Detect, Protect, Perfect: care of patients with Atrial Fibrillation across Wessex. A report for Wessex AHSN ‘Atrial Fibrillation: Detect, Perfect, Protect’ Programme. Dr Anastasios Argyropoulos, Wessex Centre for Implementation Science.

1. Detect, Protect, Perfect: care of patients with Atrial
Fibrillation across Wessex
A report for Wessex AHSN ‘Atrial Fibrillation: Detect, Perfect, Protect’ Programme
Dr Anastasios Argyropoulos
Centre for Implementation Science
A.Argyropoulos@soton.ac.uk
Wessex AHSN Atrial Fibrillation Senior Programme Manager: Vicki Rowse
Wessex AHSN Atrial Fibrillation Clinical Lead: Sharron Gordon

2. • Introduction page 2
• Detect page 3
• Protect page 12
• Perfect page 27
• Summary of opportunities page 33
• Clinical impact of planned interventions page 34
• Cost impact analysis page 37
• Appendix A: Data definitions, description-methodology page 40
• Appendix B: Cost impact analysis Year 1,Year 2 and Year 3 page 47
• References page 50
Contents
1

3. Introduction
Atrial Fibrillation
Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia affecting 1-2% of the UK population. AF becomes more common
with increasing age, affecting approximately 10% of the population over 75 years old and 18% of those over 85 years old.
AF is associated with a 5-fold increased risk of stroke compared to other stroke causes. Clinical outcomes in terms of increased disability, are
considerably worse for AF-associated compared to stroke not associated with AF, and mortality from stroke is doubled in patients with
AF. Overall 15% of strokes are caused by AF but AF is the predominant cause of stroke in the elderly which is clearly of concern with an
ageing patient demographic.
Bed days for patients with a primary or secondary diagnosis of AF are estimated to have cost the NHS £2.8 billion in 2005 in direct care costs
with wider costs in terms of lost productivity and social care amounting to an additional £4.2 billion. [1]-[3]
2

4. DETECT
Detection- Key Findings
Increasing the detection of AF should result in increased
anticoagulation rates and a reduction in stroke rates as a
consequence. Detection rates are increasing across the
region but 21,043 potential AF patients remain to be found
across Wessex.
Evidence
1. Actual vs expected AF prevalence
2. Percentage of practices uploading GRASP-AF [6] data
3. AF prevalence
4. Patients potentially undiagnosed with AF in 2016-2017
5. AF related strokes
3

5. 1. Detect
4

6. 1. Detect
The diagnosis of AF has increased across all CCGs, slowest rates of detection are in Isle of Wight, Southampton, Portsmouth
and Wiltshire.
5

7. 2. Detect
Uploading GRASP AF data to chart online enables review of AF activity in a timely manner. Rates have increased across all
CCGS where GRASP AF is in use (Data were not available for IOW & Wiltshire). All CCGs need to reach 90% in order to allow
confident monitoring of AF data.
6

8. 3. Detect
7

9. 3. Detect
8

10. 4. Detect
Prevalence is increasing across all CCGs. The rate of identification is slower in some CCGS and support maybe required to
increase identification rates.
9

11. 5. Detect
As processes improve in delivering consistent review and anticoagulation of patients with AF the rates of stroke reduce. Stroke
rates are reducing in some CCGs.
10

12. 5. Detect
11

13. PROTECT
Protection- Key Findings
Anticoagulation reduces the risk of AF related stroke by 66% therefore
increasing the rates of anticoagulation will result in reduced stroke rates.
Anticoagulation rates are increasing across Wessex.
Evidence
1. Patients diagnosed AF missing a risk assessment
2. Patients treated with anticoagulation
3. Patients treated with anticoagulation drug therapy with CHA2DS2-VASc≥ 2
4. Patients risk assessed and eligible for treatment not on anticoagulant
5. Patients contraindicated or declined anticoagulation
6. Patients treated with antiplatelets solely
7. AF related stroke patients not on anticoagulants
12

14. 1. Protect
13

15. 1. Protect
14

16. 2. Protect
15

17. 2. Protect
16

18. 3. Protect
17

19. 3. Protect
18

20. 4. Protect
19

21. 4. Protect
20

22. 5. Protect
Patients are contraindicated or declined anticoagulation where treatment is seen as inappropriate. In some cases exclusion
maybe inappropriate and based on a lack of clinical expertise. Rates of exclusion are declining across all CCGs in Wessex but
exclusion rates are higher than the national average.
21

23. 5. Protect
22

24. 6. Protect
Antiplatelet medicine was historically viewed as an appropriate therapy for AF related stroke. Increased understanding now
guides anticoagulation as the best treatment and antiplatelet use is reducing year on year in all CCGS in Wessex
23

