STROKE  PREVENTION  SERVICES  QUALITY  AND  SAFETY  INDICATORS  IN  A  CHANGING  CONTEXT  

•  David  Pa;erson  MD  FRCP  FRSPH  •  Professor  of  Cardiovascular  Medicine  •  Consultant  Cardiologist    •  Department  of  Cardiovascular  Medicine,  WhiMngton  Health    •  CHIME,  University  College  London  •  Helicon  Health,  Chief  ExecuPve    

HeartBeat/HeliconHeart - Seamless anticoagulation and stroke prevention services across north London building on 20 years of world-leading research on electronic health records

Good European ���Health Record 1992

1996

2000

1998 1996

2002 2004 2006 2006

2008

20 years of international research on the requirements, design, implementation, sharing and protection of electronic health records

Leading a global open source EHR Foundation Leading the development of

European and International EHR standards

implementation of an ISO EN 13606 conformant EHR server with a suite of cardiovascular web applications

Set up and seed funded by UCL in 2012 Key partners CHIME and Whittington Health

HeartBeat Anticoagulation���management and���advisory system 2006

1999

2011

2012

HeliconHeart  is  a    unique  package  of  clinical  services  comprising:  -­‐    Web  soSware  -­‐    Clinically  useful  Electronic  Health                      Record,  standards-­‐based  -­‐    Decision  support  –  which  drugs                to    use,  how  and  when  -­‐    CollaboraPon  tools  -­‐      EducaPon  -­‐      Governance  &  data  analyPcs  

NICE  AF  GUIDELINES  2014

Key  prioriPes  for  implementaPon:  

•         Personalised  package  of  care  and  informaPon  

•         Referral  for  specialised  management  •         Assessment  of  stroke  and  bleeding  risks  

•         IntervenPons  to  prevent  stroke  •         Rate  and  rhythm  control  

2014  ATRIAL  FIBRILLATION  AWARE  WEEK  24TH  NOVEMBER  -­‐  29TH  NOVEMBER  

The  aims  of  the  AF  Aware  week  are  simple:                AF  -­‐  Detect,  Protect,  Correct:  

!  Detect:  OpportunisPc  Screening  has  been  shown  to  increase  detecPon  of  AF  !  Protect:  IdenPficaPon  and  treaPng  paPents  with  AF  at  an  early  stage  will  

deliver  significant  health  and  cost  benefits  !  Correct:  Early  detecPon,  diagnosis  and  appropriate  medical  management  leads  

to  fewer  appointments  &  admissions,    saving  individuals  long-­‐term  ill  health    

The  All-­‐Party  Parliament  Group  on  AF    (APGAF)  has  played  a  key  role  in  helping  to  establish  that  AF  should,  in  both  policy  and  clinical  domains,  be  considered  a  discrete  enPty  within  “the  family  of  cardiovascular  disease”.    

APGAF  meets  again  tomorrow    to  explore  the  sPll  exisPng  barriers  for  paPents  to  gain  access  to  the  opPmal    treatment.      

WHAT  ARE  THE  REASONS  FOR    OFFERING  ANTICOAGULANT  AND  STROKE  PREVENTION  TREATMENT  TO  PATIENTS  ?  

“AnPcoagulaPon  therapy  is  required  for  people  with  different  condiPons,  who  are  idenPfied  in  a  range  of  seMngs  and,  in  the  case  of  deep  venous  thrombosis  and  pulmonary  embolism,  require  urgent  intervenPon.”    NICE  2013  Based  on  epidemiological  data  and  other  informaPon,  it  is  concluded  that  the  number  of  adults  aged  18  or  over  in  England  who  require  anPcoagulaPon  therapy  and  may  need  access  to  an  anPcoagulaPon  therapy  service  include:  

CondiEon AnEcoagulaEon  therapy  service

Atrial  fibrillaEon  (CHADS2  score=1) 226,000

Atrial  fibrillaEon  (CHADS2  score>1) 476,000

VTE  including  PE  and  DVT   125,000

Others 155,000

“Therefore,  it  is  suggested  that  the  indicaPve  rate  for  people  needing  anEcoagulaEon  therapy  is  up  to  2.4%  or  2400  per  100,000  of  the  populaPon  aged  18  years  or  over”    NICE  2013  

ARE  WE  IDENTIFYING  ALL  THE  PATIENTS  WITH  AF  WHO  SHOULD  BE    ANTICOAGULATED?  

