Stroke Prevention in Atrial Fibrillation project

Detect – Protect – Perfect

Kent Surrey Sussex Academic Health Science Network (KSS AHSN) Alliance for AF aims to reduce the number of people dying or disabled by AF related stroke, by optimising the use of anticoagulants in line with NICE CG180 guidelines. To include educating and upskilling of primary care practitioners around stroke prevention, to sustain the learning and close the AF prevalence gap described by Public Health England across KSS.

Background

The NHS Long-Term Plan and Cardiovascular Disease (CVD) ambition aims to prevent 150,000 strokes, heart attacks and dementia cases over the next 10 years and understands this burden cannot be placed on General Practitioners alone, therefore it concludes that the wider NHS workforce (pharmacists, allied health professionals etc) will be an integral part of the delivery of this ambition.

As an example of this, NHS England has invested £500,000 in procuring Lead-1 ECG devices that have been distributed by all 15 AHSNs to Health Care Professionals across every region and a further £9million in the delivery of an Atrial Fibrillation Stroke Prevention medicines’ optimisation demonstrator programme (the Lambeth & Southwark AF virtual clinic model) in 23 CCGs across England, with support from the Academic Health Science Networks (AHSNs).

Healthcare costs relating to CVD are estimated at £9bn per year, with the cost to the UK economy (including premature death, disability and informal costs) estimated to be £19bn.

The costs of treatment and rehabilitation are particularly high. For example, the cost to the NHS for a patient in the first year following a stroke is around £12,228. When including the costs of social care, this rises to £22,439 in the first year, and £46,039 over five years. In contrast, the cost of treating a patient with Atrial Fibrillation (AF) with anticoagulants is on average under £500 per patient per year.

Project impact so far

The primary target to benefit from this project is the patient.

Impact methodology:

Every 25 possible AF’s detected saves 1 stroke. *

The financial cost of each stroke in the first 5 years is £46,038 but the personal cost is higher. *

Year 1: 2017 – 2018: Review & Protect: The Alliance collaborated with three independent review organisations to work in 29 GP Practices across Kent Surrey Sussex (KSS), looking at the Known AF population. The review identified 1,390 patients eligible for anticoagulation therapy. By the end of May 2018, 503 individuals had had their medicines optimised by their GP Practice, thereby avoiding 14 AF-related strokes. As well as avoiding the debilitating effects on individuals and their families, this will also represent a health and social cost reduction of more than £380,000 over 5 years for the NHS. *

The impact would be far greater if all the remaining 887 eligible individuals were optimised on anticoagulation therapy. A further 24 AF-related strokes could be avoided, with an additional Health & Social Care cost saving of over £620,000. (total 38 strokes avoided and £1m cost impact). *

Year 2: 2018 – 2019: Detect: Latest Kent,Surrey,Sussex activity data following the distribution of the 560 AliveCor Kardia Mobile Lead 1 ECG Devices, we are tracking activity results every month:

  • Timeline: April 2018 to December 2019
  • Traces taken: 13,318
  • Possible AF detected: 1,368
  • Strokes saved: 55 *
  • Health & Social Care cost saving of
    £2.267 million over five years *

Note – the 55 AF-related strokes saved, avoids debilitating effects on individuals and their families and provided all possible AF results are confirmed AF and anticoagulated, avoiding costs to state-funded Health & Social Care of just over £2.2 million over 5 years. *

Activity Data Extension until March 2020: KSS and North East North Cumbria (NENC) AHSNs secured agreement with AliveCor Kardia to extend the monthly’ activity data for another year to March 2020. This means that any Health Care Professionals that have registered to participate in the project and using an AliveCor device in the KSS and NENC AHSN regions will continue to receive monthly activity data for the next year. This also means that any additional devices purchased by healthcare organisations and then registered through the AHSN project will have all activity data automatically counted and the impact reported.

