whole systems integrated care (wsic) dashboards: stroke ......stroke prevention dashboard | af &...
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Whole Systems Integrated Care
(WSIC) Dashboards:
Stroke Prevention (AF only) User Guide – V1.0
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North West London Collaboration of
Clinical Commissioning Groups
Version History
Date Version Author Notes
21/03/18 0.1 Julie Orrey First Draft
09/08/2018 0.2 Dr. A Fragoyannis & Rachel Meadows
Amendments added
09/08/2018 0.3 Titilayo Shoroye Calculation Definitions added
13/08/2018 0.4 Rachel Meadows Finance Dashboard Calculations added, amendments made, formatting. Sent for comments and sign off
20/09/2018 1.0 Rachel Meadows Added AF Radar, Signed off
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Contents
Version History .................................................................................................................................................................. 2
Section 1: Introduction to the Stroke Prevention Dashboard .......................................................................................... 8
Clinical uses of the Stroke Prevention Dashboard .......................................................................................................... 12
Section 2: Step by Step Guide ......................................................................................................................................... 13
Stroke Prevention Dashboard | Homepage .................................................................................................................... 14
Stroke Prevention Dashboard | How to use the Dashboard .......................................................................................... 15
Stroke Prevention Dashboard | AF Landing Page ........................................................................................................... 16
Stroke Prevention Dashboard | Navigating the Dashboard ........................................................................................... 17
Stroke Prevention Dashboard | AF Overview ................................................................................................................. 18
Stroke Prevention Dashboard | AF & Primary Care Key Indicators ................................................................................ 19
Stroke Prevention Dashboard | AF & Primary Care Key Indicators ................................................................................ 20
Stroke Prevention Dashboard | Finance Indicators ........................................................................................................ 21
Stroke Prevention Dashboard | Red Flags ...................................................................................................................... 22
Section 3: Calculation Definitions ................................................................................................................................... 23
Stroke Prevention Dashboard | AF Patient Calculation Definition ................................................................................. 24
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Stroke Prevention Dashboard | CHADSVASC Score in Last 12 Months Calculation Definition ...................................... 24
Stroke Prevention Dashboard | CHADSVASC Score greater than 1 Calculation Definition ............................................ 24
Stroke Prevention Dashboard | Patients on Warfarin Calculation Definition ................................................................ 25
Stroke Prevention Dashboard | Patients on a NOAC Calculation Definition .................................................................. 25
Stroke Prevention Dashboard | Patients NOT on anti-coagulation medicine Calculation Definition ............................ 26
Stroke Prevention Dashboard | Patients on a single agent anti-platelet Calculation Definition ................................... 26
Stroke Prevention Dashboard | Patients on agent anti-platelet Calculation Definition ................................................ 27
Stroke Prevention Dashboard | HAS-BLED score Calculation Definition ........................................................................ 27
Stroke Prevention Dashboard | HAS-BLED score and Medication Review Calculation Definition ................................. 28
Stroke Prevention Dashboard | Alcohol review Calculation Definition ......................................................................... 28
Stroke Prevention Dashboard | Blood pressure Calculation Definition ......................................................................... 29
Stroke Prevention Dashboard | Liver function test Calculation Definition .................................................................... 29
Stroke Prevention Dashboard | Electrolytes test Calculation Definition ....................................................................... 30
Stroke Prevention Dashboard | Creatinine clearance Calculation Definition ................................................................ 30
Stroke Prevention Dashboard | New Oral Anticoagulant Calculation Definition ........................................................... 31
Stroke Prevention Dashboard | Full blood count Calculation Definition ....................................................................... 31
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Stroke Prevention Dashboard | Palliative Diagnosis Calculation Definition .................................................................. 32
Stroke Prevention Dashboard | Co-ordinate My Care plan Calculation Definition ........................................................ 32
Stroke Prevention Dashboard | Thyroid Function Calculation Definition ...................................................................... 32
Stroke Prevention Dashboard | Time in Therapeutic Range of more than 65% Calculation Definition ........................ 33
Stroke Prevention Dashboard | Recommended Therapeutic Range Calculation Definition .......................................... 34
Stroke Prevention Dashboard | More than 6 weeks to reach therapeutic range Calculation Definition ...................... 34
Stroke Prevention Dashboard | Medication review Calculation Definition ................................................................... 35
Stroke Prevention Dashboard | Patient with a Stroke had been diagnosed with AF Calculation Definition ................. 35
Stroke Prevention Dashboard | Stroke patient not prescribed an anticoagulant Calculation Definition ...................... 36
Stroke Prevention Dashboard | Stroke patient with CHADVASc score Calculation Definition ...................................... 36
Stroke Prevention Dashboard | Bleeding Admission Calculation Definition .................................................................. 37
Stroke Prevention Dashboard | International Normalised Ratio Calculation Definition ............................................... 37
