Ready for change? Understanding and improving anticoagulation services An audit of local commissioning by AntiCoagulation Europe
October 2014 Support for AntiCoagulation Europe in carrying out this audit has been provided by MHP Health, whose services are paid for by Bayer HealthCare. Bayer has checked the copy for factual accuracy and compliance with the ABPI code of practice. Date of preparation: October 2014
About AntiCoagulation Europe
AntiCoagulation Europe is a leading UK charity founded in the year 2000. We work with patients, healthcare professionals, NHS trusts, Industry, governments, key opinion leaders, other charities and patient groups and a wide range of other healthcare organisations. Our Aims are:
the prevention of thrombosis the provision of information, education and support relating to all aspects of anticoagulation the promotion of patient choice and independence – supporting people to take an active part in the decisions around their treatment options and management of their condition
For more information about our current campaigns and initiatives, please visit our website at: www.anticoagulationeurope.org
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Table of contents Report of findings Foreword ...................................................................................................................................................... 3 Preface .......................................................................................................................................................... 4 Methodology ................................................................................................................................................ 5 About the conditions requiring anticoagulation therapy ............................................................................. 6 Audit findings................................................................................................................................................ 8 1.
Assessment of the local demand for and configuration of services ................................................ 9
2.
Implementation of NICE guidance.................................................................................................. 11
3.
Service quality monitoring.............................................................................................................. 13
4.
Patient experience measures ......................................................................................................... 15
5.
Anticoagulation service design/redesign ....................................................................................... 17
Conclusion .................................................................................................................................................. 19 Annex 1 – FOI requests ............................................................................................................................... 20 Annex 2 – List of CCGs which responded to the Freedom of Information requests .................................. 22 Annex 3 – List of acronyms ......................................................................................................................... 24 References – Report of findings ................................................................................................................. 25
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Foreword Anticoagulation is a personal issue for me. My wife, a sufferer of atrial fibrillation (a disease that causes an irregular heartbeat), thankfully receives anticoagulation treatment that reduces the risk of her experiencing a stroke. Treatment like this doesn’t just impact her health, it reduces my fear of what a stroke would mean for her, and for us. Up to 1.5 million people suffer from atrial fibrillation (AF), around half of whom aren’t diagnosed and don’t know they are at risk. Around 1.25 million people in the UK currently receive oral anticoagulation therapy either for this disease, as a result of being given prosthetic heart valves, or for other conditions linked to dangerous blood clots, like deep vein thrombosis (DVT) or pulmonary embolism (PE). Therefore, it is not just a personal issue for me, it is a personal issue for a great many people – almost as many as are living with cancer in England – not to mention those who love them, and in many cases provide practical care for them. Meanwhile, it is an issue that can have a significant impact on the incidence of stroke, which costs this country £2.5 billion a year. It is therefore nothing short of a national scandal that so many with AF, as an example of one area where anticoagulation is needed, are undiagnosed; that of those diagnosed, 8.5 per cent do not receive treatment for the prevention of strokes; and that 35 per cent receive aspirin despite updated guidance from the National Institute of Health and Care Excellence (NICE) specifying that this is an ineffective treatment. It is also staggering, particularly for anyone with direct experience of the challenges of adhering to warfarin as an anticoagulation treatment, that recently developed anticoagulant therapies that are easier for patients, easier for doctors and deemed cost effective are only being used in around 6 per cent of cases of atrial fibrillation treatment, compared to an expected figure of about 40 per cent, as per NICE’s recent templates. I warmly welcome this report, along with the important work being done to advance these issues by AntiCoagulation Europe and others. The pages that follow do not make for encouraging reading but there are strong examples of good practice within what appears to be an overall message of a system lacking in detailed knowledge and over-endowed with inertia. I feel confident that campaigning in this area is now at a new level and it will not allow demands for progress to die away. Anticoagulation is a personal issue, it should be a national priority, and ensuring the spread of best practice and the addressing of areas of concern revealed in this report must be an urgent action for all involved.
Barry Sheerman, Member of Parliament for Huddersfield
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Preface The outlook for people needing anticoagulation treatment has improved greatly over recent years, with improvements in diagnosis, increased flexibility in how treatment is delivered and the availability of recently developed treatments. As an organisation providing information and support to patients and their loved ones, we strive to ensure that people live well with their condition, encouraging them to engage with their treatment and be informed of their options. However, despite improvements in what can be achieved, we hear too many stories of people experiencing barriers that stand between them and the treatment they need and want. This report, based on information received from the vast majority of clinical commissioning groups (CCGs) across England, paints a detailed, and rather challenging picture suggesting that there is much more to do to ensure that those providing services locally are as engaged in this important area as we are encouraging patients to be. What we ask on behalf of patients is not “rocket science�. We make simple recommendations regarding understanding the needs at a local level, monitoring services that are provided and reviewing them to ensure that the local system is fit for delivering the best cost effective care, and fits the patient, rather than the patient having to fit the system. At AntiCoagulation Europe we are committed to education and support. As well as helping patients and their families we provide materials to support local decision makers in commissioning their services so that together we can promote independence for people requiring such treatment and achieve the best outcomes both for the individuals and for the local budgets. Faced with an increasingly ageing population, and budgets that will break under the strain of more and more strokes, local commissioners need to think differently, they need to take tough decisions, and they need to be ready for change. We hope that, reviewing the findings that follow, all involved in driving forward improvements in anticoagulation treatment will redouble their efforts, challenge themselves and those around them to do more, and will commit themselves to ensuring that more patients achieve the better outcomes that are now possible.