*Reference: Xu XM, Vestesson E, Paley L et al. The economic burden of stroke care in England, Wales and Northern Ireland: Using a national stroke register to estimate and report patient-level health economic outcomes in stroke. Eur Stroke J 2018; 3(1): 82-91. (Reference: https://www.ncbi.nlm.nih.gov/pubmed/29900412/)

East Kent AF Project

Year 3: April 2019 – April 2020: Perfect:

A project plan, based on learnings so far, focussed on 10 GP practices in East Kent working with 30 local clinical pharmacists that work across the 4 East Kent  CCGs (Thanet, South Kent Coast, Canterbury & Coastal and Ashford) with16 newly formed Primary Care Networks (PCN) for the 67 GP Practices with a total population of 722,036 patients (GPP population as at 1st January 2020).

Kent is placed just within the most deprived 50% of all counties and unitary authorities in the South East. Thanet continues to rank as the most deprived local authority in Kent.

Cardiovascular Disease (CVD) accounts for more than a quarter of deaths in England and is the largest cause of premature mortality in deprived areas, with mortality from CVD up to three times higher in the least deprived decile compared to the most affluent decile.

The project work is still focussed on the three key areas of Detect, Review and Protect. However, the approach is adding Perfect and is supporting the 30 Pharmacists and the GP practices by offering a quarterly CVD education programme, a weekly mentorship programme, support to implement the virtual anticoagulation clinic demonstrator programme, an innovative Stoke Prevention Atrial Fibrillation (SPAF) Audit & Case finding service and a robust overall evaluation that will demonstrate how the GP Practices services deliver improved quality, reduce variation, place patients at the centre of change and deliver value for money.

Kent Surrey Sussex Academic Health Science Network (KSS AHSN) is the lead organisation and neutral network to support and facilitate the execution of the project. Working in collaboration with partner organisations which include:

  • NHS – NHS England (NHSE), Public Health England (PHE), Sustainability Transformation Partnerships (STP), Clinical Commissioning Groups (CCG), Primary Care Networks (PCN) and GP Practices participating in the project;
  • Independent sector – Oberoi Consulting and Pharma K Healthcare Ltd.

What did we do?

KSS AHSN collaborated with East Kent CCGs as key delivery partner to co-ordinate the implementation of the AF package of support in 10 GP practices.

Implementing a robust package of AF tools and resources to ten GP practices that will support them to deliver in the 3 key focus areas of Detect-Protect-Perfect. In addition, the provision of Clinical Pharmacists upskilled in education and mentorship programmes.

AF package of support includes:

Detect: AliveCor Kardia Mobile Lead 1 ECG Devices, training, supporting pathways and resources.

Opportunistic Case finding prompts through the Oberoi SPAF & Case Finding Service.

Protect: Virtual Anticoagulation Clinic Model (NHSE AF Patient Optimisation Demonstrator Programme).

Perfect: System searches to increase optimal anticoagulation, monitoring and ensure correct coding recorded.

Clinical Audit & Reporting Data: Measured the ongoing impact of detect, protect and perfect at Practice, PCN and CCG level through the Oberoi SPAF & Case Finding Service.

Education: CVD Education Programme for Clinical Pharmacists (quarterly).

Mentorship: CVD webex for Clinical Pharmacists led by CVD Clinical Lead (weekly).

Resources: Access to a KSS wide CVD online platform to access shared learning and resources.

Including: Atrial Fibrillation, Heart Failure, Cardiac Rehabilitation, Cholesterol and Familial Hypercholesterolemia.

Next steps

The aim in 2020 is to spread the Oberoi SPAF & Case Finding Service further using secured Medical Education Goods Services (MEGs) funding, across the whole of East Kent in all 67 GP Practices, West Kent CCG in 15 Practices and East Surrey CCG in 18 Practices, to support in-house practice clinicians to increase the prevalence of AF and rates of optimal anticoagulation to at least 90% and ‘perfect’ anticoagulation thereby delivering on CVD Prevention.

We will work with all the practices to share all the elements of the AF package, including access to the CVD online platform, education and mentorship opportunities and all the supporting documents and resources to progress implementation in line with NHS guidelines.

If you would like more information on Atrial Fibrillation, or you would like to know more about our project and how it could be replicated in your area, please contact Jen Bayly, KSS AHSN, Cardiovascular Programme Lead: jennifer.bayly@nhs.net

 

 

Resources (access case study here)