Summary of the example
Anticoagulation is key to reducing the risk of stroke in atrial fibrillation (AF). However ensuring that the anticoagulant is prescribed at the correct dose for the correct patient is essential to realise the benefits in terms of stroke risk reduction whilst reducing the risk of harm to the patient. With the introduction of the direct acting oral anticoagulants (DOACs) there are increasing treatment options available but also increasing complexity for prescribers.
This project is an example of how a CCG pharmacy team worked with GP practices to optimise the prescribing of anticoagulation in the AF population. By working with the GP practices this allowed discussion of individual patient cases, which we believe, had the added benefit of prescriber education as part of the process and a legacy effect for the on-going management of current and future patients.
Why we think it’s important
Patients with AF have an increased risk of stroke and AF related strokes tend to be larger strokes with higher mortality and/or greater ongoing disability. These strokes are largely preventable.
There has been a focus on identifying patients with AF (DETECT) and increasing the uptake of anticoagulation in the AF population to reduce the risk of stroke (PROTECT). However, it is also important to ensure that when anticoagulation is prescribed this is optimised for the individual patient to realise the benefits in reducing the risk of stroke whilst minimising bleeding risk (PERFECT).
This example is important as it demonstrates the interventions in a CCG wide project around AF relating to PERFECT and would be reproducible in other primary care geographies.
Learn more about the example
Aims and objectives of the work
The aim of the PERFECT part of this project was to ensure that where anticoagulation is already prescribed for atrial fibrillation that treatment is optimised for the individual patient.
The objectives were:
1) A pharmacist reivew of anticoagulation and antiplatlet(s) prescribed for all patients on the AF register for all GP practices in B&H CCG to be undertaken.
2) As a result of this review a patient level action plan to be agreed between the pharmacist and the GP practice for optimisation of anticoagulation and antiplatelet(s) .
3) The agreed action plan to be implemented by the GP practice.
4) Outcomes from the implementation phase to be reported back to the CCG medicines management project lead by the agreed project deadline.
By undertaking this work, B&H CCG were aiming to improve the uptake of the recommendations of NICE CG 180 on the optimisation of anticoagulation in the AF population.
(NB Whilst this project also focussed on PROTECT this report is only for the outcomes for the PERFECT aspect of the project).
The project plan was agreed by CCG as part of their annual Prescribing Quality Incentive Scheme for GPs. A clinical lead for the project was nominated by each GP practice.
The project lead (Consultant Pharmacist Cardiology) trained the CCG pharmacist team (n=6) and worked alongside them to undertake a review of anticoagulation for AF patients on the practice register at all GP practices (n=35) in B&H CCG.
As a result of the review, the pharmacists made recommendations for individual patients relating to the prescribing of anticoagulation, which were then discussed with the GP practice lead in a virtual clinic for agreement and where appropriate implementation.
For the PROTECT project the key areas discussed related to the patient’s current prescription :
1) already prescribed a direct acting oral anticoagulant (DOAC):
Is the dose for the patient prescribed in line with the licensed dose?
If up-to-date weight and renal function were not available, these were requested and the dose re-assessed.
2) already prescribed warfarin:
Is warfarin well controlled? What is the time in therapeutic range (TTR)?
Are there any concerns over the warfarin management?
3) prescribed antiplatelet therapy alone:
Does the patient meet the criteria to offer anticoagulation? If yes can this be offered?
If no is the antiplatelet solely for AF – in which case can this be stopped?
4) prescribed antiplatelet(s) in combination with anticoagulation:
Is there an indication for continuing the antiplatelet(s) in combination with the anticoagulant or should any of the medicines be stopped?
Once the plan had been agreed the GP practice led on the implementation and reported back on the outcomes to the CCG using a standardised data collection form.
All 35 GP practices engaged with the project.
The key findings were :
- 1298 patients were already prescribed a DOAC.
176 dose changes were recommended (13.6% of patients). The majority related to a dose reduction for renal function in line with the licensed dose recommendations. 159 dose changes were implemented.
Key risks related to the GP use of eGFR rather than calculation of the creatinine clearance and patients weights being poorly recorded on the GP systems.
- 1698 patients were already prescribed warfarin and the TTR was available for all but two of these patients.
Patients with a TTR of less than 65% were put forward for review if there were ongoing issues with warfarin control (n=97). 79 of these patients were reviewed.
- 147 patients were identified for antiplatelet(s) to be stopped. This included patients commencing anticoagulation as well as patients prescribed combinations where the antiplatelet was no longer indicated.
Alongside the project local guidance for anticoagulation for AF was developed and an offer of education which was taken up by a number of the practices.
In B&H warfarin monitoring is undertaken by a community pharmacy anticoagulation service (CPAMS). GPs have access to the internet based records for their patients but relied on the CPAMS service and/or annual report to highlight any warfarin management issues. To mitigate this risk steps have been taken to ensure GP practices have log in access to the CPAMS system and the majority of GP practices are now using this on a more regular basis to check their warfarin patients.
The project highlighted that prescribing of anticoagulation is complex and that there are many safety aspects to consider. Critical to the success of this project was the role of the pharmacy project team.
Heart Rhythm Congress 2019 Poster A Warren
National guidance, data and publications
The NICE guideline for atrial fibrillation (CG 180) outlines the role of anticoagulation to reduce the risk of stroke in patients with atrial fibrillation.
The recommended dose regimes for each of the DOACs in AF is covered in the summary of product characteristics and is derived from the key clinical trial for each of these agents.
More recently the dosing of DOACs in relation to renal function has been highlighted by the MHRA.
Combining anticoagulation and antiplatelet(s) leads to an increased bleeding risk. The European Society of Cardiology Focussed Updated on Dual Antiplatelet Therapy (2017) gives guidance on different scenarios where these combinations may be indicated and consensus opinions on durations of therapy. This is an evolving field.
Director, London Medicines Information Services, Specialist Pharmacy Service