Summary of the example
The Oxford Academic Health Science Network (AHSN), together with Buckinghamshire Healthcare NHS Trust is currently establishing a new model of service delivery for the initiation of anticoagulation therapy in primary care. The Primary Care Anticoagulation Initiation Service (PCAIS) is delivered by dedicated Specialist Pharmacists who assess and counsel patients in the primary care setting and prescribe an appropriate anticoagulant.
The overall aim of the project, which is currently in pilot phase, is to reduce the number of AF related strokes in participating CCG areas through increasing the number of patients with known AF who are receiving appropriate anticoagulation therapy. The Primary Care Anticoagulation Initiation service (PCAIS) will achieve this through:
- taking the burden of “decision to anticoagulate” away from the GP consultation and into an environment where there is sufficient time for a structured conversation and shared decision making
- providing a secondary care level of expertise in a GP practice setting
- ensuring consistency in prescribing via a team of Specialist Pharmacists working to agreed guidelines
Why we think it’s important
Anticoagulants are widely used for a variety of indications. 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. There are various models used to improve patient care involving anticoagulants. Some models advocate increasing the knowledge base of prescribers in general practice. This model advocates having a team of specialist pharmacists working in primary care and managing the initiation and titration of DOACs and warfarin through a Primary Care Anticoagulation Initiation Service.
Learn more about the example
Aims and objectives of the work
1) Improve the quality of patient care
- All patients with AF being considered for anticoagulation receive a consultation with a Specialist Anticoagulation Pharmacist.
- This consultation includes a full discussion of risks and benefits of anticoagulation with the patients so that a shared decision can be made.
- By centralising the decision to initiate anticoagulation into one service provider, patients across the CCG can expect consistent advice on the risks, benefits, efficacy and suitability of each anticoagulant.
- A high quality consultation and the opportunity to discuss side effects (follow-up after 2 weeks) may increase patient adherence with the treatment regime which will reduce the risk of AF related stroke.
2) Increase the rate of update of innovation
- Immediate and future challenges facing GP recruitment require new and innovative approaches to dealing with the shortfall; this proposal draws on the specialist skills of pharmacists to deliver a service traditionally delivered by GPs.
- The project takes a “proof of concept” approach that enables the rapid creation of a robust and real evidence base. This is essential for influencing commissioning decisions and ensuring diffusion and spread.
The service is led by a Consultant Pharmacist and delivered by dedicated Specialist Pharmacists. GPs refer via email using a proforma template. Referrals are accepted for:
- Treatment naïve patients
- Patients who should be considered transition from Warfarin to DOAC due to poor time in therapeutic range (TTR)
- Patients who should be considered for an alternative anticoagulant due to unacceptable side effects, new or resolved contraindications
- Patients who have previously declined treatment but are now willing to discuss treatment
Patients are given a 30-minute structured consultation including information about stroke risk and bleeding risks. Shared decision-making techniques are used to ensure that patients are offered the most appropriate anticoagulant for their clinical condition and preference. All Specialist Pharmacists employed within the service are non-medical prescribers and issue the first-month’s prescription. The consultation is detailed on EMIS.
Patients initiated on warfarin are referred to their local anticoagulation clinic for on-going monitoring. Patients initiated on a DOAC have a telephone follow-up after 2-3 weeks where any side-effects, anxieties or concerns will be discussed. A helpline will be available for patients and GPs to discuss any queries or concerns.
A summary of the results to date:
- 371 patients reviewed in first 5 months
- Average age 79
- Average stroke risk – 9% per annum
- 121 anticoagulation naïve patients reviewed; 82 (67%) initiated on anticoagulation
- 250 warfarin patients reviewed – 131 (53%) transitioned to a DOAC
This project is still a work in progress and results continue to be analysed. Key issues that need to be addressed to ensure that sustainable step changes in anticoagulation rates are achieved are:
- Confidence and expertise in initiating anticoagulation
- Capacity in primary care to have detailed and prolonged conversations with patients about the risks and benefits of anticoagulation
The Oxford AHSN project report summary from March 2018 is provided below.
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.
Interim co-director, South West Medicines Information and Training, NHS England South