Stroke Prevention Dashboard | Paroxysmal Atrial fibrillation Calculation Definition .................................................... 38
Stroke Prevention Dashboard | Heart Failure Calculation Definition ............................................................................ 38
Stroke Prevention Dashboard | Hypertension Calculation Definition ............................................................................ 39
Stroke Prevention Dashboard | Diabetes Calculation Definition ................................................................................... 39
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Stroke Prevention Dashboard | Controlled Blood Pressure Calculation Definition ....................................................... 39
Stroke Prevention Dashboard | BMI Calculation Definition ........................................................................................... 40
Stroke Prevention Dashboard | Pulse Check Calculation Definition .............................................................................. 40
Stroke Prevention Dashboard | Blood Pressure measure YTD Calculation Definition ................................................... 41
Stroke Prevention Dashboard | NHS Health check Calculation Definition ..................................................................... 41
Stroke Prevention Dashboard | Total NEL Spend Calculation Definition ....................................................................... 41
Stroke Prevention Dashboard | Spend – complex electro physiological investigation Calculation Definition .............. 42
Stroke Prevention Dashboard | Spend for AF patients who had a stroke Calculation Definition .................................. 42
Stroke Prevention Dashboard | Patient Activation Measure Calculation Definition ..................................................... 42
Stroke Prevention Dashboard | Length of Stay Calculation Definition .......................................................................... 43
Stroke Prevention Dashboard | Admitted with Stroke and AF Calculation Definition ................................................... 43
Section 4: Use Cases........................................................................................................................................................ 44
Stroke Prevention Dashboard | Case Finding ................................................................................................................. 45
Stroke Prevention Dashboard | Stroke Risk ................................................................................................................... 45
Stroke Prevention Dashboard | Stroke Risk: Calculation Definitions ............................................................................. 46
Stroke Prevention Dashboard | Bleed Risk ..................................................................................................................... 46
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Stroke Prevention Dashboard | Bleed Risk: Calculation Definitions .............................................................................. 46
Stroke Prevention Dashboard | Treatment/Prescribing ................................................................................................. 47
Section 5: AF Radar ......................................................................................................................................................... 48
AF Radar | Introduction .................................................................................................................................................. 49
Clinical uses of the AF Radar ........................................................................................................................................... 49
AF Radar | Homepage ..................................................................................................................................................... 50
AF Radar | How to use the radar .................................................................................................................................... 51
AF Radar | How to use the radar .................................................................................................................................... 52
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Section 1: Introduction to the
Stroke Prevention Dashboard
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Introduction
Diseases caused by high blood pressure are estimated to cost the NHS over £2 billion every year. Over 5 million
people are unaware they have high blood pressure, yet it affects more than 1 in 4 adults and is one of the biggest
risk factors for premature death and disability in England. High blood pressure accounts for 12% of all visits to GPs in
England. People from the most deprived areas are 30% more likely to have high blood pressure.
Atrial fibrillation (AF) is the most common heart arrhythmia in the UK. People with undetected AF are at increased
risk of experiencing a stroke (nearly 500%), which may lead to death or significant disability. This means early
detection of AF to allow initiation of protective anticoagulant therapy is vital.
The clinical drivers for stroke prevention are undeniable. For AF, the national and locally reported prevalence has
been rising for the last 4 years, mainly due to the fact that patients over 65 are most likely to develop AF. Over time,
as the local population ages, the risk of stroke will increase. It is estimated that around 14,000 people across North
West London have undiagnosed AF and a further 4,500 are undertreated. For hypertension, the figure is almost
205,000 undiagnosed, as well as 22,000 not receiving the appropriate treatment.
In 2016-17 there were 1937 strokes across NWL
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Stroke prevention is a key priority for the North West London Sustainability and Transformation Plan (STP) and is
being addressed through cross sector collaborative work. The aim of the Stroke Prevention Programme is to reduce
strokes caused by undetected or poorly managed AF and Hypertension. Its key objectives are:
1. To reduce variation in care and improve clinical outcomes for AF and hypertension by
adopting consistent quality standards and guidelines
providing training and support to healthcare professionals
sharing knowledge and expertise across the health economy
2. To increase detection of AF and hypertension through targeted and opportunistic case finding
3. To improve management of AF and hypertension through improved management of known cases through:
anti-coagulation for eligible patients, thereby reducing risk of stroke
reducing blood pressure and thereby reducing AF in the population
By delivering the activities in this programme – reducing variation in practice and improving processes for detection
and management of AF and hypertension - we hope to mitigate the on-going impact of stroke on local NHS services
as well as the wider health economy including social care.