Eve Knight, Co-Founder and Chief Executive, AntiCoagulation Europe
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Methodology The purpose of this report is to evaluate processes for planning and assessing the effectiveness of local anticoagulation services and differences in approaches adopted by commissioners across England. This analysis provides a comprehensive picture of how commissioners are assessing and responding to unmet needs of people requiring anticoagulation therapy, and identifies a series of measures that should be considered to improve the services. To make such evaluation possible an audit was undertaken under the Freedom of Information Act 2000. A series of fourteen requests were submitted by AntiCoagulation Europe to all CCGs in January 2014. The information requested from commissioners focused on the following issues: Assessments of prevalence of AF, DVT and PE Commissioning arrangements and configuration of local anticoagulation services Data held by the CCGs on the number of people accessing anticoagulation services Understanding of the cost of anticoagulation services, including per person costs Awareness of commissioning guidance on anticoagulation services Use of the NICE commissioning and budgeting tool for anticoagulation therapy Awareness of NICE technology appraisals and steps taken to encourage implementation Awareness of the Catalogue of potential innovations The full list of questions is included as Annex 1 of this report.
Response rate In total, 176 responses were received by 19 March 2014, representing a response rate of 83 per cent. We are grateful to all the CCGs that responded, and a list of those CCGs is available in Annex 2. It should be noted that more than half of responses (51 per cent) were provided by Commissioning Support Units (CSUs), which provide administrative support to CCGs. Differences in the quality and quantity of information supplied by CCGs was observed, suggesting that questions regarding data collection arrangements and how this information is used to inform robust and evidence-based commissioning decisions. As a result of variation in the detail of responses, the information provided has been subject to analysis and interpretation in the writing of this report.
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About the conditions requiring anticoagulation therapy Long-term anticoagulation therapy is needed for a range of conditions which can be identified and managed in a variety of health and care settings as set out in guidance from the National Institute for Health and Care Excellence (NICE)1. The planning and commissioning of care for people requiring longterm anticoagulation therapy can be particularly complex. Conditions requiring long-term anticoagulation therapy notably include:
Atrial fibrillation Deep vein thrombosis Pulmonary embolism Prosthetic heart valves
Atrial fibrillation Atrial Fibrillation (AF) causes an irregular and often abnormally fast heart rate and affects up to 835,000 people in England alone, a number which is rising year on year2, 3. AF is a known risk factor for stroke, which is currently the third largest cause of death in England, and costs the NHS £2.8 billion a year4, 5. It has been estimated that 12,500 strokes are directly attributable to AF each year and that AF increases the risk of strokes by five to six times6, 7. The consequences can be devastating for patients, their families, carers and the wider NHS. For patients diagnosed with AF, anticoagulation is an effective treatment option to help reduce their risk of having a stroke, as set out in guidance from NICE8. However, the Sentinel Stroke National Audit Programme (SSNAP) recently found in August 2013 that only 36 per cent of patients with known AF admitted to hospital with a stroke are taking anticoagulants9. The Government has estimated that up to 7,100 AF-related strokes could be prevented annually if everyone with AF was appropriately managed10.
Deep vein thrombosis and pulmonary embolism Deep vein thrombosis (DVT) and pulmonary embolism (PE) sit within the broader umbrella of venous thromboembolisms (VTE), commonly called blood clots11. A DVT is a thrombus, or a blood clot, in one of the deep veins in the body12. If the clot lodges in the lung, this can lead to a potentially serious condition, PE, which is a blockage in the pulmonary arterial system13. These conditions are a major cause of disability and death in England14. In fact, one in 20 people in the UK will have a blood clot at some point in their life15. It has been estimated that as many as one in 1,000 adults could be affected by DVT in England each year, with 86.3 in 100,000 affected by PE16. Aside from the physical impact, the Health Select Committee estimated in 2005 that the total cost to the UK for the management of blood clots was approximately £640 million a year, and that the annual costs of treating venous leg ulcers, a consequence of VTE, in the UK were in the region of £400 million1718.
Prosthetic heart valves Prosthetic or artificial heart valves can be required for people with heart valve disease, which consists of abnormalities of the heart valves19. These artificial valves help to ensure appropriate blood flow to the heart, making sure that the blood cannot leak backwards and that it flows onward in the correct direction20. When people have prosthetic valves, they will need anticoagulation therapy for the rest of their lives to prevent clots forming21. Anticoagulation is indeed effective in preventing clot formation on the artificial surfaces of the valve22. 6
Summary of recommendations
1. Assessment of the local demand for and configuration of services – All CCGs should undertake a robust assessment of the local need for anticoagulation services, including evaluation of: The prevalence (estimated and diagnosed) of AF, DVT and PE, and the number of people with a prosthetic valve across all care settings in the local area The type and setting of anticoagulation services delivered locally so as to clearly map out what services are available to patients 2. Implementation of NICE guidance – CCGs should take steps to encourage the implementation of the latest NICE guidance. This should include taking account of the latest recommendations when: Developing service specifications for the procurement of anticoagulation services under the ‘Any Qualified Provider’ (AQP) model Producing local guidance for providers, ensuring that it does not duplicate analysis carried out by NICE or guide selection of therapy in a way that imposes restrictions on access to particular treatments, or undermines confidence in any particular NICE-approved treatment 3. Service quality monitoring – As part of quality monitoring requirements, all local anticoagulation service providers should be reporting to their CCG against a series of quality indicators. These indicators should be developed by clinicians in consultation with patients as well as taking account of the latest national guidance available, and should include: Minimum time in therapeutic range Percentage of unplanned hospital admissions Year on year improvement in the percentage of people in therapeutic range Number of adverse events which did not result in an unplanned admission Number of complaints received out of the number of patients treated Number of patients with DVT diagnosed and treated in primary care Number of patients on novel oral anticoagulants being managed in primary care 4. Patient experience measures – CCGs should ensure they collect information on patient experience and clinical outcomes for all the anticoagulation services they commission in the local area. As part of this, they should take steps to encourage providers to gather feedback from clinicians and patient support groups on their services, and to share this feedback with commissioners through their quality monitoring requirements. Questions to include could ask: How long it took to access anticoagulation therapy after suspecting there was a problem Whether the patient understood the explanation of what was wrong Whether the need for anticoagulation therapy was explained to the patient Whether the patient was supported in making an informed decision about their treatment, eg through the use of the new NICE patient decision aid resource for people with AF23 Whether the patient was given a choice of different types of treatment and was involved in decisions about treatment
5. Anticoagulation service design/redesign – CCGs should ensure they take account of the views of patients and predicted trends in uptake of innovations when reviewing the need to redesign local anticoagulation services. To this end, they should ensure that they involve patients and patient support groups from the very beginning of the design/redesign of services 7
Audit findings
have contraindications, are not able to stay on the treatment, or are not offered it32.
