GRASP-AFThe National Picture

Vanessa BrownNational Improvement Lead

Ian RobsonSenior Analyst

Outline

• AF and stroke• Objective• Management of stroke risk• Changes to QOF• GRASP-AF practical demonstration• Q & A

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

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

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

Objective: To reduce the number of strokes caused by AF

• Improved detection and diagnosis– Raised awareness– Promote opportunistic detection

• Ensure optimal treatment for those diagnosed with AF

– Improved assessment of risk- CHADS2, CHA2DS2-VASc

– Appropriate management of risk- GRASP-AF– Improve anticoagulation services

The GRASP-AF Toolto improve the management of AF

• Identifies patients on your system with diagnosed atrial fibrillation

• Searches for co-morbidities and works out both a CHADS2 and CHA2DS2-VASc score

• Searches for current medication– warfarin, aspirin or newer oral anticoagulant

• Searches for recorded reasons for NOT treating with warfarin• Gives a simple alert for those at high risk and not on warfarin or

newer oral anticoagulant

QOF changes for 2012 / 13

Old target

AF3

The percentage of patients with atrial fibrillation who are currently

treated with anti-coagulant drug therapy or an anti-platelet drug

therapy

QOF changes for 2012 / 13

New targets

AF5

The percentage of patients with Atrial Fibrillation in whom stroke risk

has been assessed using the CHADS2 risk stratification scoring

system in the preceding 15 months

QOF changes for 2012 / 13

New targets

AF6

In those patients with Atrial Fibrillation in whom there is a record of a

CHADS2 score of 1, the percentage of patients who are currently

treated with anti-coagulation drug therapy or an anti-platelet therapy

AF7

In those patients with Atrial Fibrillation in whom there is a record of a

CHADS2 score of greater than 1, the percentage of patients who are

currently treated with anti-coagulation drug therapy

Ian RobsonSenior Analyst, NHS Improvement

• Demonstration of GRASP-AF• Live demonstration of CHART Online

The GRASP-AF tool

What is it?

Uses free / commonly used software

A series of searches of a GPs clinical system

Looks at patients with a history of AF

Then looks at their medication and other relevant medical history

Gives a practice over view – Dashboard

Gives a patient list

The GRASP-AF tool

CHADS2 / CHA2DS2-VASc

Risk Factor CHADS2 CHA2DS2-VASc

Cardiac failure 1  

Congestive HF / LVSD   1

Hypertension 1 1

Diabetes 1 1

Stroke or TIA 2 2

Age 65 - 74   1

Age >75 1 2

Female   1

The GRASP-AF tool

The GRASP-AF tool

The GRASP-AF tool

QOF changes for 2012 / 13

New targets

AF6

In those patients with Atrial Fibrillation in whom there is a record of a

CHADS2 score of 1, the percentage of patients who are currently

treated with anti-coagulation drug therapy or an anti-platelet therapy

AF7

In those patients with Atrial Fibrillation in whom there is a record of a

CHADS2 score of greater than 1, the percentage of patients who are

currently treated with anti-coagulation drug therapy

The GRASP-AF tool

The GRASP-AF tool

The GRASP-AF tool

What changes have been made?

626 practices uploaded more than once

2.32% increase in high risk patients on anticoagulation

68 AF-related strokes prevented

35 if population standardised

5.73% increase in high risk patients coded as anticoagulation

contraindicated / declined

The GRASP-AF tool

Future projections

In all 1,746 practices that have uploaded data:

55.35% high risk patients on anticoagulation

35.90% high risk patients on antiplatelet

8.75% high risk patients on nothing

14.05% high risk patients coded as anticoagulation contraindicated /

Declined

Current treatment prevents 2,180 AF-related strokes / 1,482 deaths

The GRASP-AF tool

Future projections

If all 1,746 practices that have uploaded data:

85% high risk patients on anticoagulation

0% high risk patients on antiplatelet

15% high risk patients anticoagulation contraindicated / declined

This treatment would prevent 2,743 AF-related strokes

An increase of 564

Would prevent an extra 383 deaths

More Information

Can be found at http://www.improvement.nhs.uk/graspaf/

E-mail support:

Support for practices, networks and other organisations working with GRASP-AF

Contact ian.robson@improvement.nhs.uk with your query

Any Questions?