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NWL Stroke Prevention Programme – Outcome Measures
Indicator description Definition Deliverables
DETECT - Case finding of patients with undiagnosed AF and hypertension
Number of patients on AF register Patients coded with AF on QOF register Increase prevalence to 1.3% of population (1.4% for Harrow and Hillingdon)
Number of patients on hypertension register
Patients coded with hypertension on QOF register
Increase prevalence by 1.5% in all CCGs (from baseline QOF 2016/17)
PROTECT - Improve the management of known AF and hypertensive patients
Number of known AF patients who are on anticoagulation medication (warfarin or DOAC)
Patients coded with AF and CHADSVASc score of 1 or more prescribed an anticoagulant
Reduction in known AF patients not anticoagulated
Reduce untreated from 22% to 5%
Reduce those on aspirin from 3% to zero
Number of patients with AF managed on warfarin who have a time in therapeutic range of above 65%
Annual audit of clinical care of patients managed under the out of hospital contract for anticoagulation
Under 5% of AF patients to have warfarin management in secondary care
Number of known hypertensive patients who have a blood pressure reading in the normotensive range
Patients coded as hypertensive on the QOF register with blood pressure below 130/90mmHg
Reduction in blood pressure for all known hypertensive patients
PERFECT - Improved outcomes across the health economy
Number of patients admitted for stroke Patients with hypertension and/or AF who have a cardiovascular incident (thromboembolic or haemorrhagic)
Improvement in outcomes for AF and HYP patients
Reduction in number of AF strokes
Prevention of hypertensive related strokes over 5 years
Prevention of CHD cases over 5 years
Reduction in mortality and morbidity from strokes
Number of patients admitted to stroke rehabilitation unit
Patients admitted for rehabilitation post stroke
Reduction in the number of patients with known AF who stroke
Patients (number and percentage) admitted to a HASU with known AF and anticoagulation status
Reduction in the number of patients with known hypertension who stroke
Patients (number and percentage) admitted to HASU with known hypertension
Reduction in the number of hypertensive patients having a cardiac event
Patients admitted for an unplanned cardiac event (specifically MI or cardiac arrest)
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Clinical uses of the Stroke Prevention Dashboard
There are a number of scenarios where we envisage that the Stroke Prevention Dashboard may be of use:
1. Case finding of undiagnosed AF patients:
Practices should check whether the prevalence of recorded AF is lower than expected - based on the characteristics of their population
Identify high risk patients by a number of parameters including red flags, risk factors, age etc. who have not had a check for pulse rhythm in the last year
2. Prioritising patients for review:
The Dashboard allows the clinician to sort patients by a number of parameters including number of red flags, number of risk factors, TTR out of range, CHA2DS2VASC score or age
3. Virtual clinics:
Exception reporting
Poorly controlled / off target patients o The dashboard allows the clinicians to review a list of patients sorted by e.g. TTR if on warfarin (or other
parameters) quite rapidly without necessarily having to open every patient’s set of notes in the GP system.
4. Recall for appointments o The medication review section allows a health professional to see who has not had medication review in
any previous given period.
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Section 2: Step by Step Guide
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Stroke Prevention Dashboard | Homepage
You can access the Stroke Prevention Dashboard from the Homepage. Please refer to the ‘How to Use’ section of this user guide, which explains some of the functionality of the Dashboard. From the landing page choose ‘Population Health’ and select ‘AF & Stroke Prevention’
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Stroke Prevention Dashboard | How to use the Dashboard
Select ‘AF landing page’
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Stroke Prevention Dashboard | AF Landing Page
The landing page shows a top level view of the key care indicators from each of the four quadrants, including an
analysis of the population, highlighting patients with AF and the Primary Key Care Indicators. It allows viewing of
aggregated data with drilldown to patient level. You can use the tabs located at the top of the screen to navigate
between the quadrants. (Lifestyle Change will be added as part of Phase 2 – Hypertension as will an AF radar section
similar to that of diabetes, allowing a tabulated view of key care indicators at a glance)
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Stroke Prevention Dashboard | Navigating the Dashboard
Click on the ‘Landing page tab’ to navigate
back to the first screen Use the other tabs to
navigate to other views
Views available
AF overview: General Population With Atrial Fibrillation
Atrial Fibrillation and Primary Key Care Indicators 1/3
Atrial Fibrillation and Primary Key Care Indicators 2/3
Atrial Fibrillation and Primary Key Care Indicators 3/3
Finance dashboard
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View total number of AF patients (Excluding any opt-out patients)
Stroke Prevention Dashboard | AF Overview
Compare actual AF prevalence
against expected
Select your CCG, network or practice by clicking on the names
Dynamic filters for various parameters
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Stroke Prevention Dashboard | AF & Primary Care Key Indicators
Patients with a recorded CHA2DS2VASc or HAS-BLED score
(medicines optimisation)
Select the organisation you’re interested in viewing
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Stroke Prevention Dashboard | AF & Primary Care Key Indicators
Assess AF patients on
Warfarin who have a
Time in Therapeutic
Range (TTR) < 65%
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Stroke Prevention Dashboard | Finance Indicators
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Stroke Prevention Dashboard | Red Flags
Red Flags are a familiar concept for clinicians, so some risk factors have been designated red flag status – for
example, red flag status has been given to:
e.g.