Context
Recently developed treatments have been recommended by NICE for a number of indications, including apixaban, dabigatran and rivaroxaban. These treatments, collectively referred to as non-Vitamin K antagonist oral anticoagulants (NOACs), hold the potential to improve quality of life as they do not necessitate regular coagulation monitoring, providing predictable levels of anticoagulation on a fixed dose.
There are around 1.25 million people in the UK who currently receive long-term anticoagulation therapy to prevent them from developing dangerous blood clots24. The therapy can be prescribed for a number of conditions or circumstances, including people suffering from atrial fibrillation (AF), deep vein thrombosis (DVT) and pulmonary embolism (PE), and people with prosthetic heart valves. This patient population is expected to grow as the UK population ages25, 26. This growing need, set against a context of increasing wider pressures on the NHS, requires the design of services that not only achieve high quality outcomes for patients, but also deliver value for money for the NHS. However, recent figures indicate that the performance of some anticoagulation services is sub-optimal27. For example, the National Institute for Health and Care Excellence (NICE) recently found that around 29 per cent of people with AF in England are not receiving any treatment, and over 22 per cent are being treated with aspirin28. Given the recommendation in the updated NICE guideline to avoid prescribing aspirin in stroke prevention for people with AF, the demand for anticoagulation therapy is set to increase29, 30. Traditional models of care have relied on the prescription of warfarin which, when appropriately used, can be an effective means to prevent blood clots and strokes. However, the treatment has a number of disadvantages, particularly in terms of patient experience, as it requires regular monitoring of coagulation parameters (often requiring frequent visits to clinics), adjustments to dosage and dietary modifications31. Moreover, NICE has found that 46 per cent of patients with AF who should be on warfarin are not receiving it, because they
Recently developed options for anticoagulation, and the rising demand for treatment, offer an opportunity to look at the most appropriate service design to achieve good experience and improved outcomes for patients while achieving efficiencies for the NHS. In recognition of this, NICE recently updated its commissioning guide on anticoagulation services to reflect its guidance on NOACs, and outline the resulting opportunities for service redesign33. AntiCoagulation Europe also published a Commissioning Resource Pack which was shared with all clinical commissioning groups (CCGs) as they took on responsibility for the commissioning of anticoagulation services34. Until now there has been no published comprehensive audit of the extent to which commissioners are prepared for the changes brought about by innovations in anticoagulation or are using current guidance and tools. This audit report evaluates the readiness of CCGs for change in anticoagulation and explores the efforts being made to understand the local need and potential requirement for service reconfiguration. It reveals key findings on local practice and makes recommendations on:
Assessment of the local demand for and configuration of services Implementation of NICE guidance Service quality monitoring Patient experience measures
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Anticoagulation service design/redesign
1. Assessment of the local demand for and configuration of services Recommendation: All CCGs should undertake a robust assessment of the local need for anticoagulation services. This should include an evaluation of: The prevalence of AF, DVT and PE, and the number of people with a prosthetic valve across all care settings in the local area The type and setting of anticoagulation services delivered locally so as to clearly map out what services are available to patients
CCGs are responsible for designing and commissioning services based on the needs of their local population35. Understanding information about prevalence and incidence of people requiring anticoagulation and the current services being delivered to address these needs is fundamental to commissioning effective services. However, as the audit has found, there is a limited understanding among CCGs of local needs. Assessment of local prevalence A relatively low proportion of CCGs have assessed the local prevalence of AF, DVT and PE, with clear difference between AF and DVT/PE (Figure A). Nearly half (48 per cent, n=85) of the CCGs that responded to the audit reported not having assessed the prevalence of AF in their local area and 78 per cent (n=137) in DVT and 83 per cent (n=146) in PE had not assessed prevalence. Of the 72 CCGs that reported having assessed or being in the process of assessing the local prevalence of AF, a quarter (26 per cent, n=19) stated using data collected through the Quality
and Outcomes Framework (QOF) disease register. In addition to QOF data, 13 per cent (n=9) referred to data uncovered through the Guidance on Risk Prevention in Atrial Fibrillation (GRASP-AF) tool. Figure A. CCGs that have made an assessment of the local prevalence of AF, DVT and PE 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Unclear/information not provided In progress
No assessment undertaken Assessment undertaken AF
DVT
PE
The gap between assessment of AF prevalence and that of DVT and PE, as demonstrated in Figure A above, suggests that the existence of tools and incentives in the case of AF, such as GRASP-AF and the QOF register, can play an important role in helping commissioners to assess the local prevalence. There are currently no such incentives or supporting tools in place to encourage collection of data on the prevalence of DVT and PE36. The actual number of people affected by AF is likely to be higher than shown on the QOF register, as some people may not have reported symptoms to their GPs or have not yet been diagnosed. It has been estimated that as many as 700,000 people in the UK may have undiagnosed AF37. This was highlighted in the response from the CCG in Lincolnshire, which noted that there are an estimated 3,500 people with undiagnosed AF in the CCG area38. North Manchester CCG has taken extra steps to assess the local need relating to AF, noting that it “has run searches on practice systems to identify those who appear to have AF but are not optimally managed and not on the (QOF) AF
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register, and worked with practices to optimally manage patients” 39. As efforts are being made to increase the diagnosis of AF, it should be noted that this will undoubtedly have an impact on demand for local anticoagulation services. Based on an understanding of prevalence, CCGs should work closely with clinicians, local stakeholders and patients to understand how to design services that best meet the local needs now, and as they develop, as set out in the NICE commissioning guide40. Interrogation of modelled or estimated prevalence against the number diagnosed should be carried out to ensure there is not an undetected and therefore untreated population41. CCGs should regularly interrogate modelled prevalence levels against reported levels to enable understanding like reported by Hull CCG which noted that “recorded prevalence [for AF] was 3,652 against a modelled prevalence of 3,528”42. As the prevalence of AF, DVT and PE increases with age 43, prevalence estimates will depend on local demographics. Local assessments, rather than national averages, are therefore essential to understanding the local need and ensuring appropriate service provision. Local configuration of services The vast majority of CCGs (n=173; 98 per cent) provided information on the anticoagulation service they commission, including whether it is in primary or secondary care:
