Don’t Wait to Anticoagulate’

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Case Study Summary
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Overview summary:
This Programme will support primary care to reduce the burden of AF-related Stroke in our population through achieving the following clinical aims: Where appropriate, to increase rates of anticoagulation use in AF patients identified as high risk of AF-related stroke not currently receiving appropriate anticoagulation; Optimise anticoagulation of AF patients unstable on Warfarin through transfer to NOACs where appropriate.  The programme is funded through a joint working project between Bayer HealthCare and West of England AHSN.
Challenge identified and actions taken :
The UK sees 150,000 strokes per year of which 20% are attributable to AF (Ball 2013) giving a figure of 30,000 AF-related strokes. Extrapolating the results from phase one may result in approximately 15% fewer strokes in high risk patients across the UK.
  • Quality Improvement: Create an approach that will enable clinicians to re-evaluate how identification, diagnosis and treatment occurs and consider NOACs alongside traditional anticoagulants
  • Strategic: Create an approach that will enable a CCG to sustainably drive implementation of the above (including appreciation of risks (financial and otherwise) of implementation).
Impacts / outcomes:
Phase One: Across eleven partner practices in phase one, 2,688 patients with AF were identified. Of these, 335 patients were rated as being at ‘high risk’ (i.e. had a CHA2DS2Vasc score of greater than one); over a three-month period, 131 patients were reviewed with regard to optimising their management.

As a consequence, it has been estimated that between five and six strokes were prevented over this period.

Investigations into the potential financial implications of a stroke have suggested an associated cost of £23,315 per stroke (National Audit Office, 2010).  Applying this principle to the findings of the innovator phase could suggest costs between £116,575 and £139,890 may have been avoided.
Supporting quote for the innovation from key stakeholders:
The programme is funded through a joint working project between Bayer HealthCare and West of England AHSN.
Which local or national clinical or policy priorities does this innovation address:
Enhancing quality of life for people with long-term conditions
Plans for the future:
 It is anticipated that accredited online training resources will be available by Q1 16/17.
Tips for adoption:
Project management resource; CCG Leads (clinical; managerial; pharmacist); Other CCG support (comms; finance; project sponsor; primary care team); Resource to deliver training (clinical updates and quality improvement); quality improvement mentoring and coaching; caseload audit resource; availability of practice support pharmacists to work with practices; informatics (to enable quantitative evaluation of impact). Online tools to support patients and practices in shared decision-making, implementing a quality improvement project are already available.
  • Clinical Champions (both at strategic and project level)
  • Modelling of Health Economic impact of adoption
  • Building a community of practice (with regard to both clinical case for change, as well as creating a shared language and experience underpinning the quality improvement element)
  • CCG also included this clinical area in their primary care offer.
It is critical that the health economic impact of the project and associated changes in prescribing costs should be explored with each CCG during initiation. We have a local health economic modelling tool that could be adapted to suit local needs.
Contact for further information:
Anna Burhouse, Director of Quality ( Stephen Ray, Programme Manager (; Phase one evaluation (full version and executive summary) available; Health economic modelling tool.
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