Diagnosis of AF but no CHA2DS2-VASc assessment/score
Diagnosis of AF with CHA2DS2-VASc score >2, but no treatment
Warfarin TTR <65%
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Section 3: Calculation Definitions
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Stroke Prevention Dashboard | AF Patient Calculation Definition
Numbers of patients that are diagnosed with Atrial Fibrillation found in the latest list of LTC of Atrial Fibrillation (AF001)
Stroke Prevention Dashboard | CHADSVASC Score in Last 12 Months Calculation
Definition
Patients diagnosed with Atrial Fibrillation have a CHADSVASC Score in Last 12 Months?
QOF 'AF006' The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHA2DS2VASc Score risk stratification scoring system in the preceding 12 months (excluding those patients with a previous CHADS2 or CHA2DS2VASc score of 2 or more)
Green if ≤2 Red if >2
Stroke Prevention Dashboard | CHADSVASC Score greater than 1 Calculation Definition
Patients diagnosed with Atrial Fibrillation have a CHADSVASC Score greater than 1
Follow the QOF rules of 'AF007' without the codes for "treated with drug" and CHADSVASC condition greater than 1 instead of 2.
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Green if ≤2 and Red if >2
Stroke Prevention Dashboard | Patients on Warfarin Calculation Definition
How many patients with a diagnosis of AF and a CHADSVASC score >1 are on warfarin?
Patients with Atrial Fibrillation LTC (AF001) and are on Warfarin drug
codes ('bs1..' ,'bs1A.','bs17.','bs1C.','bs18.','bs19.','bs14.','bs15.','bs16.')
Green if ≤2 andRed if >2
Stroke Prevention Dashboard | Patients on a NOAC Calculation Definition
How many patients with a diagnosis of AF and a CHADSVASC score >1 are on a NOAC
Codes('bs7..','bs72.','bs74.','bs4..','bs4y.','bs4x.','bs4z.','bs8..','bs84.','bs85.','bs86.','bs71.','bs73.','bs81.','bs82.','bs83.','bs42.','bs43.','bs41.','bs6..','bs6z.','bs6y.','bs6w.','bs6x.','bs61.','bs62.','bs64.','bs63.')
Green if <=2 and Red if >2
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Stroke Prevention Dashboard | Patients NOT on anti-coagulation medicine Calculation
Definition
How many patients with a recorded CHADSVASC Score >= 2 are NOT on anti-coagulation medicine
Follow the QOF rules of 'AF007' worksheet attached without the codes for "treated with drug".
Green if <=2 and Red if >2
Stroke Prevention Dashboard | Patients on a single agent anti-platelet Calculation
Definition
How many patients with a recorded CHADSVASC Score ≥2 are not on anti-coagulation medicine but are on single agent anti-platelet medication?
As per AF007 QoF indicator AND who also have Codes in COMBSAL, SAL, CLO, DIPY QoF Cluster areas
Green if <=2 and Red if >2
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Stroke Prevention Dashboard | Patients on agent anti-platelet Calculation Definition
How many patients with a recorded CHADSVASC Score ≥2 are on anti-coagulation medicine and anti-platelet medication?
Patients with CHADVASC QoF Cluster AND who have ANTICOAG and COMBSAL, SAL, CLO, DIPY QoF Cluster area codes
Green if <=2 and Red if >2
Stroke Prevention Dashboard | HAS-BLED score Calculation Definition
How many patients with AF and a recorded CHADSVASC Score have a HAS-BLED score recorded in last 12 Months?
