Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention
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Background Updated evidence-based guidelines for the management of atrial fibrillation (AF) necessitate patient review, particularly with respect to oral anticoagulants, to ensure maximum health gain around stroke prophylaxis. Objective To quantify the level of anticoagulation utilisation in patients with a CHA2DS2-VASc ≥1/≥2 (male/female) according to evidence-based guidelines and to assess the impact of a pharmacist-led intervention to optimise therapy. Setting Fifteen general medical practices in Liverpool, North-West England with a practice population of 99,129. Method GRASP-AF software was employed to interrogate patient electronic medical records to identify and risk stratify AF patients (using CHA2DS2-VASc). A pharmacist then reviewed the medical records of those of patients not anticoagulated and with a CHA2DS2-VASc ≥1/≥2 (male/female). Recommendations were discussed with a general practitioner (GP) and those patients in whom the need for anticoagulation was agreed were invited for a consultation with either the pharmacist or GP and therapy optimised where appropriate. The GPs were responsible for managing those patients referred for diagnosis confirmation or further specialist opinion. Main outcome measure Proportion of patients eligible/not eligible for anticoagulation; proportions in whom anticoagulants initiated, refused, antiplatelets discontinued. Results Five hundred and twenty-three patients (31% of patients identified with AF and a CHA2DS2-VASc ≥1/≥2 (male/female)) were not receiving an anticoagulant (26 subsequently died or left the practice leaving 497). Three hundred and eighty-two (77%) pharmacist recommendations to a GP were agreed without modification. Following outcomes of diagnostic investigations and specialist referrals, 202 (41%) patients were candidates for anticoagulation, 251 (51%) were not eligible for anticoagulation, 103 (21%) were anticoagulated (56 warfarin, 47 DOAC). Conclusion A pharmacist-led intervention re-aligned oral anticoagulant therapy to the latest evidence based guidelines for stroke prophylaxis, whilst simultaneously correcting the over-utilisation of antiplatelet therapy.
KeywordsAnticoagulant Atrial fibrillation Pharmacist Stroke United Kingdom
Conflicts of interest
- 3.Go A, Hylek E, Phillips K, Chang Y, Henault L, Selby J, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the an ticoagulation and risk factors in atrial fibrillation (ATRIA) study. JAMA. 2001;285:2370 (Accessed 4 Oct 2016).CrossRefPubMedGoogle Scholar
- 12.Mant J, Hobbs FD, Fletcher K, Roalfe A, Fitzmaurice D, Lip GY, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet. 2007;370:493–503.CrossRefPubMedGoogle Scholar
- 17.National Institute for Health and Care Excellence (NICE) Atrial fibrillation: the management of atrial fibrillation (Clinical guideline 36) 2006.Google Scholar
- 19.National Institute for Health and Care Excellence (NICE). Atrial fibrillation: the management of atrial fibrillation (Clinical guideline 180) 2014. http://guidance.nice.org.uk/CG180. Accessed 4 Oct 2016.
- 24.National Institute for Health and Care Excellence. Costing report: atrial fibrillation—implementing the NICE guideline on atrial fibrillation (CG180). 2014. http://www.nice.org.uk/guidance/cg180/resources/cg180-atrial-fibrillation-update-costing-report2. Accessed 4 Oct 2016.
- 25.NHS Commissioning board. The functions of clinical commissioning group, prepared by: Commissioning Development Directorate 2013. https://www.england.nhs.uk/wp-content/uploads/2013/03/a-functions-ccgs.pdf. Accessed 26 Nov 2016.
- 31.NHS England. The general practice forward view report. Gateway publication reference: 05116, 2016. https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf. Accessed 4 Oct 2016.
- 32.Public Health England. Commissioning for value: pathways on a page. NHS Liverpool CCG. 2014. https://www.england.nhs.uk/wp-content/uploads/2014/11/cfv-liverpool.pdf. Accessed 4 Oct 2016.
- 33.National Institute for Health and Care Excellence (NICE). Patient decision aid. Atrial fibrillation: medicines to help reduce your risk of stroke—what are the options. 2014. http://guidance.nice.org.uk/CG180/PatientDecisionAid/pdf/English. Accessed 4 Oct 2016.
- 34.Wexler R. Six steps of shared decision making, Informed Medical Decisions Foundation, 2012. http://informedmedicaldecisions.org/wp-content/uploads/2012/02/Six_Steps_SDM_Language.pdf. Accessed 4 Oct 2016.
- 35.Banerjee A, Lane DA, Torp-Pedersen C, Lip GY. Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a ‘real world’ atrial fibrillation population: a modelling analysis based on a nationwide cohort study. Thromb Haemost. 2011;107:584–9.CrossRefPubMedGoogle Scholar
- 36.Kerr M. Cost and benefits of antithrombotic therapy in England: an economic analysis based on GRASP AF. 2013. Insight health econonomics for NHS improving quality. http://www.nhsiq.nhs.uk/media/2566025/af_economic_analysis_final.pdf. Accessed 4 Oct 2016.
- 37.Kambhampati S, Ashvetiya T, Stone N, Blumenthal R, Martin S. Shared decision-making and patient empowerment in preventive cardiology. Curr Cardiol Rep. 2016;18 (Accessed 4 Oct 2016).Google Scholar
- 51.Bruhn H, Bond C, Elliott A, Hannaford P, Lee A, McNamee P, et al. Pharmacist-led management of chronic pain in primary care: results from a randomised controlled exploratory trial. BMJ Open 3:p.e002361 (Accessed 4 Oct 2016).Google Scholar
- 52.Tsuyuki R, Houle S, Charrois T, Kolber M, Rosenthal M, Lewanczuk R, et al. A randomized trial of the effect of pharmacist prescribing on improving blood pressure in the community: the Alberta clinical trial in optimizing hypertension (RxACTION). Can J Cardiol. 2014;30:S125–6 (Accessed 4 Oct 2016).CrossRefGoogle Scholar