ATRIAL  FIBRILLATION  IS  A  MAJOR  PREVENTABLE  CAUSE  OF  STROKE  NaPonal  data  obtained  from  GRASP-­‐AF  show  

that  only  66%  of  high  risk  paPents  are  managed  using  oral  anPcoagulaPon  

(May  2014  –  33%  of  all  pracPces  in  England)    

This  is  in  spite  NaPonal  Guidelines  from  NaPonal  InsPtute  for  Health  and  Care  Excellence  and  the  European  Society  of  Cardiology  promoPng  their  use  

RAISING  AWARENESS  –  IDENTIFYING  PATIENTS  WITH  AF  

The  Atrial  FibrillaEon  AssociaEon  (AFA)  and  the  Stroke  AssociaEon  have  undertaken    awareness-­‐raising  events:  

Know  your  pulse              EducaEonal  events  

OpportunisEc  is  cost-­‐effecEve  

Flu  vaccinaEon  programme                                  Surgery  pre-­‐assessment                                                              Eye  appointments            Pharmacy  visit                                                                              Supermarket  visit                                                                                  Pub  visits?  

     

OpportunisEc  or  screening  programme?  

NICE  (2013)  SUPPORT  FOR  COMMISSIONING:  ANTICOAGULATION  THERAPY  NICE  GUIDELINES  FOR  AF  (2014)  

•  There  is  such  an  inPmate  relaPonship  between  AF  and  other  manifestaPons  of  CV  Disease  (The  Family  of  Cardiovascular  Disease)  and  to  anPcoagulant  and  prevenPon  services  for  strokes  

•  It  is  an  essenPal  step  to  idenPfy  paPents  with  AF  and    direct  appropriate  paPents  to  anPcoagulant  and  stroke  prevenPon  therapy    in  order  to  reduce  the  incidence  of  stroke.    

ATRIAL  FIBRILLATION  Hypertension  

Raised  lipids  

Coronary  artery  disease  

HEART  FAILURE  Hypertension  

Coronary  artery  disease  

Raised  lipids  

ANTICOAGULATION  Monitoring  

Frequent  visits  

PST  &  PSM  opPons  

WHY  ARE  WE  HERE?    

Cardiovascular disease (CVD) is the biggest killer in the UK

Costs of CVD are massive

Strokes are avoidable with preventive treatment

Wide variations in quality and safety

Strokes are very costly to the patient and society

Poor clinician and patient education

of UK population have CVD

ONS 2011

>11% £19b BHF 2014   Stroke Association 2014  

153,000 Strokes/year UK

Not on effective therapy to reduce strokes

NICE UK

44% £23k Saving from each stroke prevented

NAO 2010

No. 1 risk “Not all staff have the required work competencies”

NPSA Risk of Anticoagulation, 2006

POPULATION  ATTRIBUTABLE  RISK  

The  contribuPon  each  risk  factor  makes  to  overall  stroke  prevalence  can  be  calculated  as  a  populaPon  a;ributable  risk  (PAR).    In  England:  

   PAR  of  smoking      13.3%  PAR  of  hypertension    34.8%  

50%  of  the  risk  of  stroke  can  be  “preventable”    by  controlling  these  2  risk  factors.    

