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Using software to cut atrial fibrillation referrals

Dr John Havard on how practices are using e-consultation to initiate warfarin at a fraction of the cost of an outpatient appointment

Dr John Havard on how practices are using e-consultation to initiate warfarin at a fraction of the cost of an outpatient appointment

From a commissioning perspective, cardiology was proving a problem for my PBC consortium. One of the cardiologists at our local Ipswich Hospital Trust was on long-term absence and three were doing the work of four, resulting in long outpatient waiting lists and increased pressure on general practice. Patients were getting lost to follow-up and not being reviewed as they simply could not be accommodated.

The PBC group held meetings with the consultants and it emerged that for AF patients who might require warfarin, the referring GP had often done much of the work in terms of rate control and working up the patient – all they wanted from the cardiologist was reassurance that their judgment was correct and the patient should be started on warfarin.

41228563I realised this could be done via e-consultation and I started thinking in terms of software and online cardiology support for primary care.

The result is The Auricle – a piece of software that gives a framework for the electronic consultation process and also has the facility to attach ECGs, echos and clinic letters and so keep a clear record of the decision-making process.

Reducing stroke risk

The aim of the initial meeting with the consultants back in 2007 was to see whether there was more we could be doing in primary care to make the best use of resources and help ease the pressure on secondary care.

We looked at the six most common cardiology conditions that actually encompass 90% of cases seen in the cardiology department. We developed referral pathways for these conditions, of which AF was one.

I discovered that AF was costing 1% of the entire NHS budget – about £1bn a year, and that 16,000 AF patients were having strokes of which 12,500 were preventable. AF patients are five times more likely to have a stroke than the normal population, and their risk of a stroke can be reduced by 70% with warfarin.

It is estimated that up to 60% of patients who could benefit from warfarin are not receiving it, and when I looked into the relative risks of giving warfarin to appropriate patients it was clear to me that more could be done in general practice. Both NICE and CHADS2 official guidance is clear about the patients who need warfarin, yet GPs are reluctant to initiate it.

I feel the main reason for this is the principle ‘first, do no harm'. As GPs we are understandably worried that warfarin can cause bleeds, and if we prescribe it such a bleed could kill. If we don't prescribe warfarin and the patient has a stroke it is seen as an act of God. But we have to accept that we are between a rock and a hard place and the true balance of risk is not reflected in our prescribing.

Doing nothing, or starting aspirin, dramatically increases mortality and morbidity because the overriding factor in most cases is the risk of a stroke. I also feel that many GPs are unaware of how high the annual stroke risk is for AF patients.

I certainly was.

The software

Health Enterprise East – the enterprise and innovation arm of the East of England SHA – agreed to fund and manage the development of the software and provide hosting and support during the early stages. This totalled £30,000. The software took six months to build and has been in use since May last year.

If a new patient presents in AF, or it is an incidental finding, the software will calculate their risk of stroke using the internationally accepted CHADS2 score. The annual risk is often a sobering figure for GP and patient alike.

The e-consultation can then take place if the GP feels it is necessary, so the decision whether or not to start warfarin is a joint one between the patient, the GP and consultant. The patient can be reassured that the GP has discussed their case with a cardiologist and the cardiologist's electronic advice sheet can be filed in the notes as evidence that the decision is supported by a specialist. In practice, the more GPs use The Auricle, the less they tend to use the referral element.

A database keeps track of the patient's NHS number and age and this can be useful when patients become older than 75 and earn an extra CHADS2 point. An email is then sent to the GP with a revised score and stroke risk.

Costs

The cost of the cardiology e-consultation is negotiable but usually under £25 (non-face-to-face services tariff under the latest PbR) and the savings extend to both short-term outpatient tariffs and long-term stroke reductions.

We have used the software on newly diagnosed AF patients and retrospectively on established AF patients who were not on warfarin. In my practice our warfarin prescribing has gone up by 32%. Warfarin is a very cheap drug but the monitoring costs are significant as is the inconvenience of INR testing. We are addressing this by using fingerprick capillary blood testing with the Coaguchek XS machine, which is accurate and more simple than venous sampling.

Near-patient testing projects are more convenient but require patients to be fully informed and motivated to be tested as required. The extra costs of monitoring have to be set against both the financial and human costs of a stroke.

We are experimenting with a trained warfarin health care assistant who operates a home service for elderly patients who find travel to the surgery most challenging. Practices that use hospital INR clinics have great potential savings and the business case for near-patient testing is a no-brainer, but rural practices will not have it so easy.

The software is free to use – the only cost is the PCT payments to the consultant cardiologist, which, at about £25, compare favourably with the cost of an outpatient appointment at about £160. Anecdotally each consultant has about two e-consultations per week. Locally, we are still running the project on pilot funding but the PCT plans to put the service on its ‘any willing provider' list.

Outcomes

All practices within my consortium (which covers 55,000 patients) have access to the software and it could become available all over the country following presentations at the NHS Improvement Heart and Stroke Networks and the National AF Consensus Group.

