AF Stroke from a PH
perspective
Greg Fell
Greg.fell@bradford.gov.uk
Some important numbers as
context
228
2,500
228
2,500
228 AF strokes per year in Bradford
811 strokes in total.
2,500 AF strokes in YH
(1% and 10% of the England pop)
12,000 and 6,000
£12,000 and £6,000
The yr 1 and subsequent year
costs of caring for stroke patients
The sub study of AF stroke – fits
into a broader picture. c15% of
strokes are AF strokes.
Anticoagulation and AF stroke “Dear NHS – must and can do
better”
AF prevalence – its not something
that is going to decline
1.6%
7,000
1.4%
6,000
1.2%
5,000
1.0%
4,000
0.8%
3,000
0.6%
0.4%
2,000
0.2%
1,000
0.0%
0
2006/07
Total patients
NB the age specific prevalence
seen in GRASP AF dataset
Patients on register
Prevalence
QOF disease register and prevalence - Atrial Fibrillation
2007/08
2008/09
Prevalence
2009/10
2010/11
Yorkshire & Humber prevalence
13% growth in Bradford in last 5
years
New cases + finding existing cases
1.5% prevalence in YH.
85% of prevalent cases CHADS2
>=1
Long term trends in AF stroke (YH)
• To insert when I have the data
• Jon is getting me 10yr trend in AF
stroke….
Dear NHS….. Must do better
Marked under use of a cheap and
effective intervention that cuts stroke risk
by c60%
This is not news.
“overuse” of anti platelet medicine
Dear NHS….. Must do better
Even in really high risk patients
34% anticoagulated
Community dwelling AF stroke survivors
N=3500.
NNT = 10-12
Here is the story of HOW to
do better
How to cut the AF stroke rate by
15% in a year.
Greg.fell@bradford.gov.uk
We know a lot about individual
clinical practice.
We know remarkably little about
how “best” to
improve population outcomes
Key features
•
•
•
•
•
•
•
•
•
Data
Benchmark
Achievable benchmark of care for pop
Single side guidance for clinicians
Consistently applied to all
Small number of measured indicators
Regular feedback
Active support.
Seems to have achieved quite remarkable results –
• 43% controlled to 84% controlled (55 -64% in
comparator)…..
And into AF
Where we started from
• 6,500 patients on AF register
• AF substantially increases risk of stroke
• Approx 2500 are on anticoagulation, significant more
should be.
• Approx 50% of people that need the intention don't
receive it
• Warfarin is and remains v effective in reducing risk of
stroke.
• An “innovation” that is 50 years old.
• Not without risk and thus needs to be used carefully
indicators
• % of AF patients (QOF) register with CHADS2
of 1 or more who are NOT receiving
anticoagulation
• Time in therapeutic range achieved by INR
monitoring providers
Aims:
“to ensure that at least 70% of patients with
AF and a CHADS2 score of 1 or above are
receiving Warfarin”
“for 80%* of those patients to achieve an INR
in range*.”
The AF Quality Improvement Project
56 (of 80) practices actively participated in
the project involved
C330,000 population
Both hospital participated in the project
trying to improve TTR in secondary care
based Warfarin clinics.
Approach was simple
•
•
•
•
•
Clear quality standard
Measurable
Measure it – practice or provider level
Make data available and public
Achievable benchmark of care target for each
practice – what level are the 2nd quintile performers
achieving
• Ten evidence based strategies were consistently
applied to the practices that were participating to
encourage improvement.
• Bespoke support and advice to practice and more
widely - Q&A / Expert events / training / Practice
visits / IT tools
• 1 year to 18 months.
Did it work?
AF QIP achievements
No. of patients
Patients with CHADS2 ≥1 on AF register
and on Warfarin
4,000
3,000
2,2742,325
2,541 2,563 2,542
2,620 2,782
2,988
2,000
1,000
0
Sept
11
Dec Apr 12 June Aug Oct 12 Dec- Mar13
11
12
12
Month12
Current achievement
714 additional
patients on
Warfarin
31% relative
improvement
AFQIP target
If you believe the NNTs - 29 Strokes and 17
deaths prevented
If 29 avoided = approx 15% of AF Stroke
AF QIP achievements –
against our target
Percentage
100
90
80
70
60
50
40
30
20
10
0
% of patients CHADS2 ≥ 1 and on
Warfarin
49
47
51
51
55
57
60
63
65
65% of patients with
CHADS2 ≥1 on
Warfarin
6% absolute
improvement
31% relative.
