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Dr Chris ArdenGP, Chandlers Ford GPSI Cardiology, SouthamptonWest Hampshire CCG Cardiovascular Lead
Friday 10th November 2017Nottingham
Optimising detection and stroke prevention strategies in patients with Atrial Fibrillation
in West Hampshire
Projected Number of Patients With AF by 2050
Olmsted County data, 2006 (assuming a continued increase in the AF incidence)
ATRIA study data, 2000
Olmsted County data, 2006 (assuming no further increase in the AF incidence)
MarketScan & Thomson Reuters Medicare databases, 2009
3.03
7.56
Chart1
1995199519951995
2000200020002000
2005200520052005
2010201020102010
2015201520152015
2020202020202020
2025202520252025
2030203020302030
2035203520352035
2040204020402040
2045204520452045
2050205020502050
ATRIA
Mayo no further increase in AF incidence
Mayo assuming a continued increase
Thomson Reuters
Year
Patients with atrial fibrillation (millions)
2.08
2.26
5.1
5.1
2.44
5.6
5.9
3.03
2.66
6.1
6.7
3.35
2.94
6.8
7.7
3.65
3.33
7.5
8.9
4.2
3.8
8.4
10.2
4.75
4.34
9.4
11.7
5.45
4.78
10.3
13.1
6
5.16
11.1
14.3
6.7
5.42
11.7
15.2
7.15
5.61
12.1
15.9
7.56
Sheet1
199520002005201020152020202520302035204020452050
ATRIA2.082.262.442.662.943.333.84.344.785.165.425.61
Mayo no further increase in AF incidence5.15.66.16.87.58.49.410.311.111.712.1
Mayo assuming a continued increase5.15.96.77.78.910.211.713.114.315.215.9
Thomson Reuters3.033.353.654.24.755.4566.77.157.56
www.escardio.org/guidelines
ANTICOAGULATION
http://www.escardio.org/guidelines
How do we screen for AF?
Preventing stroke in West Hampshire
We want to: improve the identification of asymptomatic/undiagnosed AF in WHCCG (an estimated
2000 patients) via opportunistic screening utilising the NICE endorsed WatchBP monitor; saving target - 30 strokes per
year at a cost of £126k with zero investment.
West Hampshire CCG 51 practices
546,000 population106,000 over 65s16,000 over 85s119,000 under 20
Ageing population
2,000undiagnosed
AF
12,000people with
AF
10,500AF high
risk stroke
Chart1
on OAC
no OAC
3,700 no OAC
6,800 on OAC
Hi risk AF
6800
3700
Sheet1
Hi risk AF
on OAC6800
no OAC3700
To resize chart data range, drag lower right corner of range.
National drivers
PROACTIVE LEADERSHIP•Awareness raising/Public Health Audit 2012•Multi-level educational sessions/events•Use of incentives/levers QOF/LES/QIPP•Analysis/needs-gap evaluation/business case
OPPORTUNISTIC SCREENING•Screening programme targeting high risk asymptomatic patients•Introduction of NICE endorsed WatchBPTool•Early adopter 3B Practices/wider roll-out WHCCG•Reinforce educational sessions
OPTIMISING ANTICOAGULATION AND REPORTING•Medicines Management LES – Quality/Safety Intervention•Anticoagulation education – NOACS v Warfarin•Improving uptake of GRASP – AF Tool + WPSAT/CHADS2VASC•Uploading to National dataset•Community Pharmacy Interventions•NICE KPIs
EVALUATION/AUDIT•Record monitor progress improvements via GRASP – AF•Increased NOAC prescribing audit•Introduction of AF/anticoagulation nurse?•Public Health Audit/participation in National trials Oxford + Southampton•Review of anticoagulation provision/increasing INR self- testing opportunities/primary care community delivered cardiology services
STEP 1
STEP 2
STEP 3
STEP 4
Preventing stroke in West Hampshire – StrategyA collaborative plan involving WHCCG Long Term Conditions/GPs/Medicines management and pharma
Optimising Care: The Plan
Identify undiagnosed AF using WatchBP tool
Identify and treat people not treated with OAC
Identify people on warfarin sub-optimally-controlled
Atrial fibrillation – screening
Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting
Honney R1,2, Su F1, Arden C3, Pears R2 & Roderick P1
Background:Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed1. Modified blood pressure devices, such as Microlife’s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF2. There is limited literature on the clinical impact of introducing such devices into UK general practice . Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol.
