Row looms over new atrial fibrillation QOF indicators

By Lilian Anekwe

GPs are set for new QOF indicators to increase the prescribing of warfarin to patients with atrial fibrillation after NICE advisors recommended they are added to the QOF – but a controversy looms over how these patients' stroke risk is assessed.

Pulse revealed in June last year that the independent QOF indicator advisory committee had 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.

The move came after the Department of Health and NICE became increasingly keen to see GPs ramp up the prescribing of warfarin, which the DH estimates could prevent up to 10,000 strokes a year.

Two indicators were piloted – the percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHADS2 risk stratification scoring system in the previous 15 months, and in those patients with atrial fibrillation in whom there is a record of a CHADS2 score of ?1, the percentage of patients who are receiving anticoagulants.

At a committee meeting in London yesterday, the results of the pilots in 30 practices were presented, and were overwhelmingly positive.

'Most practices found that very few extra patients needed to start warfarin and that most patients found the idea acceptable', the pilots found, while 'the workload of calculating the CHADS2 score seemed to largely fall to practice managers, although GPs were the final arbiters of whether a patient should be called into talk about starting warfarin'.

But the committee identified potential issues around the use of the CHADS2 score – and the potential that it could be superseded by a more refined version of the tool, the CHADS2-VASC tool, which produces vastly different estimates of patients' stroke risk and assigns patients different to either aspirin or warfarin.

Committee members debated that if the recommended indicators are included in the QOF, they could need to be renegotiated in future to accommodate new risk scores – and practices could be forced to rescreen patients and put even more patients on warfarin.

But despite these concerns the committee opted to recommend the piloted indicators to the GPC negotiators, and NHS Employers, to include in the QOF from 2012/13.

Dr Colin Hunter, a GP in Aberdeen and the chair of the primary care QOF indicator advisory committee, said: 'We are trying to do two things. Identify people who would not benefit from anticoagulation and encourage clinicians to give warfarin to patients who would benefit.'

'I can't think there isn't a good reason not to recommend a catch-up where everyone on the register is reviewed. It's eminently sensible to recommend that to negotiators for them to decide.'