25. 6. Protect
24

26. 7. Protect
As more patients are identified within the population and reviewed for anticoagulation less patients should present with a
stroke where AF was known but untreated. 3 CCGs in Wessex have data sets showing an increase in numbers, this needs to be
investigated.
25

27. 7. Protect
Our target aim for anticoagulation in AF is that 85% of patients will receive treatment
26

28. PERFECT
Perfection- Key Findings
Between 30-50% of patients do not take their medicines as intended. This
results in up to £150 million or avoidable medicines waste in the NHS and
poor patient outcomes. The New Medicines Service (NMS) provides support
for people with long-term conditions newly prescribed anticoagulation to
help improve medicines adherence.
Increasing NMS discussions will increase adherence by at least 10%
Evidence
1. Anticoagulant or antiplatelet MUR
2. Anticoagulant or antiplatelet NMS
3. Treated patients without adequate anticoagulation
27

29. 1. Perfect
MUR reviews represent an annual opportunity to assess adherence, drug interactions and assess risk / benefit. An increase in
reviews is desirable but these reviews are reducing across Wessex.
28

30. 1. Perfect
29

31. 2. Perfect
NMS provides an excellent opportunity to assess side-effects, explain the risks and benefits and offer support to patients
newly initiated on anticoagulation to. Rates are increasing in the majority of CCGs in Wessex.
30

32. 2. Perfect
31

33. 3. Perfect
32

34. SUMMARY OF OPPORTUNITIES
4. Detect | 1. Protect | 4. Protect | 3. Perfect
33

35. Key Findings
A potential total number of 32,214 patients should be identified and treated
across Wessex:
• 10,522 patients potentially undiagnosed with AF
• 1,829 patients diagnosed AF missing a risk assessment
• 9,589 patients assessed and eligible for treatment not on anticoagulant
• 10,274 patients likely to be receiving inadequate anticoagulation
Evidence
1. Clinical impact of planned interventions
2. Clinical impact of planned interventions preventable strokes & major
bleeds
CLINICAL IMPACT OF PLANNED INTERVENTIONS
34

36. CLINICAL IMPACT OF PLANNED INTERVENTIONS
35

37. CLINICAL IMPACT OF PLANNED INTERVENTIONS
36

38. Key Findings
Total potential 3-year savings in direct medical costs of approximately £2.9m
are achievable across Wessex.
Total potential 3-year savings including social care costs of approximately
£44.17m are achievable across Wessex.
Evidence
1. Cost impact analysis year 1
2. Cost impact analysis year 2
3. Cost impact analysis year 3
4. Cost impact analysis years 1-3
5. Cost impact analysis summary
COST IMPACT ANALYSIS
37

39. COST IMPACT ANALYSIS: years 1-3
38

40. COST IMPACT ANALYSIS: summary
39

41. Definition Description- Methodology
DETECT
1. Actual vs expected AF prevalence
a. Actual AF prevalence was obtained from [4],[5]
b. CCG list sizes were obtained in 5-year age bands from [6],[7]
c. Age-sex specific prevalence rates of AF in 2010 were obtained from [8] (Table A1) and were applied to each CCG population to derive the
expected AF prevalence
2. Percentage of practices uploading GRASP-
AF data
Number of GP practices uploading GRASP-AF data [9] divided by the total number of GP practices per CCG [4],[5],[10].
3. AF prevalence Percentage of patients with known AF [9].
4. Patients potentially undiagnosed with AF
2016-17
a. Expected AF population 2016-17 (from 1. Actual vs expected AF prevalence)
b. Actual AF population 2016-17 (from 1. Actual vs expected AF prevalence)
Percentage Number of patients
(a-b)/a a-b
5. AF related strokes Percentage of patients with AF before stroke. Item reference F6.3 obtained from [11].
Appendix A: Data definitions, Description-Methodology (1/7)
40

42. Age group
(years)
Male Female
Population (n) Af (n) Prevalence (%) Population (n) Af (n) Prevalence (%)
0-19 8,894 0 0 8,394 0 0
20-29 4,389 4 0.1 3,804 0 0
30-39 4,445 15 0.3 4,076 4 0.1
40-44 2,502 26 1.0 2,360 1 0
45-49 2,483 22 0.9 2,417 4 0.2
50-54 2,575 53 2.1 2,575 10 0.4
55-59 2,710 86 3.2 2,549 17 0.7
60-64 2,736 115 4.2 2,596 43 1.7
65-69 2,383 164 6.9 2,450 83 3.4
70-74 1,874 212 11.3 1,957 112 5.7
75-79 1,405 228 16.2 1,797 183 10.2
80-84 1,015 206 20.3 1,478 231 15.6
85-89 549 126 23.0 924 180 19.5
90-94 157 44 28.0 355 86 24.2
95-99 24 4 16.7 67 14 20.9
100+ 1 0 0 4 1 25.0
All 38,142 1,305 3.4 37,803 969 2.6
Table A1 Prevalence of AF for men and women in the Skellefteå region in 2010 according to age [8]
Appendix A: Data definitions, Description-Methodology (2/7)
41