Results:The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI=1.02-1.56). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI=1.00-1.57).
The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually.
The proportion of newly diagnosed high risk patients receiving anticoagulation was not
significantly different between WHCCG (72.21%) and control (71.57%) practices (χ2=0.0456, p=0.831).
Conclusions:Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme.
Methods:This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity.
1University of Southampton, Southampton. UK. 2Hampshire County Council, Winchester. UK. 3West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: [email protected]
References: 1The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.Public HealthEngland; 2013. 2Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7):1046-8.
mailto:[email protected]
Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting
Honney R1,2, Su F1, Arden C3, Pears R2 & Roderick P1
Background:Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed1. Modified blood pressure devices, such as Microlife’s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF2. There is limited literature on the clinical impact of introducing such devices into UK general practice . Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol.
Results:The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI=1.02-1.56). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI=1.00-1.57).
The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually.
The proportion of newly diagnosed high risk patients receiving anticoagulation was not
significantly different between WHCCG (72.21%) and control (71.57%) practices (χ2=0.0456, p=0.831).
Conclusions:Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme.
Methods:This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity.
1University of Southampton, Southampton. UK. 2Hampshire County Council, Winchester. UK. 3West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: [email protected]
References: 1The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.Public HealthEngland; 2013. 2Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7):1046-8.
mailto:[email protected]
Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting
Honney R1,2, Su F1, Arden C3, Pears R2 & Roderick P1
Background:Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed1. Modified blood pressure devices, such as Microlife’s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF2. There is limited literature on the clinical impact of introducing such devices into UK general practice . Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol.
Results:The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI=1.02-1.56). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI=1.00-1.57).
The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually.
The proportion of newly diagnosed high risk patients receiving anticoagulation was not
significantly different between WHCCG (72.21%) and control (71.57%) practices (χ2=0.0456, p=0.831).
Conclusions:Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme.
Methods:This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity.
1University of Southampton, Southampton. UK. 2Hampshire County Council, Winchester. UK. 3West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: [email protected]
References: 1The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.Public HealthEngland; 2013. 2Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7):1046-8.
mailto:[email protected]
Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting
Honney R1,2, Su F1, Arden C3, Pears R2 & Roderick P1
Background:Atrial fibrillation (AF) is a leading cause of preventable stroke but 20% of patients remain undiagnosed1. Modified blood pressure devices, such as Microlife’s WatchBP, have been shown to be more sensitive and specific than manual pulse palpation when used to opportunistically screen for AF2. There is limited literature on the clinical impact of introducing such devices into UK general practice . Although stroke reduction is a primary aim of the Health Check process, assessment of pulse rhythm is not explicitly stated in the Health Check protocol.
Results:The introduction of WatchBP devices was associated with an adjusted 26% relative increase in AF detection rate compared to current best practice (Incident Rate Ratio=1.26, 95% CI=1.02-1.56). The rate of high risk AF diagnoses also increased (IRR=1.25, 95% CI=1.00-1.57).
The mean absolute increase rate of AF detection observed in the intervention practices was 0.4 cases per 1000 person years, which extrapolated throughout WHCCG would be 188 additional AF diagnoses annually.
The proportion of newly diagnosed high risk patients receiving anticoagulation was not
significantly different between WHCCG (72.21%) and control (71.57%) practices (χ2=0.0456, p=0.831).
Conclusions:Given the observational nature of the study design and with limited follow up time and a lack of data on device usage, these results should be interpreted as preliminary. However, the study does suggest that WatchBP may increase rates of AF diagnosis in primary care, ultimately contributing to stroke risk reduction. Using WatchBP to measure blood pressure as part of a Health Check may increase the clinical impact of the programme.
