clinical decision-making is exclusively the responsibility of the cardiology team. The PCHF service methodology was developed by Inspira Health, replicating its primary care atrial fibrillation service methodology, 16 and funding for the service was provided by Medtronic.…”

A National Programme to Optimize Anticoagulation in Patients with Atrial Fibrillation

“…Despite the range of anticoagulants available for use in patients with AF, the National Institute for Health and Care Excellence (NICE) estimate that up to 45% of patients who should be anticoagulated are not. 4 The NHS Long Term Plan emphasizes the importance of anticoagulation, stating that their use can avert approximately four strokes in every 100 patients with AF, thus preventing serious disability or even death. 5…”