Background: Suboptimal anticoagulation in patients with atrial fibrillation (AF) is associated with increased risk of stroke. In 2014/15 across 44 general practitioner (GP) practices in a South London Clinical Commissioning Group (CCG), only 73% of patients with AF at risk of stroke were anticoagulated. In the cohort of 489 patients who are not anticoagulated the CCG would expect to see up to 25 strokes per annum. At the time, the introduction of the CHA2DS2VASc score to assess stroke risk in primary care was expected to identify a higher number of at-risk patients requiring anticoagulant therapy.
Aims: 1. To ensure all patients on the AF register have had an assessment of stroke risk using CHA2DS2VASc from 2015/16
2. To ensure all patients considered at risk are offered anticoagulant therapy, including reviewing any patients currently treated with aspirin for stroke prevention in AF
3. To educate practice staff on the use of stroke risk assessment tools, bleeding risk assessment tools and the role of anticoagulation in stroke prevention in AF.
Methods: A standardised search was set up by the medicines optimisation team to identify all patients on the AF register not currently anticoagulated. Resources in the form of an audit tool and prescribing guidance were provided to GP practices. Local specialist anticoagulant pharmacists delivered virtual clinics, worked with practice staff to assess stroke and bleeding risk and, where appropriate, ensure patients were prescribed anticoagulant therapy in line with national guidance. The project was included as an essential part of the local prescribing incentive scheme to encourage GP engagement.
Results: Data was submitted by 41 of 44 GP practices (93%) in the CCG. In these practices, 566 patients were reviewed in virtual clinics between Jan and December 2016. During the course of the project an additional 725 AF patients have been anticoagulated across all 44 GP practices in the CCG, increasing the total anticoagulation rate to 83% in Southwark CCG and out-performing London as a whole (see figure 1). This increase in anticoagulation rates is expected to prevent up to 25 strokes per annum.
Conclusion: This project, which offered multi-faceted support to GP practices in the form of an audit tool, prescribing guidance and virtual clinics run by specialist anticoagulant pharmacists, has improved the uptake of anticoagulant therapy in patients with AF. Stroke rates across the CCG have begun to fall as a result, although the full impact of the project on AF-related stroke rates will not be realised until 2017/18. Cost savings in the order of £300,000 and £1,113,000 are expected in year one and over 5 years respectively as a result of the strokes prevented.