By Lilian Anekwe
Exclusive: GPs could be set for new QOF indicators to encourage them to prescribe warfarin rather than aspirin to atrial fibrillation patients at highest risk of stroke, Pulse can reveal.
The current AF3 QOF indicator offers 12 points for ‘the percentage of patients with atrial fibrillation currently treated with anticoagulation drug therapy or an antiplatelet therapy.’
But the Department of Health, and now NICE, are keen to see GPs ramp up the prescribing of warfarin, which the DH estimates could prevent up to 10,000 strokes a year.
At a meeting in Manchester this week, the QOF indicator advisory committee heard that there is an inappropriately low use of warfarin in primary care and reluctance among some GPs to use warfarin in suitable patients.
The committee asked for indicators to be developed for piloting that will modify the AF3 indicator and introduce a structured risk assessment, using the CHADS2 or other appropriate risk scoring tool, to stratify patients with atrial fibrillation into those at high, medium or low risk of stroke.
Patients classed at low or medium risk of stroke could be prescribed aspirin or warfarin, but those at high risk should be treated with warfarin or other anticoagulants.
Dr Colin Hunter, chair of the independent advisory committee and a GP in Aberdeen, said: ‘I don’t think we can [yet] make a decision on which tool to use but there is sufficient concern about the variation in care that warrant it going forward to piloting.
‘We will pilot a number of different ways of [incentivising warfarin prescribing]. Warfarin is a much better drug than aspirin.’
GPs often cite an increased risk of falls as a reason not to prescribe warfarin, and to prescribe aspirin instead. But evidence suggests that it would take an additional 360 falls a year to justify not putting a patient on warfarin.
Pulse first revealed in March that GPs were set for stricter warfarin targets, when Professor Roger Boyle, the Department of Health’s heart tsar, told an RCGP debate on cardiovascular disease that he had submitted evidence to NICE to prompt them to consider a change to existing QOF indicators for atrial fibrillation.
He told Pulse: ‘The notion that patients forget to take their tablets, or take the wrong tablets and are falling all over the place and are bleeding just is not true. The NICE guideline needs to be updated and we also need to update the QOF.’
Warfarin Warfarin versus aspirin in AF
• The risk of stroke, arterial embolism and intracranial haemorrhage is significantly lower in AF patients on warfarin compared to aspirin
• There is no evidence higher doses of aspirin are any more effective than 75mg but are more likely to cause major haemorrhage
• Studies suggest only 46% of patients with AF aged over 75 in primary care are taking warfarin
• A target INR of 2-3 has been shown to have clear benefit with no evidence of harm compared to aspirin
To read our CPD module on anticoagulation click here.