1. NOAC but NICE Conference 16th July 2013

2. Anticoagulation and stroke in atrial fibrillation patients Martin Davis, Debbie Hilder, Maggie Kelly, Matt Johnson, Robert Pears, Hugh Sanderson, Jo Wall

3. What we know about AF stroke • AF stroke related to lower Quality of Life. • Healthcare costs higher for strokes in patients with AF. • Cost of stroke between £9,500 and £14,000 in first year. AF more likely to be at upper end. • Inpatient costs 8% higher for AF stroke. • National cross-sectional studies: • GRASP AF (21% of GP practices) and Q Research (600 GP practices) • Suboptimal prescribing of anticoagulants • Too much prescribing of anti-platelets

4. What local audit adds • Follow up of AF patients in SHIP for 5 years: 21/12/2007 to 20/12/2012. • Differences in treatment and outcome for men and women. • Strokes and TIAs as outcomes. • Comparison of local performance with self selecting GP practices in national audits.

5. Methodology • Data from Hampshire Health Record on 21/12/2012. • Treatment determined at various time points: • Current treatment: medication prescribed in most recent 6 months. • In AF stroke patients: • Before stroke: treatment in 6 months prior to stroke • After stroke: treatment 6 months after stroke. If died in time period removed from analysis. • Risk of stroke measured using CHA2DS2-VASc.

6. Patient characteristics: prevalence

7. Patient characteristics: age & sex n=33077

8. Treatment: current treatment by CCG • SHIP: 40.0% on anticoagulants (98.4% warfarin, 1.4% dabigatran, 0.1% rivaroxaban) • GRASP AF: 54.8% (CHADS2 score 2 or more) • QResearch: 50.7% (CHA2DS2-VASc 2 or more)

9. Treatment: rates by age and sex

10. Treatment: contraindications • SHIP: 38.7% contraindicated • GRASP-AF: 9.6% • QResearch: 13.4%

11. Treatment: contraindications by age and sex

12. Treatment: relationship between risk and treatment type • Anticoagulation rates are lower for patients with higher CHA2DS2VASc scores. • AF not only reason for being prescribed OAC or APs

13. Outcomes: strokes during 5 year follow up

14. Outcomes: type of stroke

15. Outcomes: INR stability before stroke

16. Outcomes: treatment before and after stroke

17. Outcomes: mortality

18. Outcomes: women compared to men

19. Limitations • Percentage of “other” strokes. • Did not pull reasons for contraindications. • 33% of stroke patients (excluding TIA) had no associated hospital admission. • Prescriptions can be for other conditions. • Patients moving to GP practices not covered by HHR may have prescription data missing.

20. Conclusions • Rates of anticoagulation lower than clinically indicated, lower than national audits. • Contraindication rates much higher than national audits • Very low percentage of patients being prescribed NOAC at time of audit. • Anticoagulants prescribed less for patients at highest risk • INR stability worse in patients who went on to develop stroke. • Women are less likely to be anticoagulated, more likely to have a stroke. • Anticoagulants may be prescribed less often after stroke than before.

21. Recommendations • CCGs should encourage GP all practices to use HHR. • GP practices should upload data to GRASP-AF. • Women need to be diagnosed and treated more aggressively. • Match national audit prescribing rates as a minimum. Supports COF target to reduce premature mortality. • Stricter criteria for contraindication: not age. • NOACs may be appropriate in some frail elderly and some patients with labile INRs. • Check anticoagulation prescribing in recent AF strokes.

22. NOAC but NICE Conference 16th July 2013