43. Definition Description- Methodology
PROTECT
1. Patients diagnosed AF missing a risk
assessment
a. Patients with atrial fibrillation in whom stroke risk has been assessed using the CHA2DS2-VASc score risk stratification scoring system in the
preceding 12 months (excluding those patients with a previous CHADS2 or CHA2DS2-VASc score of 2 or more). AF006- Denominator plus
Exceptions, obtained from [4],[5]
b. AF006- Numerator [4],[5]
c. Patients without current CHA2DS2-VASc score: a-b
Percentage Number of patients
(c/a) × 100
c × 0.842 (assumes that 84.2 % of patients have CHA2DS2-VASc score of
2 or more [12])
2. Patients treated with anticoagulation Percentage of high risk patients treated with anticoagulation [9].
3. Patients treated with anticoagulation drug
therapy with CHA2DS2-VASc ≥ 2
In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated
with anti-coagulation drug therapy. AF007- Patients receiving intervention (per cent), obtained from [4],[5].
4. Patients risk assessed and eligible for
treatment not on anticoagulant
a. In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently
treated with anti-coagulation drug therapy. AF007- Denominator plus Exceptions, obtained from [4],[5]
b. AF007- Numerator [4],[5]
Percentage Number of patients
((a-b)/a) × 100 a-b
5. Patients contraindicated or declined
anticoagulation
Percentage of high risk patients contraindicated or declined anticoagulation [9].
6. Patients treated with antiplatelets solely Percentage of high risk patients treated with antiplatelets solely [9].
7. AF related stroke patients not on
anticoagulants
Percentage of patients with AF before stroke not on anticoagulant medication. Item reference F6.14 obtained from [11].
Appendix A: Data definitions, Description-Methodology (3/7)
42

44. Definition Description- Methodology
PERFECT
1. Anticoagulant or antiplatelet MUR Percentage of MUR patients on anticoagulant or antiplatelet medication [13].
2. Anticoagulant or antiplatelet NMS Percentage of NMS patients on anticoagulant or antiplatelet medication [13].
3. Treated patients without adequate
anticoagulation
a. AF007- Numerator [5]
b. Oral Anticoagulants % items obtained from [14] for January 2017- March 2017
c. Patients currently treated with novel oral anticoagulant (NOAC): a × b
d. Patients currently treated with warfarin: a-c
Assumptions
i. Proportion of warfarin patients with Time in Therapeutic Range (TTR)> 65%: 60%
ii. Proportion of NOAC patients adequately anticoagulated: 95%
Percentage Number of patients
1- [( (d × i)+(c × ii) )/ a ] a- [ (d × i)+(c × ii) ]
SUMMARYOF
OPPORTUNITIES
4. DETECT | 1. PROTECT | 4. PROTECT | 3.
PERFECT
Appendix A: Data definitions, Description-Methodology (4/7)
43

45. Definition Assumptions
CLINICALIMPACTOFPLANNEDINTERVENTIONS
1. Clinical impact of planned interventions
Anticipated impact of planned interventions
Assumptions regarding the percentage of patients in each gap who will be potentially identified and treated [15]:
a. 4. DETECT: 50%
b. 1. PROTECT: 90%
c. 4. PROTECT: 80%
d. 3. PERFECT: 80%
Anticipated timescale for planned activities
Assumptions regarding the timescale over which intervention will be made [15]:
a. 4. DETECT: 12 months
b. 1. PROTECT: 12 months
c. 4. PROTECT: 12 months
d. 3. PERFECT: 12 months
It is assumed that patients will be targeted at a uniform rate over the course of the intervention period.
It is assumed that clinical benefits will be accrued in a linear fashion over the course of treatment.
The number of patients identified in each gap (Summary of opportunities: 4. DETECT| 1. PROTECT| 4. PROTECT| 3. PERFECT) multiplied by the
percentage of patients in each gap who will be potentially identified and treated.
2. Clinical impact of planned interventions
preventable strokes & major bleeds
Clinical assumptions for impact assessment
Annual risk of stroke:
a. Untreated: 5.82% [12], [16],[17]
b. Warfarin: 2.09% [12], [16]-[18]
c. NOAC: 1.52% [12], [16], [17], [19], [20]
Annual risk of major bleed [12], [16]-[18]:
a. Untreated: 0.49%
b. Warfarin: 1.07%
c. NOAC: 1.02%
Default assumptions [15]:
a. Unidentified patients have the same CHA2DS2-VASc profile as known population
b. All new patients will be adequately anticoagulated
c. Patients inadequately anticoagulated at baseline will have baseline risk of stroke and major bleed
d. 90% of inadequately anticoagulated patients will switch to NOAC
Appendix A: Data definitions, Description-Methodology (5/7)
44

