Cardiovascular disease (CVD) affects over 6 million people in England and is responsible for 1 in 4 deaths. CVD is strongly associated with low income and social deprivation and shows a North–South divide, with higher rates in the north of England. County Durham is a predominantly rural county with a large and increasing aging population, it has hard to reach communities and experiences higher levels of deprivation than the national average, and hence significant health inequalities.
Atrial fibrillation (AF) is the most common heart rhythm disorder and if left untreated it is a significant risk factor for stroke and other morbidities. The Academic health Sciences Network (AHSN) identified two key areas for improvement in line with the national AF ambitions, to 'Protect' and 'Perfect'.
Protection Gap 1 - Patients with AF who have not been risk assessed CHA2DS-VASc
Protection Gap 2 - Patients eligible for anticoagulant but are untreated
Perfection Gap - Patients who are inadequately anti-coagulated
The Rapid Actionable Insight Driving Reform (RAIDR) primary care dashboard identified a gap in AF treatment across County Durham leaving potentially high-risk patients untreated and many more not optimised on their current treatment.
NHS England mandated nationally that the AHSN assist commissioners in focussing upon AF and subsequently the ASHN NENC offered to support the implementation of this programme of work as part of a joint working agreement with Bristol Myers Squibb (BMS) on behalf of the BMS-Pfizer Alliance.
The project was mapped out across three quarterly medicines optimisation workstreams to support achievement of the aims and objectives of the project and reduce the 'protect' and 'perfect' gaps. Education on AF from a local GP with Specialist Interest was held for all primary care clinicians. To promote a local clinical pathway which reduced unwarranted clinical variation, we worked closely with the CDRC to embed the relevant tools into day- to- day practice. Patients were clinically reviewed, and treatment initiated, medication optimised, or patients coded appropriately.
Over the 9 month project period, 6,350 patient reviews were undertaken by pharmacists, nurses and GPs in primary care across the 61 County Durham practices.
Key outcomes:
Protect
• 622 additional patients with high/moderate risk AF were anticoagulated at the end of the project. This was a 6.1% increase on the baseline.
• The proportion of high/moderate risk patients anticoagulated increased from 88.1% to 89.2%.
• There was a 57% reduction in the number of patients with a missing or incorrect CHA2DS2-VASc (n=2,243).
Perfect
• 45% reduction in the number of patients on a DOAC, for any indication, without a Cockcroft-Gault Creatinine Clearance recorded (n=3,306)
The project resulted in significant improvements in the identified 'protect' and 'perfect' gaps and improvements were also seen in AF prevalence and potential stroke rates. This project addressed the unmet need around AF treatment and resulted in standardisation of care, using CDRC digital tools, across the whole County Durham population as part of population health management.