62 per cent (n=108) have services in place in both primary and secondary care settings 21 per cent (n=36) have services in secondary care settings only 16 per cent (n=27) commission services in primary care exclusively
Figure B. Care setting where anticoagulation services currently sit 1%
Both
21% 16%
Primary care
62%
Secondary care Unclear/information not provided
32 CCGs also said that they commissioned anticoagulation services in the community, mostly anticoagulation monitoring clinics offered by the secondary care provider. The findings highlight that there is not a single adopted approach to anticoagulation service delivery, which means that the patient pathway may vary significantly from one CCG area to another. There is indeed an array of possibilities when it comes to the configuration of anticoagulation services for people with AF, DVT and PE, including hospital outpatient models, primary care and community-based models, as well as patient self-testing and management. This could be welcomed as a means to allow commissioners to design services that address the specific needs of local populations. However, where there is a mixed model of care locally, it is particularly important to ensure an integrated, patient-centric pathway so that patients are appropriately followed up – particularly between secondary and primary care settings. As NICE’s commissioning guide sets out: “Commissioners may wish to consider commissioning anticoagulation services in several different ways, and mixed models of provision may be appropriate across a local health economy.” 44
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A recent report by the General Medical Council (GMC) showed that in some cases GPs did not even know which of their patients were on anticoagulation, and that some patients had not been monitored for over two years45. There are indeed numerous cases of patients that have been affected by the disconnect between primary and secondary care, where patients are prescribed one medicine when in hospital, but find their prescription changed when they see their GP46. In some cases, patients can be left without treatment for periods of time, or resort to buying their treatment privately47. NICE’s commissioning guide recognises the importance of integrating care for people who require long-term anticoagulation therapy and recommends that the anticoagulation care pathway should be “person-centred and integrated with other elements of care”48.
2. Implementation of NICE guidance Recommendation: CCGs should take steps to encourage the implementation of the latest NICE guidance. This should include taking account of the latest recommendations when: Developing service specifications for the procurement of anticoagulation services under the ‘Any Qualified Provider’ (AQP) model Producing local guidance for providers, ensuring that it does not duplicate analysis carried out by NICE or guide selection of therapy in a way that imposes restrictions on access to particular treatments, or undermines confidence in any particular NICE-approved treatment
Local commissioners have an important role to play in ensuring that national guidance is implemented by service providers. In particular, it is a statutory obligation for commissioners to make funding for treatments available within three months of being recommended by a NICE technology appraisal49. However, CCGs retain flexibility in how they make this happen and what models to use50.
Case study – Delay in diagnosis Margaret waited seven months from first going to her GP before being diagnosed with AF. She was not involved in choices about her treatment and feels that she was forced into accepting what the hospital wanted regardless of whether it suited her lifestyle.
Findings from the audit suggest that a number of CCGs have local guidance or protocols in place that depart from NICE guidance for the treatment of nonvalvular AF, DVT and PE. The analysis found that some guidelines or protocols, while referring to the introduction of NOACs, recommended initiation of these treatments only after trying warfarin, despite NICE technology appraisals making no restriction to the place of NOACs in the treatment algorithm.
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In response to the audit, 54 CCGs provided information on guidance in place to support anticoagulation prescribing decisions:
Six per cent (n=3) were guidelines issued by the provider rather than the CCG 83 per cent (n=45) applied across the CCG area, issued by the CCG itself, the former stroke network or the local prescribing area team 78 per cent (n=42) either referred to warfarin as the preferred option, or did not refer to NOACs as a treatment option for people with nonvalvular AF, DVT or PE, despite recommendations from NICE guidance
Figure C. Proportion of local guidelines favouring warfarin over NOACs
Reported local guideline favouring warfarin over NOACs
9% 13%
Reported local guideline not favouring warfarin over NOACs 78% Unclear/information not provided
Lack of alignment with NICE guidance may be due to the fact that some local guidelines were several years old. However, even within more recent guidelines, while reference was made to the need to follow NICE guidance, a number of CCGs appeared to impose restrictions on the use of NOACs, despite NICE recommendations. In the case of AF some maintained that warfarin should remain the first-line option. One CCG shared information stating that “well controlled Warfarin is a well-established, safe and effective treatment option for the prevention of stroke in atrial fibrillation and should be considered the treatment of choice for all current and new patients. It remains the first line treatment” 51. Such advice is contrary
to NICE guidance, including the updated 2014 NICE clinical guideline on AF (CG 180), which stipulates that NOACs are recommended for use in nonvalvular atrial fibrillation as equal first line with warfarin52. One local guideline for the prevention of AFrelated strokes recommended prescribing aspirin for patients with low to medium stroke/thromboembolic risk53. While this was common practice in the past, evidence has shown that antiplatelets such as aspirin reduce the risk of AF-related stroke by only 19 per cent versus 64 per cent for oral anticoagulants such as warfarin54. This has been reflected in the updated 2014 NICE clinical guideline on AF55. The updated NICE guideline on AF recommends that clinicians “do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation” 56. In recognition of current challenges in access to NOACs and of “the myth about the superior safety of aspirin”, the NICE Implementation Collaborative (NIC) recently published a consensus statement on the use of NOACs to reduce stroke risk in nonvalvular AF57. The statement outlines the barriers to using NOACs, and how these might be overcome to facilitate appropriate use. It has been endorsed by a range of healthcare professional and patient group representatives including the Royal College of Physicians, Royal College of General Practitioners and Royal College of Nursing58. By creating restrictions or failing to provide upto-date advice, CCGs may exacerbate regional variations in prescribing practice and access to treatments, precisely the kind of variation that NICE appraisals are designed to remove. Such strong consensus is, therefore, an important and welcome step.