46. Cost-inputs
COSTIMPACTANALYSIS
Cost inputs for impact assessment
Year 1 cost of stroke care: £12,228 [12], [17], [21]
Year 2+ cost of stroke care: £2,430 [12], [17], [21]
Cost of major bleed: £1,173 [12], [17]
Cost of screening for AF (per patient screened): £16.34 [22]
Annual cost of treatment for Warfarin (drug cost): £41.32 [12]
Annual cost of treatment for Warfarin (monitoring): £242 [12], [17]
Annual cost of treatment for NOAC: £664.06 [14], [23]
Social care cost estimation
Stroke savings including social care costs calculations were based on the ratio of direct care costs to social care costs as reported in [21].
Assumptions- Limitations
Planned future changes to NOAC use [15]
Projected percentage of NOAC use for year 1, year 2 and year 3 for new patients was assumed to be equal to the Oral Anticoagulants % items for each CCG obtained from [14] for January 2017- March
2017.
Projected percentage of NOAC use for each CCG for year 1, year 2 and year 3 for patients inadequately anticoagulated was assumed to be 90%.
The impact of switching therapy for existing stable patients is not taken into consideration.
Year 1, year 2 and year 3 cost impact analysis
Expected AF not identified costs are subject to considerable uncertainty due to the fact that expected AF was calculated using age-sex specific prevalence rates of AF in 2010 [8] (Table A1).
Appendix A: Data definitions, Description-Methodology (6/7)
45

47. COSTIMPACTANALYSIS
Cost impact calculation
4. Detect. Patients potentially undiagnosed with AF are used to evaluate [15]:
a. The cost of screening for patients in the current population (>65 years of age)
b. The additional cost of treating the newly identified patients at year 1, year 2 and year 3, based on the current warfarin/NOAC use
c. The total cost of a major bleed in patients started on anticoagulant
d. The cost impact on improved stroke prevention at year 1, year 2 and year 3, if all patients were to receive effective anticoagulation
1. Protect. Patients diagnosed AF missing a risk assessment [15]:
a. The additional cost of treating the newly risk-assessed patients who qualify for anticoagulation
b. The total cost of a major bleed in patients started on anticoagulant
c. The cost impact on improved stroke prevention at year 1, year 2 and year 3, if all patients were to receive effective anticoagulation, and continue on treatment with adequate compliance
4. Protect. Patients assessed and eligible for treatment not on anticoagulant [15]:
a. The anticipated additional year 1 cost of treating patients who are not currently anticoagulated. This assumes warfarin and NOAC treatment patterns remain consistent with the currently treated
local AF population. The initiation of NOAC therapies in patients who have previously declined warfarin are accounted for in the population
b. The total anticipated cost of a major bleed in patients started on anticoagulant
c. The potential cost impact on improved stroke prevention at years 1, 2 and 3, if all patients were to receive effective anticoagulation and continue on treatment with adequate compliance.
3. Perfect. Treated patients without adequate anticoagulation [15]:
a. The anticipated additional cost of changing treatment in inadequately treated patients. This assumes 25% of warfarin-treated patients will switch to a NOAC and 20% will increase their warfarin
costs for the subsequent year to reflect a higher dose
b. The total anticipated cost of a major bleed in patients started on adequate anticoagulation. It is assumed that inadequately treated patients will have had the same risk of bleed as an untreated
patient
c. The potential cost impact on improved stroke prevention at years 1, 2 and 3, if all patients were to receive effective anticoagulation, and continue on treatment with adequate compliance. It is
assumed that inadequately treated patients will have the same risk of stroke as an untreated patient
Appendix A: Data definitions, Description-Methodology (7/7)
46

48. 47
Appendix B: Cost Impact Analysis Year 1

49. 48
Appendix B: Cost Impact Analysis Year 2

50. 49
Appendix B: Cost Impact Analysis Year 3

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