Introduction: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a five-fold increase risk of stroke. NICE recommends that patients with AF are assessed for stroke risk using a validated risk score (e.g. HA2DS2VASc). In the absence of contra-indications (use a score e.g. HAS-BLED to identify modifiable bleeding risk factors) patients with a CHA2DS2VASc of two or more should be offered anticoagulation either with warfarin or a direct acting oral anticoagulant (DOAC) in line with the product license. Despite this guidance Brighton and Hove Clinical Commissioning Group (B&H CCG) General Practice Quality Outcomes Framework (QoF) for 2015/16 only achieved a rate of anticoagulation for AF of 70.38% – which was in the lowest centile for England. Furthermore, compared to their Right Care comparator group B&H CCG had the lowest rate of anticoagulation for AF.
Aim: The aim of this project was to improve the uptake (PROTECT) and appropriateness of anticoagulation (PERFECT) for AF in B&H with a pharmacist led medicines optimisation initiative.
Methods: Following approval and undertaking a pilot (six practices) the project was rolled out across the CCG. The clinical pharmacists received training from the project lead (Consultant Pharmacist Cardiology) with ongoing support throughout the project. To improve engagement from GP practices the project was included in the Prescribing Improvement Scheme which gives a small financial incentive to GP practices to engage in CCG wide quality improvement initiatives.
The GP practice identified an AF project lead and the pharmacist reviewed the records for all patients on the practice AF register. An assessment was made of the patient’s stroke risk, bleeding risk and any contra-indications relating to anticoagulation. Current prescription of anticoagulation and/or antiplatelets was reviewed along with time in therapeutic range for warfarin and appropriateness of dose for DOACs. A list of recommendations were made for optimising anticoagulation and the pharmacist met with the GP AF lead to undertake a ‘virtual clinic’ to discuss the recommendations and agree an action plan for the GP to implement for which an outcome was required to be submitted to the CCG project lead by 31/05/18.
Results: All practices (n=36) undertook the project and 4,458 AF patients were reviewed. Fifty-six percent of the patients were male and 65% were aged 75 years or more. The mean CHA2DS2VASc score was 3.4. Of those already prescribed an anticoagulant 1,686 were on warfarin and 1,298 a DOAC. The table outlines the actions agreed from the virtual clinics and a summary of implementation as of 31/5/18. The CCG QoF data for 2017/18 showed a 7.53% increase in uptake of anticoagulation with a further increase predicted in 2018/19.
Conclusions: This pharmacist led quality improvement project has had a positive effect on PROTECT and PERFECT for the AF population in B&H with a high proportion of the recommendations implemented. Furthermore, we predict that the educational aspects of the virtual clinics, the work in progress at project submission and the legacy effects from the project will result in further improvements which will be seen when the results of the QoF submission for 2018/19 are published.