Follow logic and codes and sub codes of AF006 QoF indicator AND '38G3.' (HAS-BLED) score
How many patients with AF and a HAS-BLED score equal or greater than 3?
AF Register (AF001) AND '38G3.' (HAS-BLED) score ≥ 3
Green if ≤3 and Red if >3
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Stroke Prevention Dashboard | HAS-BLED score and Medication Review Calculation
Definition
How many patients with AF and a HAS-BLED score equal or greater than 3 have had a medication review in the last 12 months?
AF Register (AF001) AND '38G3.' (HAS-BLED) score ≥3 AND Medication Review V2 codes IN ('8BMH.', '8BMX.', '8BT3.', '8BT2.', '8BI..', '8B31B', '8B3y.', '8BMY.', '8BIC.', '8B3V.', '8B3x.', '8BIH.', '8BIy.', '8B3h.')
Green if <=3 and Red>=3
Stroke Prevention Dashboard | Alcohol review Calculation Definition
How many patients with AF and a HAS-BLED score equal or greater than 3 have had an alcohol review in the last 12 months?
AF Register (AF001) AND '38G3.' (HAS-BLED) score ≥3 AND ALC QoF Cluster
Green if ≤3 and Red if >3
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Stroke Prevention Dashboard | Blood pressure Calculation Definition
How many patients with AF and a HAS-BLED score equal or greater than 3 have had a Blood Pressure Reading in the last 12 months?
AF Register (AF001) AND '38G3.' (HAS-BLED) score ≥3 AND 246A. (Diastolic numeric reading) AND 2469. (Systolic Numeric Reading)
Green if ≤3 and Red if >3
Stroke Prevention Dashboard | Liver function test Calculation Definition
How many patients with AF and a HAS-BLED score equal or greater than 3 have had a Liver Function Test in the last 12 months?
AF Register (AF001) AND '38G3.' (HAS-BLED) score ≥3 AND LIVER QoF Cluster
Green if ≤3 and Red if >3
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Stroke Prevention Dashboard | Electrolytes test Calculation Definition
How many patients with AF and a HAS-BLED score equal or greater than 3 have had Urea and Electrolytes Tests in the last 6 to 12 months?
AF Register (AF001) AND '38G3.' (HAS-BLED) score ≥3 AND RENAL QoF Cluster
Green if <=3 and Red if >3
Stroke Prevention Dashboard | Creatinine clearance Calculation Definition
How many patients with AF and a HAS-BLED score equal or greater than 3 that have had Urea and Electrolytes Tests in the last 6 to 12 months have a Creatinine clearance greater than 50?
AF Register (AF001) AND '38G3.' (HAS-BLED) score >= 3 AND RENAL QoF Cluster AND 4513. (Creat Clearance) > 50
Green if <=3 and Red if >3
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Stroke Prevention Dashboard | New Oral Anticoagulant Calculation Definition
How many patients with AF and a HAS-BLED score equal or greater than 3 that have had Urea and Electrolytes Tests in the last 6 to 12 months have a Creatinine clearance less than 30 and are on New Oral Anticoagulant?
AF Register (AF001) AND '38G3.' (HAS-BLED) score ≥3 AND RENAL QoF Cluster AND 4513. (Creat Clearance) < 30 AND Drug Codes IN
(bs7..,bs72.,bs74.,bs4..,bs4y.,bs4x.,bs4z.,bs8..,bs84.,bs85.,bs86.,bs71.,bs73.,bs81.,bs82.,bs83.,bs42.,bs43.,bs41.,bs6..,bs6z.,bs6y.,bs6w.,bs6x.,bs61.,bs62.,bs64.,bs63.)
Green if <=3 and Red if >3
Stroke Prevention Dashboard | Full blood count Calculation Definition
How many patients with AF and a CHADSVASC Score greater than 1 have had a Full Blood Count in the last 6 months?
AF Register (AF001) AND ReadcodeV2 - '38G3.' score >1 AND (424.., 424Z.)
Green if ≤2 and Red if >2
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Stroke Prevention Dashboard | Palliative Diagnosis Calculation Definition
How many patients diagnosed with Atrial fibrillation have received a palliative diagnosis?
AF Register (AF001) AND PC1 QoF Cluster (Palliative Care Codes)
Stroke Prevention Dashboard | Co-ordinate My Care plan Calculation Definition
How many patients diagnosed with Atrial Fibrillation have received a palliative diagnosis and have a Co-ordinate My Care plan in place?
