Prior to the introduction of DOACs, patient choice for drug management of NVAF was limited. NICE has issued single TA's for all the DOACs. Once a diagnosis of AF and the decision to anticoagulate has been made, NICE recommended the following- 'discuss the options for anticoagulation with the person and base the choice on clinical features and preferences.
As DOACs are novel drugs there are distinct differences between each drug. Historically anticoagulants have been initiated in secondary care clinics. Dudley Health Economy developed 'Dudley a AF advisor' to support prescribers in decision making with patients to commence immediate anticoagulation and to ensure that DOACs continue to be prescribed safely as patient factors (such as weight, renal function and age) vary. Clinicians have a professional obligation to ensure patients are anticoagulated immediately after diagnosis of vascular and arrhythmic conditions.
The Dudley AF Advisor therefore aims to support prescribers in decision making when reviewing need for initiation and the ongoing prescribing of an anticoagulant.
An initial flowchart for the initiation of DOACs was developed using the Dudley briefing on DOACs, NICE TAGs and the Keele decision aid on anticoagulants along with the SPCs for the individual DOACs. This flowchart was then developed into a template on EMIS Web. The template has undergone extensive testing and modification on a range of different patient scenarios from the steering group and has now been developed further to flag individual patient variables such as weight, renal function and age which influence DOAC dosage.
The ultimate beneficiaries of the Dudley AF advisor tool are patients where an anticoagulant can be initiated immediately after diagnosis of AF and thereby managing and reducing the associated risk of stroke. The intention is to reduce the burden on hospital anticoagulation clinics by reducing the referral/ waiting times for the initiation of an anticoagulant. The tool helps to upskill GPs to confidently initiate a DOAC in primary care and supports the aim of delivering more services in a primary care setting. (Historically all anticoagulation in Dudley has been initiated and managed in secondary care circa.17 years).
The tool also has the advantage of supporting clinicians with repeat prescribing of DOACs, flagging monitoring requirements and dose changes requirements as a result of changes in patient characteristics e.g. weight, age and renal function.
There have been a number of achievements to date including the development of a highly complex decision support aid that effectively embeds into the existing clinical system. Developers at EMIS are keen to further refine and adapt the tool for roll out across all EMIS users. Dudley CCG are already one of the highest users of DOACs in the UK and roll out of the tool will further support prompt and accurate initiation of DOACs as well as supporting ongoing long term management of safe and effective DOAC prescribing.
