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GPs face drive to prescribe warfarin alternatives under new NICE plans

GPs face a drive to prescribe warfarin alternatives, as NICE has decided to consider new QOF indicators for anticoagulation control.

NICE QOF experts will look at three potential indicators that would reward practices for making sure patients have more thorough and regular checks.

The decision, taken at a meeting of the NICE QOF advisory panel yesterday, comes as atrial fibrillation experts said too many patients taking warfarin have poor anticoagulation control, and are at high risk of stroke as a result.

Panel members suggested the move would be likely to mean more patients being offered one of the newer non-vitamin K oral anticoagulants (NOACs) like rivaroxaban, with some predicting prescribing of these would ‘rocket’.

The three indicators put forward for piloting were:

  • The proportion of adults with atrial fibrillation taking a vitamin K antagonist who have their time in therapeutic range (TTR) recorded at each visit for INR assessment.
  • The proportion of these who maintain an INR of 2-3.
  • The proportion with poor anticoagulation control who have it reassessed.

Since updated NICE guidelines last year, GPs are advised to offer NOACs to patients unwilling to undergo regular monitoring, since these require less close monitoring than warfarin.

But the advice has been resisted by GP leaders who warned over-burdened GPs would not have the resources to go through the newer options with patients and help them weigh up the risks and benefits.

Yesterday’s meeting heard that rates of NOAC prescribing vary massively between CCGs, from as little as 1.4% to 62.1%.

A GP expert, who cannot be directly quoted under reporting rules from the meeting, said lower rates were down to CCGs restricting access to the more expensive drugs, rather than making sure patients on warfarin were well controlled.

The meeting also considered indicators for the CCG outcomes indicator set (CCG OIS), for which atrial fibrillation management was also considered to reflect the updated guidelines.

In response, the panel discussed GPs being tasked with carrying out regular pulse checks in patients over 65 under the OIS, with the aim of picking up more than 400,000 people with as-yet undetected atrial fibrillation.

This would see hypertension and heart disease patients tested annually and all other over-65s tested opportunistically.

Although the National Screening Committee has previously ruled out systematic screening, the recent SAFE study showed that opportunistic case-finding would be beneficial, the NICE panel was advised.

Readers' comments (13)

  • How blooming patronizing!

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  • Home monitoring is cheap (£10pcm),easy to implement, is linked to DAWN / INR STAR and linkS to GP record systems.

    Diabetics do it every day.

    Let's shift patients out of clinics into home care and free up GP / hospital clinic resources

    Dr N Robinson

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  • I am a doctor as well a warfarin patient. I use home INR machine with 6 monthly venous INR check at hospital. I prefer switching to rivaroxaban as it reduces monitoring and also avoid INR fluctuation due to dietary habits. But my GP not yet willing to change!!

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  • Show me EBM.

    Too many conflicts of interest for my liking.

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  • Our trust lead community elderly suggests Noac if 2 inr readings below 2 or above 3 in 6 months and stop warfarin

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  • INR monitoring is done here by the haematology clinic. we put in a bid a few years ago to do local monitoring but it was deemed too expensive.
    My qof will not alter the haematology clinic so this change is useless.
    We send all AF patients to have a discussion with the cardiologists to assess which anticoagulant is appropriate for them. This reduces my stress/responsibility. If there is a problem they can always go back to ask the specialist

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  • Vinci Ho

    I think the big trend is towards NOAC whether you like it or not unless there is new evidence concerning adverse reaction. CCGs are the road blocks merely because of cost. Will be interesting to know what will happen in 6 years time( that is of course presuming general practice is still around!)

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  • Russell Thorpe

    Im with 1.02pm conflict of interest at work here. First we have the central push to diagnose AF and now this.

    IMO NOAC's with no monitoring are dangerous.

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  • I would like to be able to refer to the anticoagulant clinic for them to take the time to go through the options with the patient. We cannot do everything in the allotted ten minutes and we should not have to .

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  • I'm a pharmacist who works with GPs in a rural area with many v elderly patients. Sending a nurse out merely to take blood for INR from one patient can be a 90 minute operation in many cases repeated fortnightly. In addition many of the elderly aren't good bleeders and also are easily confused by frequent dose adjustments and having several strengths of warfarin tablets. For many of these a NOAC has been a god-send. over the six years of both hospital experience with DVT prophylaxis and community with AF etc., I have only seen one "incident" with a NOAC (non-fatal), whilst in the same period I have seen many warfarin INRs over 5 and at least half a dozen in double figures.

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  • Samuel Lewis

    Dear anonymous, 12.45

    Show your GP the NICE rivaroxaban guidance, and ask why he disregards it !!
    We offered our NVAF patients rivaroxaban, and cut our one workload in half. The HB AND A WALES AWMSG cannot overrule NICE !

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  • Samuel Lewis

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  • Dear 12:45pm
    Similar problem.
    Had to stop Warfarin as I am seldom home to be tested. Do not want to go the home testing route, so hope my GP see the light soon.
    They had an good CQC report but that means they disregard clinical insight and stricly follow rules. Unless NICE forces them to change I may have to buy my own NOAC ... as I already have to do with my bloodpressure tablets.
    But £700 per year is quite a bit.

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