AF Register (AF001) AND PC1 QoF Cluster (Palliative Care Codes) AND Co-ordinate My Care plan(Y10b5) Not Implemented- Could not find the corresponding V2 Code for 'Y10b5'
Stroke Prevention Dashboard | Thyroid Function Calculation Definition
How many patients diagnosed with Atrial Fibrillation have received a palliative diagnosis and have received a Thyroid Function test in the last 6 months?
AF Register (AF001) AND PC1 QoF Cluster (Palliative Care Codes) AND TFT QoF Cluster
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How many patients diagnosed with Atrial Fibrillation have a Thyroid Function test result within 6 weeks of diagnosis of AF
AF Register (AF001) AND TFT QoF Cluster (within 6 weeks of patient being placed on the AF register).
Stroke Prevention Dashboard | Time in Therapeutic Range of more than 65% Calculation
Definition
How many patients diagnosed with Atrial Fibrillation and who are on Warfarin have a Time in Therapeutic Range of more than 65%?
AF001 QoF indicator and DrugCodes in
(bs1B.,bs11.,x01O4,bs1..,bs1A.,bs17.,bs1C.,bs18.,bs19.,bs14.,bs15.,bs16.) AND GP Readcode '42QE2' have Numresult >65%
Green if >=65% and Red if <65%
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Stroke Prevention Dashboard | Recommended Therapeutic Range Calculation Definition
What is the length of time that it takes patients with a diagnosis of AF on Warfarin to be within their recommended Therapeutic Range?
AF001 QoF Indicator and DrugCodes in
(bs1B.,bs11.,x01O4,bs1..,bs1A.,bs17.,bs1C.,bs18.,bs19.,bs14.,bs15.,bs16.) AND GP Readcode '42QE.' have NumResult (range 2-3)
Green if <=6 weeks and Red if > 6 weeks
Stroke Prevention Dashboard | More than 6 weeks to reach therapeutic range Calculation
Definition
How many patients with a diagnosis of AF on Warfarin took more than 6 weeks to reach their Therapeutic Range?
AF001 QoF Indicator AND DrugCodes IN
(bs1B.,bs11.,x01O4,bs1..,bs1A.,bs17.,bs1C.,bs18.,bs19.,bs14.,bs15.,bs16.) AND GP Readcode '42QE.' have NumResult (range 2-3) within time less than 6 weeks
Green if <=6 weeks and Red if > 6 weeks
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Stroke Prevention Dashboard | Medication review Calculation Definition
How many patients with a diagnosis of AF on Warfarin and Time in Therapeutic Range of less than 65% have received a medication review in the 6 months?
AF001 QoF Indicator
AND DrugCodes bs1B., bs11., x01O4, bs1.., bs1A., bs17., bs1C., bs18., bs19., bs14., bs15., bs16.
AND Xaa68 <65%
AND GP Readcode -'8B314' (med review code cluster) in last 6 months
Green if >=65% and Red if <65%
Stroke Prevention Dashboard | Patient with a Stroke had been diagnosed with AF
Calculation Definition
How many patients admitted with a Stroke had been diagnosed as having atrial fibrillation?
SUS stroke event AND prior AF001 QoF cluster code on S1
How many patients admitted with a Stroke had been diagnosed as having atrial fibrillation and were prescribed an anti-coagulant?
SUS stroke event AND prior AF001 QoF cluster AND ORANTICOAG
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Stroke Prevention Dashboard | Stroke patient not prescribed an anticoagulant
Calculation Definition
How many patients admitted with a Stroke had been diagnosed as having atrial fibrillation and were not prescribed an anticoagulant?
SUS stroke event AND prior [AF001 QoF cluster NOT ORANTICOAG]
Stroke Prevention Dashboard | Stroke patient with CHADVASc score Calculation
Definition
How many patients admitted with a Stroke had been diagnosed as having Atrial Fibrillation and have a CHADSVASC Score?
SUS stroke event AND prior AF001 QoF cluster AND XaY6i
Green if <=2 and Red if >2
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Stroke Prevention Dashboard | Bleeding Admission Calculation Definition
How many patients with AF and on an anticoagulant and a HAS-BLED Score of equal to or greater than 3 have had a Bleeding Admission?
AF Register (AF001) AND '38G3.' (HAS-BLED) score ≥3 AND SUS code for admission with "haemorrhage, bleeding"
Green if ≤3 and Red if >3
Stroke Prevention Dashboard | International Normalised Ratio Calculation Definition
How many Atrial Fibrillation patients on Warfarin have an International Normalised Ratio greater than 8 recorded in the last 6 months?