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Case study – Local protocols and gaps between secondary and primary care John was diagnosed with AF and was prescribed a NOAC by his hospital consultant. However, when he went to see his GP for a repeat prescription he was told that their protocols did not allow them to prescribe his anticoagulant and that he would either need to get his consultant to regularly prescribe the drug or go onto warfarin. He is now having to pay privately in order to obtain the anticoagulant of his choice.
3. Service quality monitoring Recommendation: As part of quality monitoring requirements, all local anticoagulation service providers should be reporting to their CCG against a series of quality indicators. These indicators should be developed by clinicians in consultation with patients as well as taking account of the latest national guidance, and should include: Minimum time in therapeutic range Percentage of unplanned hospital admissions Year on year improvement in the percentage of people in therapeutic range Number of adverse events which did not result in an unplanned admission Number of complaints received out of the number of patients treated Number of patients with DVT diagnosed and treated in primary care Number of patients on novel oral anticoagulants being managed in primary care
CCGs however still appear not to be doing enough to ensure that services they commission are fit for purpose and constitute the most effective use of NHS resources. Monitoring demand for and access to services Commissioners have a limited understanding of the demand for and costs of the services they commission. Of the CCGs providing information:
43 per cent (n=74) have not assessed the number of people using these services 15 per cent (n=26) provided only partial information on this topic, covering only one type of anticoagulation service or care setting in their local area, or one condition Only 33 per cent (n=57) reported having undertaken an assessment of the number of people using services in their area Six per cent (n=10) were in the process of conducting such an assessment
Figure D. CCGs that have assessed the number of people using anticoagulation services 3% 15%
Particularly at a time of significant budgetary pressures, it is important that services are reviewed regularly to ensure resources are put to optimum use and patients achieve the best outcomes and experiences of treatment. Many
6%
43%
Assessment undertaken
33%
No assessment undertaken Assessment in progress Partial response Unclear/information not provided
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A number of CCGs reported recording the number of patients accessing local anticoagulation services through Secondary Uses Service (SUS) data held by the Health and Social Care Information Centre (HSCIC), or via commissioning support unit (CSU) contracting. NHS Brent CCG, which only commissions anticoagulation services in secondary care, noted that it “records, on a monthly basis the number of patients using the secondary care service using SUS data”59. Most CCGs reported that they haven’t assessed the costs of the anticoagulation services they commission, which questions their ability to monitor the cost-effectiveness of their services. Only a third (34 per cent, n=58) of CCGs were able to confirm that they have assessed the total costs of those local services and only 28 per cent (n=48) have taken steps to calculate the costs per patient. Figure E. CCGs that have made an assessment of the total costs and per patient costs of their local anticoagulation services
services is essential as it supports commissioners in planning and managing their budgets effectively. The cost assessment, whether total or per patient, should take account of all costs associated with the provision of anticoagulation therapy, and contain as many breakdowns as possible for a greater understanding of potential for savings across the care pathway60. Assessing the quality of services Beyond the financial monitoring of the services commissioned, the audit sought to establish the extent to which commissioners are taking steps to assess the quality of their local anticoagulation services. The findings suggest that a large proportion of CCGs that commission an anticoagulation service have not yet conducted such assessments (Figure F):
60% 50% 40%
30% 20%
10% 0% Assessment of total costs
Assessment of costs per patient
Assessment undertaken No assessment undertaken Assessment in progress Partial response Unclear/information not provided
Only 41 (24 per cent) out of the 173 CCGs that responded on this point reported having assessed both the total costs and the costs per patients of the services. Assessing the full extent of the resources required to deliver
41 per cent (n=71) reported not having assessed the quality of their services Six per cent (n=11) provided a partial response – eg where quality had been assessed for one condition but not all 24 CCGs reported having only monitored the quality of their primary care or community service whereas they also commission an anticoagulation service in secondary care Five per cent (n=9) also reported being in the process of conducting such assessment
Figure F. CCGs that have assessed the quality of their anticoagulation services 60%
40% 20% 0% Data collection undertaken No data collection undertaken Data collection in progress Partial response Unclear/information not provided
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These findings suggest that there are variations among CCGs in the extent and the scope of monitoring quality. There should be a greater focus on quality reporting on clinical and patient outcomes and there should therefore be requirements for all local anticoagulation service providers to report to their CCG against a series of clinical outcomes quality indicators. NHS South Worcestershire CCG and NHS Wyre Forest CCG indicated that an annual audit of the primary care service has been undertaken to look at the following quality measures61, 62 Initiation of treatment: -
-
-
Record keeping, including recording all complications of treatment, bleeding and hospital referrals or admissions Clinical audit, including untoward incidents and the success of the practice in establishing an INR within the planned range within 3 months of initiating treatment Details of training and education of staff providing services
Patient monitoring/ Review of treatment, reflecting nationally recommended safety indicators for patients on anticoagulants including: -
Number of patients on register Number of bleeding episodes requiring hospital admission Deaths caused by anticoagulants Untoward incidents Numbers of patients whose INRs are subtherapeutic
4. Patient experience measures
Recommendation: CCGs should ensure they collect information on patient experience and clinical outcomes for all the anticoagulation services they commission in the local area. As part of this, they should take steps to encourage providers to gather feedback from clinicians and patient support groups on their services, and to share this feedback with commissioners through their quality monitoring requirements. Questions to include could ask: How long it took to access anticoagulation therapy after suspecting there was a problem Whether the patient understood the explanation of what was wrong Whether the need for anticoagulation therapy was explained to the patient Whether the patient was supported in making an informed decision about their treatment, eg through the use of the new NICE patient decision aid resource for people with AF Whether the patient was given a choice of different types of treatment and was involved in decisions about treatment
The provision of effective anticoagulation treatment can significantly improve the outcomes of patients at risk of stroke and blood clots. However, achieving good management presents challenges for many patients and the impact on quality of life can be significant. In a reformed NHS, with great emphasis on patientcentred or ‘whole-person’ care, it is particularly timely for commissioners to take steps to understand patients’ experience of services so
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that their overall health outcomes and quality of life can be improved.