Sept 11
Dec 11Apr 12
June 12
Aug 12Oct 12Dec12Feb13Mar13
Month
Current achievement
All
AFQIP Target (70%)
Aim was 70%
Remember only 2/3
of our units “played”
60
50
40
0
Ashwell Medical Centre
Bingley Medical Practice
Bowling Hall Medical Practice
Carlton Medical Practice
Dr Hamdani
Farfield Group Practice
Farrow Medical Centre
Frizinghall Medical Centre
Grange Medical Centre
Haigh Hall Medical Centre
Haworth Medical Practice
Heaton Medical Practice - Haworth Rd
Highfield Health Centre - Dr Micallef &…
Highfield Health Centre - Dr Mills &…
Holycroft Surgery
Horton Bank Practice
Idle Medical Centre
Ilkley Moor Medical Practice
Kensington Street Health Centre - Dr…
Kilmeny Surgery
LCD Bradford at Hillside Bridge…
LCD Bradford at Manningham Medical…
Leylands Medical Centre
Ling House Medical Centre
Little Horton Lane Medical Centre - Dr…
Low Moor Medical Centre
Mayfield Medical Centre
Moorside Surgery
Oakworth Health Centre
Park Grange Medical Centre
Parklands Medical Practice
Parkside Medical Practice (Horton…
Picton Medical Centre
Primrose Surgery
Rooley Lane Medical Centre
Saltaire Medical Centre
Silsden Health Centre
Sunnybank Medical Centre
The Bluebell Building - Dr Malik
The Lister Surgery
The Ridge Medical Practice
The Rockwell & Wrose Practice
The Surgery, Newton Way
Thornton Medical Centre
Westcliffe Medical Centre
Whetley Medical Centre - Dr Masood
Willows Medical Centre
Wilsden Medical Centre
Windhill Green Medical Centre
Woodroyd Centre - Dr Fenwick &…
Woodroyd Centre - Dr Longfield &…
The Bradford Moor Practice
Bilton Medical Centre
The Grange Practice
Shipley Medical Practice
Valley View Surgery
Percentage
AF QIP practices – some
achieved their own
Target.
Some
didn’t.
% of patients CHADS2 ≥ 1 who are on Warfarin - March 2013 Fixed
100
90
denominator
90
80
76
70
64
77
67
68
58
48
73
76 75
51
31
72
71
53
76
62
68
65
62 61
68
80 83
52
41
33
Current achievement
78
65
50
76
83
65
70
62
38
42
30
Target
66
55
47
51
72 74
65
57
74
81
59
66
50
50
59
43
50
29
20
10
100
90
0
Ashwell Medical Centre
Bingley Medical Practice
Bowling Hall Medical Practice
Carlton Medical Practice
Dr Hamdani
Farfield Group Practice
Farrow Medical Centre
Frizinghall Medical Centre
Grange Medical Centre
Haigh Hall Medical Centre
Haworth Medical Practice
Heaton Medical Practice - Haworth Rd
Highfield Health Centre - Dr Micallef…
Highfield Health Centre - Dr Mills &…
Holycroft Surgery
Horton Bank Practice
Idle Medical Centre
Ilkley Moor Medical Practice
Kensington Street Health Centre - Dr…
Kilmeny Surgery
LCD Bradford at Hillside Bridge…
LCD Bradford at Manningham…
Leylands Medical Centre
Ling House Medical Centre
Little Horton Lane Medical Centre -…
Low Moor Medical Centre
Mayfield Medical Centre
Moorside Surgery
Oakworth Health Centre
Park Grange Medical Centre
Parklands Medical Practice
Parkside Medical Practice (Horton…
Picton Medical Centre
Primrose Surgery
Rooley Lane Medical Centre
Saltaire Medical Centre
Silsden Health Centre
Sunnybank Medical Centre
The Bluebell Building - Dr Malik
The Lister Surgery
The Ridge Medical Practice
The Rockwell & Wrose Practice
The Surgery, Newton Way
Thornton Medical Centre
Westcliffe Medical Centre
Whetley Medical Centre - Dr Masood
Willows Medical Centre
Wilsden Medical Centre
Windhill Green Medical Centre
Woodroyd Centre - Dr Fenwick &…
Woodroyd Centre - Dr Longfield &…
The Bradford Moor Practice
Bilton Medical Centre
The Grange Practice
Shipley Medical Practice
Valley View Surgery
Percentage
Most got better though.