This service is more convenient for patients as it cuts unnecessary appointments and trips to hospital. It will also save money on referrals, though my primary purpose in developing the software was to save patients from strokes rather than from secondary care.

There has been no opposition from secondary care locally – they have been very happy to have their clinics freed up. But, I feel it is important to ensure consultants are properly paid for the e-consultation.

The response from other cardiologists up and down the country has been very positive, and The Auricle won the NHS Alliance PBC prize for 2008.

It is being trialled in Bradford by a group of GPs and cardiologists supported by Bradford PCT (see box).

There is also a heart and stroke network in north-east London that wants to use The Auricle to feed ECGs and possibly community echos to Bart's Hospital for interpretation and a group of consultant psychiatrists in the Midlands plans to use the e-consultation facility to send ECGs to cardiologists prior to using potentially cardiotoxic psychiatric drugs.

Dr John Havard is a GP in Saxmundham, Suffolk, and chair of PBC consortium Commissioning Ideals Alliance. He has no financial gain from the wider use of The Auricle unless NHS Innovations East is able to license the software commercially

It's estimated up to 60% of patients who could benefit from warfarin are not receiving it It's estimated up to 60% of patients who could benefit from warfarin are not receiving it Dr John Havard Dr John Havard

Patients are reassured their care has been discussed with a cardiologist.

60-second summary How the software was adopted by four commissioning groups in Bradford alone

Dr Matthew Fay explains how his PBC group made a successful business case for The Auricle to be used I came across

The Auricle in my role as PCT clinical lead for the implementation of the CHD National Service Framework section on arrhythmias, and put together a PBC business case to use the software in all four commissioning groups in the Bradford area as ‘invest to save' for a year-long pilot. The initial costs would be funded from the PBC budget and supported with a tariff of £60 per case.

The idea was that the GP would use The Auricle in the consultation room so that the patient was appropriately risk-stratified and anti-coagulation started. The warfarin can either be supplied by the service established in secondary care, or by anticoagulation clinics working in the PBC market place. It is this latter option that works at my practice, Westcliffe Medical Practice. The GP is paid £45 to use The Auricle as a locally enhanced service on a cost per case basis with the money coming from freed-up resources.

The electronic link to the consultant helps reassure the patients that anticoagulation
is the right thing to do.

There has always been a good relationship between primary care and consultants in Bradford Hospitals so it wasn't a problem to approach them and Dr Paul Smith, a local consultant cardiologist, said he would be happy to get involved. Each of the eight pilot practices has an SLA with Bradford Teaching Hospitals Trust, which is reimbursed £15 for each e-consultation.

The PCT's concern was that the scheme should be shown to save money. The plan nearly stumbled – not because of the cost of using The Auricle in primary care compared with a hospital outpatients appointment, as the tariff price is £60 (of which £15 is the consultant's fee) compared with a referral to outpatients where the cardiology tariff would be £152, but because of the increased costs of putting more patients on warfarin than would otherwise have been treated.

It is clear from information available from the Heart Improvement Program that the
cost for the hospital component alone of an atrial fibrillation-induced stroke exceeds the cost of intervention in the number of patients who need to be appropriately anticoagulated to prevent one stroke. This is without even including the ongoing medical and social costs of treating the stroke-affected individual and the psychological and social injury inflicted on the patient and carers.



Agreeing the way forward
Dr Campbell Cowan, the national lead for arrhythmias, arranged for a group of national experts and key stakeholders to meet to discuss a consensus on how to proceed with the appropriate detection and intervention in atrial fibrillation. This
has resulted in a document, prepared with commissioners in mind, on stroke prevention and the role of atrial fibrillation. Commissioning for stroke prevention in primary care – the role of atrial fibrillation is being finalised and will be available
on the NHS Improvement website.

This demonstrates that anticoagulation costs about £383 per patient per year
(mostly monitoring costs) which means every stroke prevented costs about £9,500. But every AF stroke costs the NHS nearly £12,000 for the first year after a stroke.
The ongoing care for the patient results in even higher costs.

Together with the clinical argument this was enough to swing it, and eight practices throughout the PCT started using The Auricle in July 2008. Once this initial audit phase is completed, it is hoped to roll it out to other interested practices, which will use the template business case developed by the general managers of two of the Bradford commissioning alliances.

Once the patient has made an informed choice regarding their need for anticoagulation, they can choose to be treated at either the local hospital-based service or at one of the increasing number of locality sites that have been developed through local commissioning structures, with practices submitting a business case defining the training and the cost per case the practice can receive for this enhanced service.
There will be some immediate outcomes from the number of patients on warfarin but the long-term effects relating to morbidity and mortality will take longer to evaluate.

Dr Matthew Fay is a GP in Shipley, West Yorkshire, chair of Yorkshire Primary Care Alliance and National Primary Care lead for atrial fibrillation

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