Managing Stroke risk in Atrial Fibrillation: Are we fulfilling our potential? Presented by Mel Varvel - NHS Improving Quality and Marion Kerr - Insight Health Economics at National Association of Primary Care ‘Best Practice’ Conference in Birmingham, October 2013 GRASP-AF tool: Identifies patients with a history of atrial fibrillation Searches for co-morbidities and calculates a CHADS2 (and now CHA2DS2-VASc) score Searches for current medication- warfarin, aspirin or newer oral anticoagulant Searches for recorded reasons for NOT treating with OAC Gives a simple alert for those at high risk and not on warfarin or newer oral anticoagulant

1. Managing Stroke risk in AF: Are we
fulfilling our potential?
Mel Varvel
NHS Improving Quality
Marion Kerr
Insight Health Economics
October 2013

2. Outline
•
•
•
•
•
•
Introduction- NHS Improving Quality
NHS Improving Quality’s role in stroke prevention
Management of stroke risk in AF
Tools to help: GRASP-AF and CHART Online
What the data is telling us about current management
Cost Effectiveness of primary prevention of AFrelated stroke
• GRASPing the potential: The GRASP Suite
• Summary

3. Introducing NHS Improving
Quality (NHS IQ)
• Set up from 1 April 2013 and hosted by NHS England
• Working to provide improvement and change
expertise to support improved health outcomes
• Bringing together and building on the wealth of
knowledge, expertise and experience of all that has
gone before:
• National Cancer Action Team, National End of Life
Care Programme, NHS Diabetes and Kidney
Care, NHS Improvement, NHS Institute for
Innovation and Improvement.

4. Improvement programmes
1. Preventing
premature deaths
2. Long term
conditions
NHS Health Check
available to all adults
in England
Evidence based
tools
Primary care,
diagnosis, enhanced
recovery, 7 days
Improved public
awareness & early
diagnosis
7 day integrated
care pathways for
frail elderly, end of
life, dementia
Rural and remote
services review
GP engagement in
the big killers:
cancer, heart,
stroke, liver, resp
3. Acute care
Children and young
people’s transition to
adult services
4. Experience
of care
Experience of care
central to
commissioning &
delivery
5. Safety
Developing an
improvement system
for safety across the
NHS

5. Preventing premature death
• Improved detection and diagnosis: Public awareness,
case finding, risk management & access to care
• Optimal management of people diagnosed with
chronic conditions
• Engagement with primary care (GPs and CCGs)
• Support for existing public health interventions and
screening programmes
• Spread of existing and new audit tools in AF, COPD
and HF to all GP practices, e.g. the GRASP Suite

6. Stroke is a frequent complication of AF
• Stroke is the leading complication of AF
• Patients with AF have a five-fold higher stroke risk
than those without AF1
• AF doubles the risk of stroke when adjusted for other
risk factors2
• Without preventive treatment, each year
approximately 1 in 20 patients (5%) with AF will have
a stroke3
• It is estimated that 15% of all strokes are caused by
AF5 and that 12,500 strokes per year in England are
directly attributable to AF6
1. NICE clinical guideline 36.June 2006. Available at http://www.nice.org.uk/guidance/CG36/?c=91497; accessed April 2010; 2. ACC/AHA/ESC guidelines: Fuster V et al.
Circulation 2006;114:e257–354 & Eur Heart J 2006;27:1979–2030; 3. Atrial Fibrillation Investigators. Arch Intern Med 1994;154:1449–57; 4. Carlson M. Medscape
Cardiology. 2004;8; available at http://cme.medscape.com; accessed Feb 2010; 5. Lip GYH, Lim HS. Lancet Neurol 2007;6:981-93; 6. NHS Improvement. June 2009.
Available at http://www.improvement.nhs.uk/heart/Portals/0/documents2009/AF_Commissioning_Guide_v2.pdf; accessed April 2010

7. Stroke is a serious complication of AF
• Stroke in AF is associated with a heavy burden of morbidity and
mortality
• AF related stroke is usually more severe than stroke due to
other causes1
• Compared with other stroke patients, those with AF are more
likely to:
– Have cortical deficit (e.g. aphasia), severe limb weakness
and diminished alertness, and be bedridden on admission2
– Have longer in-hospital stay with a lower rate of discharge to
their own home3
• The mortality rate for patients with AF is double that in people
with normal heart rhythm4
1. Savelieva I et al. Ann Med 2007;39:371–91; 2. Dulli DA et al. Neuroepidemiology 2003;22:118–23; 3. NICE clinical guideline 36.June 2006. Available at
http://www.nice.org.uk/guidance/CG36/?c=91497; accessed April 2010; 4. Benjamin EJ et al. Circulation 1998;98:946–52