AF QIP before / after
across AFQIP practices
% of patients CHADS2 ≥ 1 who are on Warfarin - Sep 11 vs. Mar13
80
70
60
50
40
30
20
10
Mar-13
Sep-11
The best improvement was in the
highest risk
80%
70%
67%
63%
60%
52%
49%
50%
55%
53%
54%
51%
53%
51%
42%
40%
35%
30%
29%
27%
20%
10%
Sep-11
Mar-13
NNT=20
NNT=13
NNT=
0%
CHADS2=0
CHADS2=1
CHADS2=2
CHADS2=3
CHADS2=4
CHADS2=5
CHADS2=6
INR didn’t change much over time.
Mean INR before the AFQIP = 76%*
Mean INR after the AFQIP= 74% *
p=0.1 no difference
Large number of new patients added
into INR clinics. Despite this – no
change in % of tests in
100%
80%
60%
40%
20%
0%
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Percentage
All anticoagulation practices - % of tests within
range
Month
*point prevalence
AF QIP practices vs. non AFQIP
Average % of patients on
Warfarin before and after
70.0
62.1
60.0
50.0
Average % of patients on
Warfarin before and after (non
60.0
AFQIP)
52.2
50.0
45.4
43.0
40.0
40.0
30.0
30.0
20.0
20.0
10.0
10.0
0.0
Before %
Difference = 16%
p>0.001
After %
0.0
Before %
Difference = 9%
After %
Economic impact of AF QIP
Was it worth it
financially
COST NEUTRAL V V V Worst case
This is highly simplistic
Cost of the intervention (warfarin +monitoring) £242
(NICE, 2012) *714= £172788
Cost of the implementation –approximately=
~£100,000
NHS cost of 29 strokes averted -29 *£13000=-£ 377000
Total net savings = - £ 104212*
This should be interpreted with caution as it is based on the assumptions used in the NICE
guidance.
We will conduct a detailed analysis in the next 2months.
To see what ACTUALLY did happen.
Equity – it is always practices in posh parts of
town that participate
• Not here! No evidence of that.
• Participation is across the board.
• Thus hard to say this approach will increase
inequity
Where this project sits in the
Scheme of “innovation”
We have “done” clean water
And vaccinations
And MRI and CT scanning / statins / Coronary artery bypass
graft surgery and …..and ….. And…..and……
And warfarin is hardly innovative
But here is an important process innovation, that is
cheap to implement and seems to make a difference at
scale.
This is a model of “innovation” that
seems to make a difference, and has
traction, and is cheap
• Developing an effective model for QI in
primary care
• One that primary care really engages with
• cheap and simple to run,
• Does rely on enthusiastic individuals with a
common goal.
• There was consistently positive feedback from
practices and those that didn't initially
participate are now requesting to do so.
Success factors?
• clear measurable indicators
• work of local GPs and other clinicians in making this
happen.
• Collaboration of a wide range of parts of the system
(provider and commissioner) and with strong PH and
clinical leadership
• live data to ensure some “competition” between
practices,
• live Q&A with experts,
• a clear approach to peer facilitation, recognising that
practices had as much to teach each other as
“experts” had to teach them
Dear NHS…. HAVE DONE better.
subsequent data analysis – 25 less
AF strokes per year
It is a challenge that CAN be
addressed. We have proved this.
So……
• Its important
• People die
• People are disabled and their families are made
miserable
• It is costly AND relatively common
• It is preventable
• The track record of the NHS in this is …
lamentable….
• Dear NHS……..
Any questions?
Greg.fell@bradford.gov.uk
Postcript – reflections.
This is work in progress
Additional slides – more detail
• approach was similar to that advocated by world leaders
in quality and safety (Provonost)
• explicitly focused on some of the reasons why existing
and well publicised guidelines are under implemented.
• directly addressed areas where there is disagreement,
we simplified guidelines so as they influence decisions at
the point of care,
• disrupted the status quo by providing comparative
performance data.
• We relentlessly focused on population based care, as
opposed to focusing on individual clinicians and the
patient / clinician interaction.
The intervention – in detail
•
•
•
•
•
•
•
•
a specifically assembled team
two indicators,
established a method for extracting data out of primary care clinical information
systems in a way that all practices that choose to participate can see all other
practices achievement.
