pan london af improvement programmeuclpstorneuprod.blob.core.windows.net/cmsassets/3...a simplified...
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Pan London AF Improvement Programme
• Where to look
Sotiris Antoniou, Consultant Pharmacist
On behalf of Pan London Primary Care AF Improvement Programme
6th June 2016
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A simplified view of the AF Pathway
1. Pre-Diagnosis
Populationscreening
Risk stratification
Case finding
Cross correlation withother registeredconditions
Contact & patientinvitation
Detect (Detect)
2. Diagnosis
Assessment
Electrocardiograms
Echocardiograms
Pulse checks
Correct
Catheter
Rhythm controlDC Cardioversion , Class1c (flecainide) or IIIantiarrhythmic drugs(amiodarone or sotalol)
Electrical / chemicalcardioversioni.e. pacemaker
Surgicalablation
Virtual clinics /Secondary caresupport
Left AtrialAppendage(LAA)
4. Treatment
Drugs /technology
Rate control (betablockers(Atenolol,bisoprolol) orrate limiting CCB(Diltiazem, verapamil)
Protect
3. Therapy
Behaviouralchange
Direct oralanticoagulant (DOAC’s)i.e. Rivaroxaban,Dabigatran, Apixaban,Edoxaban
“Don’t wait Anti-coagulate” i.eWarfarin
Perfect
5. Living with AF
Monitoring
INR devices
Patientactivation
Wearable heart monitor
Telehealth remotemonitoring
INRtesting
Medicationcompliance
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Source: Stroke association: https://www.stroke.org.uk/professionals/af-page/af-page-%E2%80%93-ccgs-d
585
348
426
SSNAP 2014/15: Strokes and known AF
Anticoagulated Aspirin only No treatment
Why? - London picture
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4Source: NCVIN 13-14 and QOF 14-15
-> 67,000 undiagnosed AF patients in London
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Prevalence data for practices in the CCG
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Barnet – 760
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Anticoagulation rates – untreated patients
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Source: QOF 14-15AF 004 no exceptionsQOF Actual
Variation in anticoagulation rates for practices in the CCG
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Anticoagulation rates
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Source: QOF 14-15AF 004 no exceptions
Could do better?
Best practice
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-2000
-1500
-1000
-500
0
500
1000
1500
2000
2500
(£15,000,000)
(£10,000,000)
(£5,000,000)
£0
£5,000,000
£10,000,000
£15,000,000
£20,000,000
Yr1 Yr2 Yr3 Yr4 Yr5
5 year change in NHS and LA spend and strokes prevented
Total costs Total savings Budget impact (savings - cost) Strokes prevented
• Based on the NICE AF costing tool (2014) with thesame modelling assumptions
• 84.21% of AF population have CHADSVASC≥ 2
• Baseline demographic data from QOF 2014/15• Current and future treatment estimates from NICE
AF costing report 2014• 3 NOACS (not edoxaban) used in equal proportion• Cost of stroke £12,228 (NICE); major bleed cost
£1,173 (NICE)• Cost of long-term nursing care £6,880 does not
include all social care costs• Drug costs from MIMS 2015• Does not include other economic benefits• Does not include increase in AF incidence year-on-
year• Does not include additional patients
identified through screening
Modelling assumptions
Health and budget impact modelling – London
Stroke
sP
reven
ted
Savi
ngs
Co
sts
Benefits
• Prevent over 2000 strokes over 5 years• ~ 400 - 500 lives saved over 5 years• Net savings seen at year 3, and accumulative
net savings to health economy of ~ £3.5 millionover 5 years.
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• Based on the NICE AF costing tool (2014) with thesame modelling assumptions
• 84.21% of AF population have CHADSVASC≥ 2
• Baseline demographic data from QOF 2014/15• Current and future treatment estimates from NICE
AF costing report 2014• 3 NOACS (not edoxaban) used in equal proportion• Cost of stroke £12,228 (NICE); major bleed cost
£1,173 (NICE)• Cost of long-term nursing care £6,880 does not
include all social care costs• Drug costs from MIMS 2015• Does not include other economic benefits• Does not include increase in AF incidence year-on-
year• Does not include additional patients
identified through screening
Modelling assumptions
Health and budget impact modelling – CCG
Stroke
sP
reven
ted
Savi
ngs
Co
sts
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Where to look
• Data set in your delegate packs
• Locally available datasets on prescribing and INR• Warfarin Patient Safety Audit tool – PRIMIS members• http://www.nottingham.ac.uk/primis/index.aspx
• National cardiovascular intelligence network, CVD primary care intelligence pack -http://www.yhpho.org.uk/default.aspx?RID=182342
• NHS Right care – commissioning for value packs for CVD -http://www.rightcare.nhs.uk/index.php/commissioning-for-value/
• QOF 2014/15 - http://qof.hscic.gov.uk/
• Sentinel Stroke National Audit Programme Website (SSNAP) -https://www.strokeaudit.org/Newspress/SSNAP-Acute-Organisational-Audit-2014-Public-Repor.pdf
• Stroke association: https://www.stroke.org.uk/professionals/af-page/af-page-%E2%80%93-ccgs-d
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Key contacts for the programme are either through your local Academic Health Science Network or the London Strategic Clinical Network:
[email protected] (Health Innovation Network AHSN, South London)
[email protected] (Imperial AHSN, North West London)
[email protected] (UCLPartners AHSN, North East and North Central London)
[email protected] (Strategic Clinical Network)
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