Methods:This natural experiment used routinely collected GP data from the Hampshire Health Record (HHR) covering 146 practices (1,146,163 people), to evaluate the clinical utility of introducing WatchBP devices to chronic disease clinics in 44 practices in West Hampshire Clinical Commissioning Group (WHCCG). The remaining 102 practices were controls. Practice rates of incident AF were compared two months after introducing WatchBP, and Negative Binomial Regression was used to adjust for practice level confounders. An internationally recognised stroke risk assessment tool, CHA2DS2-VASc, was used to assess for changes in newly diagnosed AF severity.
1University of Southampton, Southampton. UK. 2Hampshire County Council, Winchester. UK. 3West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: [email protected]
References: 1The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.Public HealthEngland; 2013. 2Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7):1046-8.
mailto:[email protected]
Evaluation of WatchBP devices in the diagnosis of Atrial Fibrillation in a Primary Care setting
Honney R1,2, Su F1, Arden C3, Pears R2 & Roderick P1
1University of Southampton, Southampton. UK. 2Hampshire County Council, Winchester. UK. 3West Hampshire Clinical Commissioning Group, Eastleigh. UK. Contact: [email protected]
References: 1The National Cardiovascular Intelligence Network. The National Cardiovascular Intelligence Network Cardiovascular disease key facts Atrial fibrillation.Public HealthEngland; 2013. 2Wiesel J, et al., Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Am J Cardiol 2014;114(7):1046-8.
mailto:[email protected]
Optimising Care: The Method
Audit tools identified patients at high risk of
stroke
Results to GPs & continuous feedback on
improvement
Education and training was
delivered
Medicines Optimisation
Incentive Scheme
identification, feedback, education = continuous health improvement
GRASP – AFAn automated tool to identify patients at high
risk of stroke in AF and not on adequate thromboprophylaxis, using existing GP data
Delivered by PRIMIS+ and available via your Cardiac Network.
Audit of Atrial Fibrillation & CHADS2-VASc ScoresClassic View
Total PercentNo. with Atrial Fibrillation 236 1.56Age >= 65 yrs with AF 203 7.62
HELPOVERVIEWPODCAST
NB: Handling of anticoagulant exclusions
©PRIMIS+ 2011
in the 73 high risk untreated
2.9
Select Risk ScorePractice:
Strokes expected annually
Total Practice Population 15148
AF prevalence (%) by age band
0.0 5.0 10.0 15.0 20.0
85+75-8465-7450-6430-490-29
Age
rang
e
AF prevalence (%)
Risk profile for thrombo-embolism
0
20
40
60
80
100
0 1 >1CHA2DS2-VASc score
Perc
enta
ge
Risk factors in patients with AF
0% 20% 40% 60% 80%
Sex = Female
Age 65-74
Vasc disease
Stroke or TIA
Diabetes
Age >=75
Hypertension
HF or LVD
Breakdown of anticoagulant & antiplatelet use by CHA2DS2-VASc score
108
13
4
13
1
0
55
10
3
18
4
7
0% 20% 40% 60% 80% 100%
>1
1
0CH
A2DS
2-VA
Sc s
core
Percentage
Anticoagulant
Both
Antiplatelet
None
Anticoagulant use in high risk patients
020406080
100
On anticoagulant(121 patients)
Not on anticoagulant(73 patients)
Perc
enta
ge
Score or review in last 15 mths
0
20
40
60
80
100
CHADS2 AF review
Perc
enta
ge
CHA2DS2-VAScCHADS2-VASc
Optimising Care: GRASP AFTotal number of expected strokes annually
Sep 14
167Mar 16
129Sept 16
128
Sep 14
2510Mar 16
1651Sept 16
1493
Mar 16
7524Sept 16
7987Sep 14
5916
Optimising Care: WPSAT
Apr 15 8.6%
Mar 168.4%
Sept 167.7%
Apr 15
59%Mar 16
67%Sept 16
67%
Optimising Care: The Results
3000 people poorly-controlled on warfarin reviewed
WPSAT
Chart1
Before
After
% warfarin TTR>65%
% patients taking warfarin well-controlled
59
67
Sheet1
% warfarin TTR>65%
Before59
After67
To resize chart data range, drag lower right corner of range.
