Introduction

3. QOF, NICE and the challenges of AF

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Dr Fay discusses the challenges of AF and how current understanding has led to changes in QOF, and how NICE guidance will have to adapt.

When we’re looking at people with AF, I feel that we have to consider why we haven’t done better in the past.  This comes down to several reasons; one, we fail to identify patients with AF.  This is interesting when you consider that they tend to be over 65, they tend to have other chronic conditions.  So they are people who are attending GP surgeries regularly for check ups and we’re missing the essential investigation, of the pulse check.  Once a patient has been identified as suffering from AF, we then struggle in assessing their risk of stroke, despite having simple tools such as the CHADS2 schema and the CHA2DS2-VASc schema.  These can identify people where intervention with an anticoagulant can dramatically reduce their risk of stroke.  However, we then come onto the third issue, that we find that there seems to be a prejudice against anticoagulants in AF to prevent stroke, and we tend to use aspirin, or antiplatelet agents which we know are dramatically less effective, if they have  role to play at all in stroke prevention in AF.

At the moment in England, we’re dealing with a NICE guideline for atrial fibrillation from 2006.  Clearly this is now old and is out of date.  If we look around the world, we can see how we may consider the NICE guidance to change.  Clearly what has come in elsewhere has been a much more aggressive version of stroke risk assessment in the form of the CHA2DS2-VASc schema, and also the removal of aspirin from a role to prevent stroke in AF.  Earlier this year [2012] we heard from the Royal College of Physicians [of Edinburgh] in their consensus statement that aspirin should not be considered to have a role in stroke prevention in AF.  And I am sure that this will be reflected in the NICE guidance when it is published in 2014.

For general practitioners, there’s an incentive to ensure that we manage people with AF better.  This is coming through the QOF, where identifying the population of patients with AF is rewarded and, in the latest version, risk stratifying them with the CHADS2 schema and then being rewarded for intervention with anticoagulants means that the general practitioner is now positively incentivised to manage AF better and also to prevent the devastating stroke that AF can cause. 

I feel that when we consider the NICE guidance is going to come out in 2014, and is going to be very different to stroke risk assessment, GPs can start preparing for this by ensuring that their patients have all been appropriately risk scored either with the CHADS2 schema or, preferably, with the CHA2DS2-VASc schema, and those patients currently receiving aspirin, to try and prevent AF-related stroke, have all been reviewed and preferably had aspirin discontinued in preference to an oral anticoagulant.

Please find below additional resources that you might find useful when learning about stroke prevention in AF

GRASP the initiative

A report from October 2012 on the practicalities of GRASP-AF and its benefits for primary care practitioners.  The report incudes a national summary of GRASP-AF patient treatment and a series of recommendations for commissioners and practitioners on the how stroke risk among AF patients can be reduced.
Report download

The AF Report

An expert report on AF and the prevention of stroke in the UK.  The AF Report was written for a general audience and presents a thorough and current distillation of the evidence and issues in AF stroke prevention.  The report also identifies current challenges and areas where action is needed to improve the care of AF patients. Download report

The AF Stroke Risk Calculator

A simple online tool for the calculation of CHADS2 and CHADSVASc scores for AF patients.  The calculator was designed to be intuitive and sufficiently easy-to-use for patients to calculate their own risk of stroke.

NHS IQ: GRASP-AF

The NHS Improving Quality website contains a wealth of helpful, practical information on GRASP-AF

The videos

Below are video clips from Dr Matt Fat and Dr Andreas Wolff on several aspects of AF patient care and the reduction of stroke risk.