CCGs shared details of their CQUIN indicator measuring patient experience, as follows63:
However, a considerable proportion of CCGs reported not having collected data on the experience of patients who attend their local anticoagulation services (Figure G):
“To devise and implement a method of capturing patient views about the service he/she has received in real time. Subsequently implement changes in response to results and measure improvement in patient experience.
Two thirds (67 per cent, n=116) had not taken steps to assess patient experience Five per cent (n=9) indicated that they were in the process of collating this information A fifth (21 per cent, n=36) reported collecting data on the experience of patients but, of these, 16 CCGs were found to be only collecting data from primary care/community services despite also commissioning services in secondary care
Figure G. CCGs that have collected data on the experience of patients accessing their local anticoagulation services
Data collection undertaken
5% 7% 21%
No data collection undertaken
67%
Data collection in progress Unclear/information not provided
Among the CCGs which did report having collected patient experience data, a number referred to a local Commissioning for Quality and Innovation (CQUIN) scheme for AQP providers, which rewards the collection of data on patient experience. For example, NHS Newcastle West and NHS Newcastle North East
“Commissioners will not prescribe a method of collecting the views of patients but the following key areas should be included:
Pre-appointment information How well the patient felt they were dealt with on the day (environmental eg facilities, access etc.) Patient/professional relationship i.e. being fully involved in the shared decision making Waiting times Overall level of happiness (including patient information and education advice and materials, clarity on what happens next, who to contact with concerns or questions) Family and friends test Patient views on how well his/her experience is integrated across their whole patient journey.”
This process of collecting patient experience data is all the more important as there is not, at this time, a national patient experience survey for people using anticoagulation services. Despite the commitment in the Cardiovascular Disease (CVD) Outcomes Strategy that “[NHS England] will consider the scope to carry out a CVD patient experience/PROMs survey […]”64, no announcement has yet been made on the development of such a survey.
Case study – Involvement in decision-making Ken had two DVTs within a year at the age of 55. He was told he needed lifelong anticoagulation. His doctor knew that his job often took him away for weeks at a time, and so discussed all the options of treatment with him. Ken said: “I felt fully involved and all the benefits and risks were explained to me in a way that made it easy for me to understand. It made sense for me to take one of the newer anticoagulants as having regular appointments for monitoring would have been very difficult.” 16
It appears that currently few steps are being taken to listen to patients’ voices, but findings from a survey trialled by AntiCoagulation Europe, following a workshop with a coalition of interested charities, have underlined the importance of capturing patient experiences and revealed wide scope for improvements65.
5. Anticoagulation service design/redesign Recommendation: CCGs should ensure they take account of the views of patients and expected trends in uptake of innovations when reviewing the need to redesign local anticoagulation services. To this end, they should ensure that they involve patients and patient support groups from the very beginning of the design/redesign of services.
In spring 2013, AntiCoagulation Europe piloted a survey of over 270 people who use, or care for people who use, anticoagulation services. It found that66:
52 per cent of respondents reported that they have some concerns about managing their anticoagulation therapy
Only 10 per cent were offered a written assessment or care plan
Only 25 per cent of respondents were completely happy with the overall level of information they were given when they first started anticoagulation therapy
75 per cent of respondents said that when their anticoagulation was discussed they were not made aware of the different options of anticoagulation available to them
56 per cent would have liked to be more involved in decisions about their treatment
Understanding patients’ experiences is essential to improving services and outcomes. This will help to ensure that patients receive effective anticoagulation treatment that significantly improves both the length and the quality of their lives.
The publication of Innovation, health and wealth in 2011 committed the NHS to embracing innovation in order for the health system to provide world class, high quality care, in times of increased demand and financial constraint67. As part of this agenda, NHS England published a Catalogue of Potential Innovations to identify innovations which could transform patient care while supporting the NHS to deliver care more efficiently, which included68:
All NICE-recommended NOACs for stroke prevention for people with AF (apixaban, dabigatran and rivaroxaban) One NICE-recommended NOAC for the treatment of DVT and PE (rivaroxaban)
The availability of NOACs has the potential to bring significant changes to treatment pathways due to their reduced requirement for monitoring and intervention. They also provide commissioners with an opportunity to consider the most appropriate service design to achieve good outcomes for patients while achieving efficiencies for the NHS. This has been recognised by NICE in its recently updated commissioning guide on relevant services, which takes into account its own guidance on NOACs and outlines the opportunities for service redesign in light of 17
their introduction69. AntiCoagulation Europe also published a Commissioning Resource Pack in January 2013 which was recently disseminated to all CCGs70. Improving treatment for people requiring anticoagulation therapy has, rightly, been recognised as an area where the NHS should embrace innovation to improve outcomes for patients and deliver care more effectively. However, findings from this audit suggest that relatively few CCGs have considered service redesign linked to introduction of NOACs (Figure H). 50 per cent (n=87) have not made an assessment of the need to reconfigure services in light of recent treatment developments and only a fifth (19 per cent, n=32) have carried out such an assessment. Figure H. CCGs that have made an assessment of the need to reconfigure anticoagulation services 4%
Assessment undertaken 19% No assessment undertaken
27%
50%
Assessment in progress Unclear/information not provided
An analysis of the rationales provided for choosing not to conduct an assessment of the need to redesign services revealed that some CCGs have only adopted a reactive approach to NOAC uptake, and are not planning proactively to encourage the diffusion of innovative treatments. For example, two CCGs claimed that, given that the uptake of NOACs was still low in the local area, there was no need for a reconfiguration of services71, 72. Another CCG explained that they would not make an assessment of the need to reconfigure its services until NOACs are more established73.
