A consultant-led anticoagulation review of all patients in one clinical commissioning group to prevent atrial fibrillation related stroke.

OBJECTIVE: Ensuring patients with Atrial fibrillation (AF) are appropriately anticoagulated across NHS Bedfordshire Clinical Commissioning Group (BCCG) with the primary goal of reducing AF-related strokes. METHODS: With Inspira Health, BCCG adopted the Primary Care Atrial Fibrillation (PCAF) Service which is led by Consultant Cardiologists. PCAF uses retrospective clinical audit to identify patients who require prospective face-to-face review on the need for anticoagulation. RESULTS: 34 GP practices participated covering a 376 311 population (80% of BCCG). 12 573 patients' medical records were audited. The initial AF register was 7301 patients (AF prevalence 1.9%) and an additional 265 patients were identified through AF casefinder resulting in an AF prevalence of 2.0%. From 7566 patients with AF, 5831 were already on anticoagulants (77.1%), with 50.5% (n = 2947) on VKA medications and 49.5% (n = 2884) on direct oral anticoagulants (DOACs). Of the DOAC patients, 595 (20.6%) required dosage review or up to date blood tests. Case notes were reviewed for 1735 patients not on anticoagulation, with 901 (51.9%) patients deemed not eligible for anticoagulation. This left 834 (48.1%) patients who were eligible for, but not on, anticoagulation. A further 407 (13.8%) patients currently taking VKA medications were deemed sup-optimal with regards to INR control with TTR < 65%. In total 1241 patients were invited for review by a Consultant Cardiologist at their local GP practice, with an attendance rate of 90%. From all face to face and virtual consultations, 908 patients had anticoagulants prescribed, changed, management of INRs improved or were in the process of being anticoagulated at the time of follow-up. From this we would expect 36.3 AF related strokes prevented and a cost saving to the NHS of £470 200 per year. CONCLUSION: Through comprehensive audit, BCCG have been able to ensure that patients with AF are appropriately anticoagulated in 80% of their catchment population. This has improved anticoagulation to prevent AF-related stroke.

A review of asthma care in 50 general practices in Bedfordshire, United Kingdom.

The United Kingdom (UK) National Review of Asthma Deaths (NRAD) (2011-2014) identified a number of contributory risk factors which had not previously been recognized by those caring for people with asthma. Only one of the 19 NRAD recommendations has so far been implemented nationally, and that only partially, and as yet systems are not in place to identify patients at risk of attacks and dying from asthma. In 2015/2016 Bedfordshire Clinical Commissioning Group (CCG) in England, UK, initiated a quality asthma audit of people with asthma to identify some of the risk factors identified in the NRAD report with the aim of optimizing patient care. Fifty (89%) of the General Practices caring for 415,152 patients (27,587 diagnosed with asthma (prevalence 7%; range 4-12%)), participated and the results identified a wide variation in process of care and presence of risk factors including: excess short acting reliever and insufficient preventer prescriptions, failure to issue personal asthma action plans, and to perform annual reviews or check inhaler technique. Identification of these patients involved high-intensity input by trained asthma nurses using sophisticated data extraction software. GP computer systems used in primary care currently do not have the functionally, without the need for manual audit, to implement the NRAD recommendations, starting with the identification of patients at risk. Modifications to existing systems within both primary and secondary care are required in order to prevent unnecessary deaths related to asthma. There is a pressing need to move towards a more pro-active model of care.