AF001 QoF Indicator
AND DrugCodes bs1B.,bs11.,x01O4,bs1..,bs1A.,bs17.,bs1C.,bs18.,bs19.,bs14.,bs15.,bs16.
AND INR Readcode '42QE.' having NumResult greater than 8 in last 6 months
Green if >=8 and Red if <8
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How many Atrial Fibrillation patients on Warfarin have an International Normalised Ratio greater than 5 recorded more than two times in the last 6 months?
AF001 QoF Indicator
AND DrugCodes bs1B.,bs11.,x01O4,bs1..,bs1A.,bs17.,bs1C.,bs18.,bs19.,bs14.,bs15.,bs16.
AND 42QE. (>5 twice within 6 months)
Green if >=8 and Red if <8
Stroke Prevention Dashboard | Paroxysmal Atrial fibrillation Calculation Definition
How many patients are diagnosed with Paroxysmal Atrial fibrillation?
Patients with ReadCodeV2 'G5732'
Stroke Prevention Dashboard | Heart Failure Calculation Definition
How many patients diagnosed with Atrial fibrillation patients have also been diagnosed with concurrent Heart failure?
Patients with AF001 QoF indicator codes AND HF Code cluster
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Stroke Prevention Dashboard | Hypertension Calculation Definition
How many patients are diagnosed with atrial fibrillation and hypertension?
Patients with AF001 QoF indicator codes AND hypertension Code cluster
Stroke Prevention Dashboard | Diabetes Calculation Definition
How many patients diagnosed with atrial fibrillation are diagnosed with Diabetes Types I or II?
Patients with AF001 QoF indicator codes AND DM Code cluster
Stroke Prevention Dashboard | Controlled Blood Pressure Calculation Definition
How many Atrial fibrillation patients have been diagnosed with Hypertension are well controlled with Blood Pressure less than 140 / 90 Within 12M?
Patients with AF001 QoF indicator codes AND HYP Code cluster AND BPSYS Code '2469.' <140 AND BPDIA Code '246A.' <90
Green if Syst: <140 Diast: <90
Red if Syst: ≥140 Diast: ≥90
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How many Atrial fibrillation patients have been diagnosed with Hypertension and Diabetes Types I and II are well controlled with Blood Pressure less than 130 / 80 within 12M?
As per 40 AND BPSYS Code '2469.' <130 AND BPDIA Code '246A.' <80
Green if Syst: <140 Diast: <90
Red if Syst: >=140 Diast: >=90
Stroke Prevention Dashboard | BMI Calculation Definition
How many patients diagnosed with Atrial Fibrillation have had their BMI recorded within the last 12 months?
AF001 QoF indicator AND BMI ReadCode '22K..'
Stroke Prevention Dashboard | Pulse Check Calculation Definition
How many patients over 65 years of age have had a Pulse Check (including ECG) in the current financial year?
Patients >65yo AND CDPULS QoF Cluster (including subcodes) in financial year
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Stroke Prevention Dashboard | Blood Pressure measure YTD Calculation Definition
How many patients over 65 years of age have had their Blood Pressure measured in the current financial year?
Patients >65yo AND BPSYS Code '2469.' AND BPDIA Code measures in current financial year
Stroke Prevention Dashboard | NHS Health check Calculation Definition
How many patients over 40 years of age have had a NHS Health Check in the current financial year?
Patients >40yo AND NHS Health Check '8BAg.' in financial year
Stroke Prevention Dashboard | Total NEL Spend Calculation Definition
What is the total non-elective spending on patients diagnosed with Paroxysmal Atrial fibrillation?
Patients with Paroxysmal AF (ReadCode in (‘G5732’)).
Grey if Elective Spend.
Orange if Non-Elective Spend.
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Stroke Prevention Dashboard | Spend – complex electro physiological investigation
Calculation Definition
What is the total spending on patients diagnosed with atrial fibrillation who have had complex electro Physiological investigations?
AF001 and HRG codes related to these electrophysiological tests
Stroke Prevention Dashboard | Spend for AF patients who had a stroke Calculation
Definition
What is the total spending of patients with a diagnosis of AF that have had stroke?
AF001 AND spend data. Will not include social cost
Stroke Prevention Dashboard | Patient Activation Measure Calculation Definition
What is the individual Patient Activation Measure?
PAM ReadCodeV2 = '38Qo.' for all the patients in GP
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Stroke Prevention Dashboard | Length of Stay Calculation Definition
What is the total length of stay for patients diagnosed with AF and who have had a stroke?