Optimising Care: The Results
39 expected strokes avoided
Before
On OAC
No OAC
2071more OAC
WatchBP
GRASP AF
Chart1
On OAC
No OAC
On OAC
No OAC
Mar-16
After
74.3
25.7
Sheet1
Sep-14Mar-16
On OAC64.5On OAC74.3
No OAC35.5No OAC25.7
To resize chart data range, drag lower right corner of range.
Sheet1
Sep-14
Mar-16
Number of reported strokes across WHCCG
Chart1
42064
42095
42125
42156
42186
42217
42248
42278
42309
42339
42370
42401
42430
42461
42491
42522
42552
42583
42614
42644
42675
42705
42736
42767
42795
52 actual strokes saved
Month
Number of Strokes - 12 Month Rolling Average
Number of Reported Strokes - 12 Month Rolling Average
92.0833333333
91.3333333333
91.6666666667
91.8333333333
91.6666666667
90.25
89.0833333333
88.4166666667
87.5833333333
87.0833333333
86.8333333333
86.9166666667
87.6666666667
88.8333333333
87.25
87.75
86.9166666667
88.1666666667
87.4166666667
Data
HHFT - BNHHFTHHFT - RHCHSHFTRBCHUHSTOTALRolling 12 Month AverageChange compared to same Month in Previous YearFinancial Year Total
Apr-140417133293
May-140389103087
Jun-142338133591
Jul-143317173694
Aug-143286173488
Sep-140418153397
Oct-1413821744102
Nov-143417113395
Dec-141278144090
Jan-15130964995
Feb-150308133687
Mar-151297113886921,105
Apr-15133520258491-9
May-150265174391924
Jun-151408103493922
Jul-15040711349292-2
Aug-15117317337190-17
Sep-151311113278389-14
Oct-15136518349488-8
Nov-15134613318588-10
Dec-150321010328487-6
Jan-16031417409287-3
Feb-161339153088871
Mar-1614371331958891,052
Apr-1614581034988914
May-16024617257287-19
Jun-160346213899886
Jul-1612876408287-10
Aug-1682731038868815
Sep-1602589327487-9
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Chart Monthly
41730
41760
41791
41821
41852
41883
41913
41944
41974
42005
42036
42064
42095
42125
42156
42186
42217
42248
42278
42309
42339
42370
42401
42430
42461
42491
42522
42552
42583
42614
42644
42675
42705
42736
42767
42795
Month
Number of Strokes
Number of Reported Strokes - HHFT, UHSFT, SHFT, RBCHFT
93
87
91
94
88
97
102
95
90
95
87
86
84
91
93
92
71
83
94
85
84
92
88
95
98
72
99
82
86
74
Chart - 12 Month Average
42064
42095
42125
42156
42186
42217
42248
42278
42309
42339
42370
42401
42430
42461
42491
42522
42552
42583
42614
42644
42675
42705
42736
42767
42795
Month
Number of Strokes - 12 Month Rolling Average
Number of Reported Strokes - 12 Month Rolling Average
92.0833333333
91.3333333333
91.6666666667
91.8333333333
91.6666666667
90.25
89.0833333333
88.4166666667
87.5833333333
87.0833333333
86.8333333333
86.9166666667
87.6666666667
88.8333333333
87.25
87.75
86.9166666667
88.1666666667
87.4166666667
Optimising Care: What next?
WatchBP to AliveCor
Review 1500 high-risk patients receiving antiplatelet monotherapy
Review 1500 high-risk patients not receiving OAC or those poorly-controlled on warfarin
Getting improvement work embedded into routine clinical practice (including care home residents)
Slide Number 1Slide Number 2Slide Number 3How do we screen for AF?Preventing stroke in West HampshireSlide Number 6National driversSlide Number 8Optimising Care: The PlanAtrial fibrillation – screeningSlide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Optimising Care: The MethodSlide Number 17Slide Number 18Optimising Care: GRASP AFOptimising Care: WPSATOptimising Care: The ResultsOptimising Care: The ResultsNumber of reported strokes across WHCCGOptimising Care: What next?