There  is  logic  in  managing  these  risk  factors  at  the  same  Pme  as  the  risks  a;ributable  to  atrial  fibrillaPon  (heart  rhythm  and  rate  control  and  oral  anPcoagulaPon)        

IMPACT  OF  HELICON  AF  &  STROKE  PACKAGE  

Strokes/year  

101  

64  37  strokes  saved  

Before   With  Helicon’s  AF&  Stroke  package  

EsPmated  cost    saving:  £592,000  

Total    populaPon:    320,000  

>60y:    57,290  

An  Urban  CCG  

“The  cost  of  stroke  could  be  cut  by  20%  with  beBer  management  of  atrial  fibrillaFon.”    NICE  2006  

UNIQUE  ONLINE  SOLUTION  FOR  SHARED  CARE  

Electronic Health Record An online care record shared across all venues of care

Clinical Decision Support Integrated tools for better diagnosis, risk assessment & treatment

Clinical Governance Analytics Robust analytics enables multi-site comparison

Clinician & Patient Education Patients are equipped for self-care and clinicians are kept up to date with accredited learning

EDUCATION

The patient The clinician It  has  features  for  the  paEent,  together  with  their  carer  or  family  member  that  include:  

!  Only  comprehensive  on-­‐line  resource  to  support  the  self-­‐tesPng  paPent  

!  Assessment  tools  to  assess  competencies  !  More  value  on  expansion  to  self-­‐

management  (inclusion  of  dosing  support)  !  Retain  support  of  local  pracPPoner  for  

skills-­‐based  training  !  Resource  that  paPent  can  share  with  their  

pracPPoner  to  facilitate  consultaPons    !  User  can  select  different  levels  of  

informaPon  based  on  learning  needs  !  Produced  and  supported  by  experts  in  

field  

Part  of  the  course  for  the  clinician  is  to  study  the  course  for  the  paEent.    

!  Offer  both  skills  and  knowledge  based  educaPon  with  assessments  of  both  

!  In  addiPon  to  the  clinical  knowledge  base  we  offer  very  pracPcal  support  in  terms  of  service  delivery,  clinical  governance    and  paPent-­‐centred  consultaPons  

!  User  can  select  different  levels  of  informaPon  based  on  learning  needs  

!  Supported  by  experts  in  field  !  UCL  branding  !  Forum  to  allow  interacPon  with  fellow  

students  and  mentors  /  tutors  !  Not  a  stand-­‐alone  product.    !  Forum  for  alumni  to  help  conPnue  their  

educaPon  and  to  share  experiences    

THE  INVOLVEMENT  OF  THE  PATIENT  AND  CARER  

CASE  STUDY  COUNTY  DURHAM  AND  DARLINGTON  NHS  FOUNDATION  TRUST  (CDDFT)  

•  In  June  2013,  200    paPents  taking  warfarin  were  idenPfied  and  recruited  for  an  INR  self-­‐tesPng  study    

•  Within  6  months  of  the  study  starPng,  70%  of  paPents  had  increased  their  Pme  in  therapeuPc  range  (TTR)  by  over  20%.  The  average  increase  was  15%.  

•  Financially,  INR  self-­‐tesPng  was  cost  neutral  when  all  CCG  costs  were  included  such  as  the  reducPon  in  adverse  events.  Self-­‐tesPng  also  freed  up  clinic  capacity.  

•  PaPents  loved  the  service  -­‐  every  paPent  in  the  study  said  they  would  recommend  it  

Average  TTR  across  all  200  paFents,  before  &  aMer  study  

6  months  before  study   59.7%  

3  months  before  study   59.0%  

3  months  ader  study   71.9%  

6  months  ader  study   74.7%  

PATIENT  SELF-­‐TESTING  AND/OR  SELF-­‐MANAGING  

 THE  CONTROL  OF  THE  INR  

!  FINGER  PRICK  TESTING  WITH  COAGUCHEK  !  COMMUNICATION  WITH  HCP:  

Grace  concludes:    •  “I  get  comfort  from  knowing  that,  thanks  to  

HeliconHeart,  all  my  clinicians  have  access  to  a  single  electronic  health  record  for  me.  I    also  like  playing  an  acFve  role  in  my  treatment  and  I  find  I  worry  less  about  my  AF.”  

