PrescQIPP

The case to standardise AF anticoagulation (2018)

Guildford & Waverley CCG

Introduction

Due to increasing usage, DOAC expenditure across the Surrey and North West Sussex Prescribing Clinical Network (PCN) health economy increased by 63% between 2015/16 and 2016/17. Projecting this trend, DOAC expenditure is predicted to account for around 20% of the area prescribing budget within the next 5 years. The rate of rise of spend is likely to be unaffordable in the face of current financial pressures in the NHS. The PCN health economy needed to look at standardising AF anticoagulation. This was led by Guildford and Waverley CCG as this PCN CCG has seen the greatest usage of DOACs versus warfarin since their introduction in 2011 and has a higher rate of DOAC versus warfarin than the national average.

How was the project established? / How is it currently being established?

Local Guildford and Waverley data and PCN data was shared with our local acute trust cardiologist who was shocked on how this was such a massive financial pressure to the wider health economy, particularly with the offer of a PrescQIPP approved rebate scheme for edoxaban which would have a significant financial benefit to the local health economy if this was the preferred DOAC. All four DOACs are approved are approved for SPAF by NICE. This was the catalyst to him wishing to be involved in a review of the available evidence. This comprehensive review demonstrated significant differences in populations studied in each of the DOAC versus warfarin studies exist and there are no trial directly comparing DOACs against each other.

Who are the main beneficiaries of the project? How would they benefit?

The main beneficiaries are the tax payer through standardising the AF anticoagulation and using the most cost effective DOAC to the health economy. The rebate to obtain a reduced price for edoxaban was obtained for all PCN CCG members and the local acute trust to Guildford & Waverley (Royal Surrey County Hospital). This meant there was a real desire from both the commissioner and provider to support this area of work due to a joint financial benefit, without compromising patient care.

What were the main outcomes and / or achievements of the project?

In August 2017 an evidence review and accompanying Anticoagulation in AF Patient Selection tool was developed by the acute cardiologist at the Royal Surrey County Hospital, was submitted to the PCN after much wider consultation, which included NICE. This was approved and supported edoxaban as the first line DOAC in the majority of patients without contraindications for the majority of our patients. For patients at highest risk of GI bleeds or with excellent renal function or where an antidote may be desirable, dabigatran was preferred.

An awareness drive in Guildford and Waverley CCG started slightly before the approval of the PCN Anticoagulant selection tool for patients with AF at the end of June 2017 and reinforced post PCN approval in August with local GPs and secondary clinicians, cardiologists, stroke physicians, haematologists. Within a year prescribing for edoxaban in Guildford and Waverley CCG has increased from 0% to 24% of total DOAC prescribing. Adopting the guidance across the PCN health economy and switching existing patients from rivaroxaban and apixaban to edoxaban could save in excess of £10M versus current costs.

Previous trends were financially unsustainable and had created unsustainable inequalities as some clinicians had opted to chose warfarin based on cost. With limited resources, more patients can be treated with edoxaban than with other DOACs and inequalities reduced.

This project has further enhanced the relationship between the CCG Medicines Management Team, the Royal Surrey County Hospital pharmacy department and the cardiologist as there was a joint vision.
The GP practices have appreciated theto unity with the cardiologist where the cardiologist and pharmacy department (with the backing of the consultant Chair of the Drugs and Therapeutics Committee at the trust) are challenging non edoxaban prescriptions for AF and feeding back to secondary care clinicians where policy is not being adhered to.

A secondary benefit is improved delivery engagement in Cardiology Advice & Guidance due to the engagement of the local cardiologist with the CCG.

To improve safety, GPs were incentivised under a Locally Commissioned Service in Guildford & Waverley CCG, to undertake an initial DOAC initiation assessment (which included provision of a locally produced DOAC patient card) and annual anticoagulation review. This included checking compliance, reducing bleeding risk, (alcohol advice, hypertension, medication review ), and that appropriate blood monitoring was performed and checking DOAC dose was correct. It is anticipated that this intervention will improve compliance and reduce risk of bleeding and audit work is in progress.

The cardiologist was keen to test the feasibility of a switch in Primary Care and worked with a local GP practice, a CCG Medicines Management Pharmacist and GPST1 trainee to review all their patients on rivaroxaban and apixaban with the intention on switching to edoxaban. The GPST1 changed the prescriptions after discussing the switch with the patient on the phone or seeing them at a face to face consultation. This scoping work has led onto the development of a business case to look at the return on investment if the CCG were to invest in a team, which included a prescriber to undertake the switch in other practices. The business case showed this wasn't cost effective given the current rate of growth within practices of edoxaban. A switch protocol has also been developed forrom practice use.

Members of the CCG Medicines Management Team and the Royal Surrey County Hospital cardiologist were invited to NHSE in November 2017 to share the work we had been involved with collaboratively.

Guildford & Waverley CCG have led the way in this area of work, as it was the biggest problem in our CCG. All tool, protocols, locally commissioned service have been shared across the PCN health economy (including Surrey Heartlands ICS), with varying uptake, but resources are available when CCGs need to use them.