9. Stroke risk in AF: CHADS2
CHADS2 risk criteria
Score
Cardiac failure
1
Hypertension
1
Age >75 yrs
1
Diabetes mellitus
1
Stroke or TIA (previous history)
2

10. Stroke risk in AF: CHA2DS2VASc
Score
Congestive heart failure/left
ventricular systolic dysfunction
1
Hypertension
1
Age ≥75
2
Diabetes
1
Stroke / TIA
2
Vascular disease
1
Age 65–74
1
Sex (female)
1

11. ESC Guidelines 2010

12. ESC Guidelines Focussed Update 2012

13. GRASP-AF
• Identifies patients with a history of atrial fibrillation
• Searches for co-morbidities and calculates a CHADS2
(and now CHA2DS2-VASc) score
• Searches for current medication- warfarin, aspirin or
newer oral anticoagulant
• Searches for recorded reasons for NOT treating with
OAC
• Gives a simple alert for those at high risk and not on
warfarin or newer oral anticoagulant

14. GRASP-AF- dashboard view- CHADS2

15. GRASP-AF- datasheet

16. CHART Online
• Voluntary upload of GRASP-AF data to CHART
online
• Web based benchmarking tool with a variety of
comparative viewing options available:
• By clicking on specific areas in the displayed data it is
possible to drill down from national level to individual
practice level
• Secure and restricted access
• For both front line staff and commissioners

17. CHART Online: Prevalence of AF

18. CHART Online: Use of OAC in High Risk Patients

19. CHART Online data- uptake
• Data from end September 2013:
– Number of practices uploading data:
– Number of patients with AF:
– Prevalence of AF:
2,515
318,039
1.77%*
*GRASP-AF searches for history of AF and includes
people coded as ‘AF resolved’

20. CHART Online data- management
Of those 183,334 patients with a CHADS2≥2 in those 2,515 practices:
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•
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48.4% patients on oral anticoagulation (OAC) alone
8.4% patients on OAC and aspirin
34.5% patients on aspirin alone
8.7% are not on either
Of those 79,082 patients not on OAC:
• 9.8% OAC declined
• 3.6% contraindicated
• 86.6% no reason given

21. Stroke risk in AF: CHADS2 and
CHA2DS2VASc

22. The GRASP Suite
• Data and audit can be a powerful driver for change
• All GRASP tools are designed to generate
improvement in primary care and have proven QIPP
value and alignment to QOF
• A number of conditions / diseases lend themselves to
this approach
• GRASP can provide the focus for improvement work
in HF, COPD and AF – preventing premature
mortality, reducing admissions, promoting primary
care management of chronic disease and improving
quality of life for millions of people

23. GRASP-COPD
• About 3 million people have chronic obstructive
pulmonary disease (COPD) in the UK
• Nearly 900,000 people in England and Wales are
diagnosed as having COPD and an estimated 2
million people have COPD which remains
undiagnosed
• Symptoms usually develop insidiously making it
difficult to determine the true prevalence of the
disease
• Most patients are not diagnosed until they are in
their fifties

24. GRASP-COPD
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•
•
•
COPD is predominantly caused by smoking and is
characterised by airflow obstruction that:
- is not fully reversible
- does not change markedly over several months
- is usually progressive in the long term
The biggest caseload for primary care arises from respiratory
conditions & it accounts for 12% of all emergency hospital
admissions
Over 1 in 3 patients admitted to hospital with COPD will be
readmitted within 30 days and 1 in 10 dies within that period
COPD costs the NHS more than £800 million each year,
(equivalent to £1.3 million per 100,000 population.)

25. GRASP-COPD dashboard

26. GRASP-Heart Failure (GRASP-HF)
• Around 900,000 people in the UK have heart failure
(HF)
• Like AF, the incidence and prevalence of HF increase
steeply with age
• The prevalence of HF is expected to rise in future as
a result of an ageing population, improved survival of
people with CHD and more effective treatments
• HF has a poor prognosis: 30–40% of patients
diagnosed with heart failure die within a year
• HF accounts for a total of 1 million inpatient bed-days
– 2% of all NHS inpatient bed-days – and 5% of all
emergency medical admissions to hospital

27. GRASP-HF
• Good heart failure care reduces premature mortality,
and improves quality of life
• Good heart failure care in primary care can reduce
hospitalisations and save money for the NHS

28. Draft GRASP-HF dashboard

29. Summary
• Almost one third of GP practices in England using
GRASP-AF and uploading data to CHART Online
• Still many high risk patients with AF are sub optimally
managed
• Moving to ESC guidance (CHA2DS2-VASc) has the
potential to save thousands more lives (and £s)
• NHS Improving Quality will continue to promote the
use of GRASP-AF as part of a ‘suite’ of similar tools
• Primary care has a pivotal role to play in the call to
action to reduce premature mortality; the GRASP
suite will help

30. @NHSIQ
#GRASP_suite
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