A few CCGs suggested that they had already benefited locally from the use of NOACs and, given that they had updated their pathways to take account of NOACs, they did not plan to consider a potential redesign of their services. NHS North, East, West Devon CCG said that “the new developments in treatment have been added as options to treatment plans and pathways so that currently [they] have services that support new developments and traditional approaches”74. It is worth noting, however, that 27 per cent of CCGs (n=47) were reviewing, or planning to review their local anticoagulation services to take account of the introduction of NOACs. NHS Gloucestershire CCG reported, for example, that it has been reviewing the current local pathway for the treatment of DVT and is now proposing a new approach to offer both NOACs and more conventional treatments75. “Gloucestershire CCG has reviewed the local care pathways in the treatment of DVT prompted by the availability of new oral anticoagulants and associated NICE guidance. This review process is still underway. The availability and possible advantages and disadvantages of the new oral anticoagulants have been an important part of the assessment. The CCG is proposing a new community pathway for adult patients with suspected DVT with the option for clinicians to use either the NOACs or more conventional treatment.” 76 When it comes to actually redesigning the services in light of the introduction of NOACs, 71 per cent (n=122) are not planning to reconfigure their services. Only 16 per cent (n=28) have plans to reconfigure services to take account of treatment developments and eight per cent (n=13) are currently in the process of determining whether a reconfiguration will need to take place.
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However, given the increasing number of patients requiring long-term anticoagulation therapy, CCGs may be further pushed to consider a reconfiguration of services in the long term. Furthermore, with more AF patients potentially being switched from aspirin to anticoagulation, as recommended in the updated NICE guideline77, it is likely that pressures on services will increase, thereby pressing the need for service review and reconfiguration. Chiltern CCG recognised in its response that current pressures on local services may require service redesign, noting it had “assessed the need to reconfigure anticoagulation services, however this is mainly due to pressures in the system�78. As CCGs consider the design or redesign of local services, it is particularly important that they take account of latest treatment developments, especially as these affect the care pathway for patients. As part of this, commissioners will need to ensure that they involve patients and patient support groups from the very beginning of the process.
As the report shows, simple steps can be taken in terms of understanding needs at a local level, monitoring services that are provided, and reviewing them to ensure that the local system is fit for purpose. NICE and AntiCoagulation Europe have also developed commissioning support guides, which summarise some of the key actions that can be taken locally to meet the challenge of growing needs in anticoagulation therapy. The introduction of recently developed technologies, such as NOACs in the field of anticoagulation, represent an unique opportunity for commissioners to reconsider the way anticoagulation services are delivered locally, notably by improving patients’ quality of life and delivering efficiencies that support other parts of the local health and care system. Those who are not ready for change should take these findings as a clear and resounding wake up call.
Conclusion This report, based on information received from most CCGs in England, provides a detailed and rather challenging picture of the commissioning of anticoagulation services in the reformed NHS. Although some areas show promise in the diffusion of innovation, and the delivery of services that fit the needs of patients, there is still much to do to ensure that CCGs evaluate and optimise services so as to improve patient outcomes and make the best use of NHS resources. There is great variation in the configuration and delivery of anticoagulation services across the country, and evidence suggests that some CCGs are not adequately implementing NICE guidance for the treatment of AF, DVT and PE, exacerbating variations in access to treatment.
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Annex 1 – FOI requests 1. Please confirm or deny whether your CCG has made an assessment of prevalence of i) atrial fibrillation, ii) deep vein thrombosis and iii) pulmonary embolisms in your area a. If confirmed, please provide details of the assessment
2. Please confirm or deny whether your CCG commissions an anticoagulation service a. If confirmed, please provide details of the commissioning arrangements, including whether it is through i) block contract or ii) payment by results b. If confirmed, is your service located in i) primary ii) secondary care iii) in both primary and secondary care
3. Please confirm or deny whether your CCG commissions an anticoagulation service under the Any Qualified Provider model a. If confirmed, please provide details of the commissioning arrangements
4. Please confirm or deny whether your CCG has made an assessment of the number of people using anticoagulation services in your area a. If confirmed, please provide details of the assessment
5. Please confirm or deny whether your CCG has made an assessment of i) the total costs ii) the per patient costs of anticoagulation services in your area a. If confirmed, please provide details of the assessments
6. Please confirm or deny whether the CCG has an agreement in place for enhanced service delivery of anticoagulation services a. If confirmed, please provide details of the enhanced service agreement
7. Please confirm or deny whether your CCG has a protocol for i) nonvalvular atrial fibrillation ii) deep vein thrombosis iii) pulmonary embolism a. If confirmed, please provide the protocols