We set a target number of patients to be considered for anticoagulation in each
practice, based on the Achievable Benchmark of Care method.
For the system as a whole, defined as all participating practices in Bradford, our aim
was to ensure that at least 70% of patients with AF and a CHADS2 score of ≥1 are
receiving anticoagulation,
and for 80%* of those patients to achieve an INR in range.
18 month period (time to change!)
ten simple but evidence based strategies (AHRQ / IHI) to encourage and incentivise
achievement the target in each practice.
– provision of bespoke support and advice to practices and more widely
– Q&A
– Expert events
– training
– Practice visits
– IT tools and templates to standardise the approach to anticoagulation decisions
in general practice and bring evidence to the point of clinical decision making.
– Updated audit at intervals – to see progress
Success factors in implementation
•
•
•
•
•
•
•
•
strong clinical and PH Leadership. visible and LOCALLY credible opinion
formers and leaders to lead
Ruthless and meticulous implementation
A small number of locally agreed high impact and measurable indicators
a clear approach to peer facilitation, recognising that practices had as much
to teach each other as “experts” had to teach them
Benchmark live data on achievements against those indicators across all
participating practices. This encourages competition within a system on
quality metrics – striving to be the best.
Single side guidance for clinicians, broader suite of tools embedded in
primary care IT system to enable better and more standardised practice.
Applied to large population over long time period.
Regular feedback on achievement – with data and softer messages.
Active evidence based strategies were consistently applied to the practices
that were participating to encourage improvement
simply hard work and sustained implementation of evidence based clinical
behaviour change strategies.
Practice visits – key intervention
•
•
•
•
•
•
•
Each practice gets 2 visits.
As part of the practice meeting (in between clinics - time restricted)
involve multiple staff groups GP, PN, HCA. More staff involved, more likely
to have a speedy up take of templates etc.
Ensuring data recording is consistent is one of the biggest battles, we want
our indicators to be as sensitive and specific as possible and consistent
methods of recording reduce false positive/negatives appearing in any
searches produced.
ask for who updates their clinical tree to come along. This is normally a data
clerk and usually not the kind of staff member they readily let out to
meetings (GPs have the monopoly on PLT still)
Running the searches with them, discussing difficult patients etc makes the
QIP real and allows tasks/recalls etc to be done whilst I am there e.g. can
we task the nurse to add a BP check to that patients appointment next
week? Or that patient is due in for a review, could we ask the secretary to
send out a letter inviting them in?
The subsequent follow up visit could be pooled, as we won’t have time for
all the first visits at this rate I think this would be a wise economy of scale
suggestion.
Examples of the tools
Spread - it is critical.
•
•
•
•
•
•
•
•
•
•
•
one of the greatest challenges
spread, both to broader geography and to other clinical areas
Constancy of purpose is important.
The NHS needs to be clear in their expectations as to this improvement
being the norm and that it cannot wait out this "flavour of the month".
important to have a realistic understanding of change fatigue and how much
process improvement the organization can do at once.
Here we deliberately focused on “the masses” rather than the “best
performers”.
Often an assumption is made that "if you improve the leading edge, the
rest will follow“, or if you “target the laggards, it will bring up the trail”.
whilst this might be true - this approach will not achieve population shift at
the same level as setting achievable targets for mass improvement.
a visual display of performance of the system really helped motivate
change, especially where there is real time shift that can spur further action.
creation of half-life type goals rather than finite targets will be important in
sustaining long term improvement.
This will embed the notion that the system does not become complacent
once a target has been achieved.
getting others on board. Tactics for
bringing along those who have not
yet adopted the change
•
•
•
•
•
•
•
•
•
The "we didn’t invent it and we think our idea is better" syndrome
we are all guilty of this
Get the vital few on board (the majority will follow) - key opinion leaders.
The remainder will need to be managed. This is the aproach taken,
seemingly very successfully, by pharma companies. Strong network of
KOLs.
Understand what prevents the remaining few from coming on board.
Qualitatively. How does it feel to them
Use KOLs and quickly find a success story. Measure and spread the word.
Some of the most effective champions are the ones who are former hold
outs.
Use leadership to force the issue. Be straightforward and ask, "Do you know
something that we don't? If you do, we need to understand it“
emphasise the importance of patients expectations and demand
Imagine a scenario of all AF patients knew that aspirin had limited to zero
net benefit and demanded anticoagulation from their doctor.
Patients need to know what to demand.