Patients with AF001 and LOS logic as below
Stroke Prevention Dashboard | Admitted with Stroke and AF Calculation Definition
How many patients have been admitted with a Stroke who have atrial fibrillation but who have not been previously diagnosed with Atrial fibrillation?
Hospital SUS data
NOT on AF001 register GP system preceding the Stroke admission
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Section 4: Use Cases
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Stroke Prevention Dashboard | Case Finding
Prevalence of AF increases with age. A variety of means may be used within a practice in order to diagnose patients with AF. In broad terms, patients with IHD, hypercholesterolaemia, chronic hypertension, heart failure, COPD, Diabetes, >60 years old ought to have pulse checks at every review systematically as well as opportunistically (e.g. during flu jab clinics) in order to detect irregularly irregular heart rhythms. Any irregular pulse ought to be followed up with a formal ECG to make the diagnosis of AF. All patients with an AF diagnosis must have a CHA2DS2Vasc score calculated and anticoagulated if appropriate.
Stroke Prevention Dashboard | Stroke Risk
Use the CHA2DS2-VASc stroke risk score to assess stroke risk in people with any of the following:
symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation
atrial flutter
a continuing risk of arrhythmia recurrence after cardio version back to sinus rhythm
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Stroke Prevention Dashboard | Stroke Risk: Calculation Definitions
Patients with atrial fibrillation in whom stroke risk has been assessed using the CHA2DS2-VASc score risk stratification
scoring system in the preceding 12 months (excluding those patients with a previous CHADS2 or CHA2DS2-VASc score
of 2 or more)
The CHA2DS2-Vasc indicator on the Dashboard will be:
Red if >2 and Green if ≤2
Stroke Prevention Dashboard | Bleed Risk
Use the HAS-BLED score to assess the risk of bleeding in people who are starting or have started
anticoagulation.
Stroke Prevention Dashboard | Bleed Risk: Calculation Definitions
Patients with AF and a recorded CHA2DS2-VASc Score have a HAS-BLED score recorded
The indicator on the Dashboard will be:
Red if >2 and Green if ≤2
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Stroke Prevention Dashboard | Treatment/Prescribing
Patients should be initiated on anticoagulation in accordance with clinical best practice (NICE CG180 and QS93)
Treatment choice is made jointly between the patient and prescribing clinician.
Offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account.
HASBLED scores >3 are not absolute contraindications to anticoagulation and each patient ought to be assessed
individually.
Patients with AF should not be prescribed aspirin as mono-therapy for stroke prevention. Patients with AF with a record of a CHA2DS2-VASc score of 2 or more currently treated with anti-coagulation drug
therapy
Patients with AF treated with anti-coagulation drug therapy who…
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Section 5: AF Radar
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AF Radar | Introduction
The AF Radar is a patient list combined view of the 12 Key Care indicators for direct care use. This provides
a case finding tool that’s easy to view.
Clinical uses of the AF Radar
There are a number of scenarios where we envisage that the Asthma radar may be of use:
1. Prioritising patients for review: o The radar allows the clinician to sort patients by a number of parameters including Patient
name, Age, #LTCs, Care Processes outstanding, Latest CHA2DS2VASc, Latest HASBLED, TTR Percentage, Blood Pressure Diastolic and Blood Pressure Systolic
2. Virtual clinics: o Sitting down with a specialist clinician and reviewing a list of AF patients can be a relatively
time efficient way of getting input into a group of poorly controlled / off-target patients. The radar allows the clinicians to review a list of patients sorted by Number of outstanding Care processes (or other parameters) quite rapidly without necessarily having to open every patient’s set of notes in the GP system.
3. Recall for appointments
o Checking the individual scores for the indicators may result in the Health Care professionals decision for the patient to be called in for an appointment to assess further.
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AF Radar | Homepage
You can access the AF Radar from the Homepage. Please refer to the ‘How to Use’ section, which explains some of the functionality of the radar.
‘Choose a Tool’ - Choose ‘Long Term
Condition Management’ - Choose ‘AF Radar’
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AF Radar | How to use the radar
The AF Radar displays traffic lights indicating if the item is a Red, Amber or Green Flag.
Notes on usage Click on a traffic light to
view patient details
X indicates that no data is available for the indicator
Hover over traffic lights to see when an item was last recorded and the most recent result
Total number of patients on list
Hover over points on the graph to show the date and value of the reading
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AF Radar | How to use the radar
Select a patient to reveal more information below about that individual
Notes on usage Click on a traffic light to
view the patient’s LTCs details
The patient demographic information and LTCs will be displayed below
North West London Collaboration of
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For more information, please email