Summary of the example
The West of England AHSN (WEAHSN) has developed the Don’t Wait to Anticoagulate (DWAC) project through phase 1, to the most recent phase 3. This summary applies to phase 1, where a group of Innovator practices across the WEAHSN geographical area, agreed to help identify the most effective mechanism for quality improvement in stroke prevention in atrial fibrillation (AF).
The DWAC project focusses on improving the knowledge base of clinicians involved in the management of atrial fibrillation in primary care, both GPs and other healthcare providers, to ensure safe, effective management of AF and a reduction in strokes caused by AF. A joint approach involving secondary care clinicians was seen to be essential. In addition the project looks to increase clinical confidence in the use anticoagulants in the management of AF.
Why we think it’s important
Phase 1 of this project looked at a variety of methods of improving the treatment of patients with AF in primary care including a GP led model, a medicines optimisation pharmacist led model, an interface clinical services model as well as considering how to upskill staff and create capacity. Practices were given access to and were expected to trial the GP clinical toolkit and handheld tool, patient decision resources and administration toolkits. The project team developed a number of resources to test during phase 1 and for roll out in phase 2 including a branded website (http://www.dontwaittoanticoagulate.com/ no longer in use), data and recording toolkit, quality improvement toolkit, patient decision aid and identified training for health care assistants, practice nurses and other AHPs.
An evaluation of this first phase and summary of the key lessons learnt provide a useful overview and resource. In addition the DWAC team have supported two further iterations of the DWAC methodology – DWAC phase 2 (undertaken in the NHS Gloucestershire CCG area) and DWAC phase 3 (undertaken in the NHS Bristol CCG area)
Learn more about the example
Aims and objectives of the work
The aims and objectives of DWAC phase 1 were:
- To optimise anticoagulation use in AF patients who are identified as high risk from AF-related stroke who are not currently receiving anticoagulation
- To optimise the anticoagulation of AF patients who are unstable on Warfarin and unable to maintain the therapeutic range by transferring this group to NOACs
- To increase clinical confidence and knowledge optimisation in the management of AF Stroke Prevention
In addition, one of the key objectives of the WEAHSN is to promote the joint working of the healthcare community and local and national industry. WEAHSN worked with the manufacturers of the NOACs available at the time. In addition, the WEAHSN worked with patients and clinicians and other stakeholders such as the Atrial Fibrillation Association in the development and design of this project.
Four operational models were developed. Practices selected an evidence based approach that was felt a good fit for the practice by the lead GP and practice manager. The models served as a basis for further innovation and practice-led quality improvements. When selecting an operational model, practices considered –
- Resource needs
- Existing capacity
- How the model fits with existing processes/structures
- Lessons learned from previous experience of working with similar models
The four operational project models were
- GP led –a standard audit and clinical review without additional support through external services or additional staff brought into the practice to deal with the review
- Medicines optimisation pharmacist (MOP) led – a standard audit and clinical review, additionally utilising the skills of MOPs to support the process. A lead clinician was upskilled to take responsibility for the delivery of AF stroke prevention.
- Interface Clinical Services model (ICS) led – ICS is a company that offers a NICE-centric Stroke Prevention in AF programme, delivered through specialist clinical pharmacists who are provided to practices. The GP practices also followed the standard audit and clinical review.
- Upskilling staff and creating capacity – a standard audit and clinical review and to resource service delivery, existing staff within the practice were identified, trained and upskilled to take responsibility for the delivery of AF stroke prevention within the practice
Practices could also choose to use –
- New Medicines Service – a dedicated AF NMS developed with a select number of pharmacies
- OPRA (Opportunities to PRevent Admissions audit) – identifying potentially preventable emergency admissions for stroke and providing feedback from individual cases to identify and support learning/improve practice and prevention through significant event audits
The DWAC Phase One project has delivered the following:
- 11 innovator practices
- Trained 22 staff who cascaded training throughout the innovator practices
- Trialled four financial delivery models
- Identified and screened 2688 Atrial Fibrillation patients of whom 335 were found suitable for clinical review
- Within the limited timescale of the project 170 patients were invited to face to face clinical review and 131 had attended by 1st May 2015
- Improved anticoagulation rates overall by 8.21%
- Improved anticoagulation rates overall for high risk patients by 8.99%
- Reduced the number of patients inappropriately using anti-platelet monotherapy by 13.89%
- The project has theoretically prevented seven stokes
- Produced a range of clinical and patient tools
- Trialled the use of an innovative quality improvement approach in primary care
It has also appears to have had the following benefits:
- Improved patient led decision making
- Helped to review how GPs were using GRASP-AF
- Improved team working and communication in some GP practices
- Increased staff confidence levels about managing AF and anticoagulation in primary care
- Helped practices consider new ways of working
- Helped practices think about other quality improvements they could make
- Helped shift the focus from “why anti-coagulate?” to “why not anticoagulate”?
Following on from phase 1, phases 2 and 3 were rolled out in the NHS Gloucestershire CCG and NHS Bristol CCG areas, utilising the resources developed and trialled in phase 1. In addition DWAC won a prestigious Anticoagulation Achievement Award in 2017, in the category “The Centre best able to demonstrate adherence to NICE quality standards for AF”. More information can be found here
The documents below are the Phase 1 evaluation of DWAC and a submission to the AFA Healthcare Pioneers
National guidance, data and publications
Atrial fibrillation (AF) is the most common cause of cardiac arrhythmia and is a major cause of stroke, TIA and systemic embolism and has a prevalence of 1.6% of the whole population of England. The risk of a stroke is five times higher in a person with AF than in a person in sinus rhythm and stroke severity is usually greater when strike is associated with AF than with other causes. Anticoagulation treatment reduces the risk of stroke by about two-thirds (NICE CKS). Anticoagulation is achieved using either warfarin or DOACs. With warfarin there are issues about maintaining the INR in the therapeutic range to ensure adequate anticoagulation. DOACs are newer agents which don’t require routine INR monitoring but do present their own issues including dose adjusting in renal impairment. The consequences of warfarin or NOACs being poorly managed may be severe for the patient.