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Warfarin care pay is a mess

Professor David Fitzmaurice, a GP in Birmingham, says GPs are up to the job of providing anticoagulant care, but remuneration needs sorting

Oral anticoagulation in the form of warfarin is one of the most effective treatments we have in the whole of medicine. Warfarin shows a remarkably consistent 68 per cent risk reduction for ischaemic stroke for patients with non-rheumatic atrial fibrillation (AF) and should be used for all patients with this condition apart from the small population with AF in the absence of underlying cardiac disease (so-called lone AF)1.

To put this into context you need to treat around 33 patients for one year to prevent one stroke (12 for secondary prevention) compared with nearer 100 patients being treated for hypertension or hyperlipidaemia.

The prevalence of AF increases with age, from 2.3 per cent in those 40 or over, to 6 per cent in those 60 or over, to 10 per cent in those over 802. Overall UK community prevalence has been estimated at 0.89 per cent2.

The prevalence is higher in men at all ages, although because of unequal death rates, the overall number of patients with AF is approximately equal between the sexes. In overall terms, about 50 per cent of patients with AF are 75 or over, and more than half of these are women. The elderly remain the most controversial with regard to oral anticoagulant therapy2.

The combination of proven efficacy and increasing prevalence has led to a huge increase in the numbers of patients receiving warfarin therapy. There are about 750,000 patients receiving warfarin in the UK with an annual increase of around 10 per cent. More than 60 per cent of patients receiving warfarin now have AF as a primary indication.

The fact that AF is essentially an end-point disease, that is resulting from underlying cardiac disease either functional or structural, means we must really start to rethink our attitudes to oral anticoagulation management.

The provision of anticoagulant care in the UK has varied considerably and in the past hospital-based outpatient clinics for anticoagulation care were standard practice. But nGMS3 includes a points system of remuneration based on the implementation of these services. The contract offers remuneration for a national enhanced service which includes the development and maintenance of a register, a call and recall system, appropriate training and audit procedures. Remuneration for the service is given for different levels of service with level 4 accruing the highest funding (see table).

But such indicative remuneration is not appropriate. For example, provision of level 4, which is based on the Birmingham model of anticoagulation management, comprising near patient INR testing, and dosing using computerised decision support software, would cost the average practice £180 per patient a year4.

The indicative remuneration for level 3 is approximately correct. If, however, we are serious about providing high-quality care, why would we want to introduce a sub-standard service? Level 3 involves substantial delay between the patient having blood taken and receiving dosing advice, and indeed introduces the possibility of error in communicating dosing advice.

Similarly, how do practices that have already established services at level 4, with contracts remunerated at substantially better rates than those suggested, continue to provide a high-quality service?

The evidence base underlying the clinical and cost-effectiveness of primary care provision of oral anticoagulation management is strong for so-called level 45. It has been demonstrated consistently that service provision through primary care using the Birmingham model is superior to standard care delivered through hospital outpatients6,7,8. This is reflected in terms of the time patients spend within therapeutic range, with primary care consistently achieving levels of over 70 per cent, and ultimately in reduction of thrombotic and haemorrhagic episodes9,10.

There is no evidence of the effectiveness of any other levels, and indeed level 3 has previously been found to be substandard with less than 50 per cent of patients achieving therapeutic INRs at any one time11. Given the relatively small marginal costs in the difference in providing level 4 services compared with level 3, and the huge potential overall savings in terms of stroke prevention, it is difficult to understand why PCTs are even considering commissioning services at less than level 4.

This is purely a cost-saving exercise and in this instance the cheapest, and clinically safer, option would be to return patients to the hospital clinic service and invest in providing more personnel and space within secondary care.

GPs have therefore been placed in an invidious position whereby attempts to improve patient care are hampered by politics, and those trying to provide the best care are penalised the most. GPs wishing to provide an anticoagulation service need to insist on providing the best care possible and negotiate with their PCTs regarding levels of remuneration. The renumeration levels set are indicative only and a case needs to be made at a local level for higher pay for providing a level 4 service than that outlined in the current contract.

If the benefits of primary care oral anticoagulation management are to be realised in terms of improved patient care and reduced stroke rates, we must grasp the nettle now, by investing in training and infrastructure so that primary care can provide high-quality health care provision for our patients throughout the 21st century.

References

1 Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation; analysis of pooled data from five randomised controlled trials. Arch Int Med 1994;154:1449-1457

2 Feinberg WM et al. Prevalence, age distribution, and gender of patients with atrial fibrillation. Arch Int Med 1995;155:469-473

3 Department of Health. 2002. General Medical Services Contract. London

4 Parry DJ et al. Anticoagulation management in primary care: a

trial-based economic evaluation.

B J Haem 2000;111:530-533

5 Fitzmaurice DA et al. Oral anticoagulation management in primary care with the use of computerised decision support and near-patient testing, randomised controlled trial. Arch Intern Med. 2000;160:2343-2348

6 DA Fitzmaurice et al. Evaluation of computerised decision support for oral anticoagulation managment based in primary care. British Journal of General Practice 1996;46:533-555

7 DA Fitzmaurice et al. Primary care anticoagulant clinic management using computerised decision support and near patient international normalised ratio (INR) testing: routine data from a practice nurse-led clinic. Family Practice 1998;15:144-146

8 DA Fitzmaurice et al. Does the Birmingham model of oral anticoagulation management in primary care work outside trial conditions? British Journal of General Practice, 2001;51:828-829

9 Parry D et al. Patient costs in anticoagulation management: a comparison of primary and secondary care. BJGP 2001;51:972-976

10 Oppenkowski TP et al. External quality assessment for warfarin dosing using computerised decision support software. J Clin Pathol 2003; 56: 605-607

11 Pell JP, Alcock J. Monitoring anticoagulant control in general practice: comparison of management in areas with and without access to hospital anticoagulant.

Br J Gen Pract 1994;44:357-358

David Fitzmaurice is a GP and professor of primary care at the University of Birmingham ­

he is a board member of the Primary Care Cardiovascular Society, for which he chairs the Anticoagulation Working Group, and he is co-author of the self-management for oral anticoagulation guidelines

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