             

 ADDRESSING  THE  CO-­‐MORBIDITIES  OF  AF  

!  BLOOD  PRESSURE  &  PULSE/HEART  RATE  !  SMOKING  !  ACTIVITY/EXERCISE/DANCE  !  WEIGHT  MEASUREMENT  (PARTICULARLY  FOR  

HEART  FAILURE  MANAGEMENT)  

SUPPORTED  BY    

!  ON-­‐LINE  EDUCATION  !  LOCAL  HEALTH  CARE  PROFESSIONAL  WITH  

ACCESS  TO  EHR  AND  ADVISORY  SYSTEMS  !  STRONG  CLINICAL  GOVERNANCE  

IVR  

Web  

App  

 STROKE  PREVENTION  SERVICES  WARFARIN  CLINIC  VISIT  

COMMUNITY  BASED  STROKE  PREVENTION  SERVICES    IN  ROMIRE  STROKE  PREVENTION  IN  PATIENTS  WITH  ATRIAL  FIBRILLATION    PERIOD    01.01.2014  –  31.12.2014  

TOTAL  NUMBER  OF  PATIENTS  SUSTAINING  A  STROKE  IN  ROMIRE    :        236  Data  from  NaEonal  SenEnel  Stroke  Audit  

THOSE  THAT  HAD  AF    

THOSE  THAT  NOW  HAVE  AF                        

AF  PREVIOUSLY  DIAGNOSED                              PROPORTION  ON  AN  OAC  AT  TIME  OF  STROKE      

PROPORTION  NOW  ON  AN  ORAL  ANTICOAGULANT  

100  80%  

100%  

40%  

QUALITY  OF  SERVICE  VKA  CONTROL                        TTR  >  70                                                                                        TTR  >  60                                                                                          

65%  81%  

NUMBER  TAKING  A  NOAC   5  

THOSE  THAT  HAD  AF  AND    SMOKED     PROPORTION  WHO  HAD  A  SMOKING  

INTERVENTION  

20  15%  

THOSE  THAT  HAD  RECOGNISED  HYPERTENSION  

PROPORTION  TAKING  HYPOTENSIVE  AGENTS                                                                                              40%   PROPORTION  WHOSE  BP  WAS  WELL  CONTROLLED    

30  %  

EXERCISE/ACTIVITY     PROPORTION  TAKING  EXERCISE  >  5  TIMES  PER  WEEK  

20%   PROPORTION  WHO  ARE  SEDENTERY   45%  

PREVENTION  OF  STROKE  NEW  OPPORTUNITIES  

The  expanded  HeliconHeart  package  that  results  from  our  new  strategic  partnership  with    InHealthCare,  is  an  integrated,  web-­‐based  soluPon  for  stroke  prevenPon,  which  makes  it  easier  for  busy  healthcare  professionals  to  plan  and  manage  AF,  oral  anPcoagulaPon  and  stroke  prevenPon  services.  It  is  also  designed  for  paPents  who  wish  to  play  a  more  acPve  role  in  managing  their  condiPon.    

THE  PACKAGE    FEATURES:  

!  Real-­‐Pme  electronic  health  record  (EHR)  shared  with  clinical  colleagues  and  paPent    

!  AnPcoagulant    &  AF  advisory  systems  

!  Interoperability  with  exisPng  GP  systems  and  other  clinical  systems    

!  Affordable  paPent  self-­‐monitoring,  using    BP  monitor  and  Roche’s  Coaguchek  

!  Hosted  on  NHS  spine  via  N3    !  EducaPon  for  clinicians    

!  EducaPon  for  paPents  

KEEP  IN  TOUCH  

To  discuss  today’s  presentaPon  or  any  ma;ers  arising  please  email  me  at  d.pa;erson@ucl.ac.uk  

I  will  be  on  the  Roche  stand  between  3  and  4  this  aSernoon  

To  find  out  more  about  Helicon  Health’s  unique  package  of  stroke  prevenPon  services,  go  to  www.heliconhealth.co.uk