Commissioning the AF pathway
The resources in this section are designed to support those who directly commission services that improve the care of people with AF. There are examples of services standards, outcome measures and new care models which span the AF patient pathway (Detect, Protect and Perfect).
Key to providing high quality services for people with AF is understanding your local data, including:
- Actual AF prevalence versus expected prevalence.
- The number of people with AF and at risk of stroke (CHA₂DS₂-VASc score of 2 or more).
- Of these, how many are receiving anticoagulation therapy.
- The AF stroke rate and the number/percentage of these patients who were known to have AF and a CHA₂DS₂-VASc score of 2 or more, that were not receiving anticoagulation.
The prevalence of AF varies between CCGs and may relate, in part, to the quality of clinical coding in electronic health record systems. People who are on treatment for AF, but who are not coded as such, may be at risk of not being recalled as part of the disease register protocol and this may have a direct impact on their risk of cardiovascular complications, quality of life, maintaining independence and survival. Equally, under-recording will artificially under-estimate the prevalence of patients with known AF and reduce practice income. A case study in this section from Dr Raj Thakker, a GP from Thames Valley, outlines the importance of correct clinical coding and how this can be undertaken at scale across a CCG.
Local audits of patient experience and service benchmarking can provide invaluable insights into the strengths of local service provision as well as areas for improvement. The London Clinical Stroke Network have developed a checklist for excellence in anticoagulation which can be found in the Perfect resources. The checklist summarises the component parts of an excellent anticoagulation pathway regardless of the model of care delivery (primary, community or acute based care) and commissioners should use the checklist to benchmark their current service provision and identify gaps.
There are contractual and informal system levers that exists to support commissioners in creating economic incentives to drive change at a local, organisational, team and individual levels, to bring about the large-scale change required to deliver a high-quality service for people with AF. Examples of this can be seen in AF detection in General Practice. Until recently AF detection was traditionally undertaken opportunistically with a manual pulse rhythm check during GP consultations or when a patient was admitted to hospital. Through QOF and local incentive schemes, General Practice has been financially recognised for actively increasing their register of patients with AF and ensuring patients receive anticoagulation therapy.
The availability of innovative mobile ECG devices has increased the options for AF testing in a range of healthcare and non-healthcare settings. With this comes the opportunity for different ways of working, aligned to new commissioning pathways, which may include testing for AF in high impact settings, such as community podiatry or alongside flu vaccination clinics for older people.
ECG patches may reduce the number of hospital visits required and reduce the time to diagnosis for someone requiring remote cardiac monitoring and provide a more cost-effective and better patient experience than traditional ECG Holter monitoring.
Ultimately providing additional incentive payments in an already overstretched health system will not automatically change how professionals interact with patients or ensure that patients are supported in adhering to recommendations or medication regimens.
The Commissioning for Quality and Innovation (CQUIN) framework from NHS England supports improvements in the quality of services and the creation of new, improved patterns of care. Commissioning AF checks in services that serve people with serious mental illness, as either inpatients or outpatients, is a way of reducing the unequal burden of cardiovascular disease and premature death seen in this population. This may be done locally or through national CQUINs. Such interventions are only as effective as the pathway they are part of, so commissioning plans need to ensure they capture the whole detect pathway which includes timely access and interpretation of a 12-lead ECG, something that can be challenging for those who are housebound. It is therefore important to consider how the commissioning of services benefits under-represented and harder to reach groups.
Ultimately providing additional incentive payments in an already overstretched health system will not automatically change how professionals interact with patients or ensure that patients are supported in adhering to recommendations or medication regimens. The process of valuing individuals, patients, and families as genuine partners in managing their health and health care should begin with health professional education and training.
When an AF diagnosis is confirmed, it is essential the patient has their bleeding and stroke risks assessed by a qualified healthcare professional before deciding whether to prescribe anticoagulant medication. With an increased drive to deliver such services in primary care, commissioning opportunities exist to ensure all patients are assessed, such as through virtual clinics, incentives for primary care to initiate anticoagulation, rather than secondary care and to commission the necessary pathways to support more timely and local initiation.
Once someone is prescribed an anticoagulant it is essential that the medication is being taken correctly, both to ensure their risk of stroke is being minimised and to reduce their risk of complications such as increased risk of bleeding. Ways of addressing this through commissioning may include annual medication reviews and providing patients on warfarin access to INR self-monitoring.
It is important that commissioning considers the whole AF pathway from detection, to treatment, to monitoring and ensures that it is underpinned by clearly agreed metrics that are based on delivering quality outcomes. It is important that the service is monitored against the service specification in a robust way to ensure the best service for patients, at the best cost to the healthcare system.
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