8. Please confirm or deny whether your CCG collects data on the experience of patients using anticoagulation services a. If confirmed, please provide details
9. Please confirm or deny whether your CCG collects data on the quality of anticoagulation services in your area a. If confirmed, please provide details of the quality measures that you use 20
10. Please confirm or deny whether your CCG has completed the National Institute for Health and Care Excellence (NICE) commissioning and budgeting tool for anticoagulation services a. If confirmed, please provide details 11. Please confirm or deny whether your CCG has made an assessment of NHS England’s Catalogue of potential innovations a. If confirmed, please provide details including those innovations which are being adopted in your area 12. Please confirm or deny whether your CCG has made an assessment of the innovations i) ‘New oral anti-coagulants’ and ii) ‘Treatment of DVT and PE’ in NHS England’s Catalogue of potential innovations a. If confirmed, please provide details including how those innovations are being adopted in your area 13. Please confirm or deny whether your CCG has made an assessment of the need to reconfigure anticoagulation services in the light of developments in treatment a. If confirmed, please provide details of that assessment 14. Please confirm or deny whether your CCG has plans to reconfigure anticoagulation services in the light of developments in treatment a. If confirmed, please provide details of those plans
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Annex 2 – List of CCGs which responded to the Freedom of Information requests NHS Airedale, Wharfedale and Craven CCG NHS Ashford CCG NHS Aylesbury Vale CCG NHS Barking and Dagenham CCG NHS Barnet CCG NHS Bath and North East Somerset CCG NHS Bedfordshire CCG NHS Bexley CCG NHS Birmingham CrossCity CCG NHS Birmingham South and Central CCG NHS Blackburn with Darwen CCG NHS Blackpool CCG NHS Bolton CCG NHS Bradford City CCG NHS Bradford Districts CCG NHS Brent CCG NHS Brighton and Hove CCG NHS Bromley CCG NHS Calderdale CCG NHS Cambridgeshire and Peterborough CCG NHS Camden CCG NHS Cannock Chase CCG NHS Canterbury and Coastal CCG NHS Castle Point and Rochford CCG NHS Central London (Westminster) CCG NHS Central Manchester CCG NHS Chiltern CCG NHS Coastal West Sussex CCG NHS Corby CCG NHS Coventry and Rugby CCG NHS Crawley CCG NHS Croydon CCG NHS Cumbria CCG NHS Darlington CCG NHS Dartford, Gravesham and Swanley CCG NHS Doncaster CCG NHS Dorset CCG NHS Dudley CCG NHS Durham Dales, Easington and Sedgefield CCG NHS Ealing CCG NHS East and North Hertfordshire CCG NHS East Leicestershire and Rutland CCG NHS East Riding of Yorkshire CCG NHS East Staffordshire CCG NHS East Surrey CCG NHS Eastbourne, Hailsham and Seaford CCG
NHS Eastern Cheshire CCG NHS Enfield CCG NHS Erewash CCG NHS Fareham and Gosport CCG NHS Fylde and Wyre CCG NHS Gateshead CCG NHS Gloucestershire CCG NHS Greater Huddersfield CCG NHS Greater Preston CCG NHS Greenwich CCG NHS Guildford and Waverley CCG NHS Halton CCG NHS Hambleton, Richmondshire and Whitby CCG NHS Hammersmith and Fulham CCG NHS Hardwick CCG NHS Haringey CCG NHS Harrow CCG NHS Hartlepool and Stockton-on-Tees CCG NHS Hastings and Rother CCG NHS Havering CCG NHS Herefordshire CCG NHS Herts Valleys CCG NHS Heywood, Middleton and Rochdale CCG NHS High Weald Lewes Havens CCG NHS Hillingdon CCG NHS Horsham and Mid Sussex CCG NHS Hounslow CCG NHS Hull CCG NHS Ipswich and East Suffolk CCG NHS Islington CCG NHS Kernow CCG NHS Kingston CCG NHS Knowsley CCG NHS Lancashire North CCG NHS Leeds North CCG NHS Leeds South and East CCG NHS Leeds West CCG NHS Leicester City CCG NHS Lewisham CCG NHS Lincolnshire East CCG NHS Lincolnshire West CCG NHS Liverpool CCG NHS Luton CCG NHS Mansfield and Ashfield CCG NHS Medway CCG NHS Merton CCG 22
NHS Mid Essex CCG NHS Milton Keynes CCG NHS Nene CCG NHS Newark and Sherwood CCG NHS Newcastle North and East CCG NHS Newcastle West CCG NHS Newham CCG NHS North Derbyshire CCG NHS North Durham CCG NHS North East Essex CCG NHS North East Lincolnshire CCG NHS North Hampshire CCG NHS North Kirklees CCG NHS North Lincolnshire CCG NHS North Manchester CCG NHS North Norfolk CCG NHS North Somerset CCG NHS North Staffordshire CCG NHS North Tyneside CCG NHS North West Surrey CCG NHS North, East, West Devon CCG NHS Northumberland CCG NHS Norwich CCG NHS Nottingham City CCG NHS Nottingham North and East CCG NHS Nottingham West CCG NHS Oldham CCG NHS Oxfordshire CCG NHS Redbridge CCG NHS Redditch and Bromsgrove CCG NHS Richmond CCG NHS Rotherham CCG NHS Rushcliffe CCG NHS Salford CCG NHS Sandwell and West Birmingham CCG NHS Scarborough and Ryedale CCG NHS Sheffield CCG NHS Shropshire CCG NHS Solihull CCG NHS South Cheshire CCG NHS South Devon and Torbay CCG NHS South East Staffs and Seisdon Peninsula CCG
NHS South Eastern Hampshire CCG NHS South Kent Coast CCG NHS South Lincolnshire CCG NHS South Manchester CCG NHS South Norfolk CCG NHS South Sefton CCG NHS South Tees CCG NHS South Tyneside CCG NHS South Warwickshire CCG NHS South Worcestershire CCG NHS Southend CCG NHS Southern Derbyshire CCG NHS Southwark CCG NHS Stafford and Surrounds CCG NHS Stockport CCG NHS Stoke on Trent CCG NHS Sunderland CCG NHS Sutton CCG NHS Swale CCG NHS Telford and Wrekin CCG NHS Thanet CCG NHS Tower Hamlets CCG NHS Trafford CCG NHS Vale Royal CCG NHS Wakefield CCG NHS Walsall CCG NHS Waltham Forest CCG NHS Wandsworth CCG NHS Warrington CCG NHS Warwickshire North CCG NHS West Cheshire CCG NHS West Essex CCG NHS West Kent CCG NHS West Lancashire CCG NHS West London (Kensington and Chelsea, Queen's Park and Paddington) CCG NHS West Norfolk CCG NHS West Suffolk CCG NHS Wigan Borough CCG NHS Wiltshire CCG NHS Wirral CCG NHS Wolverhampton CCG NHS Wyre Forest CCG
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Annex 3 – List of acronyms AF
Atrial fibrillation
AQP
Any qualified provider
CAB
Commissioning and budgeting
CCG
Clinical commissioning group
CQUIN
Commissioning for Quality and Innovation
CSU
Commissioning support unit
CVD
Cardiovascular disease
DVT
Deep vein thrombosis
GMC
General Medical Council
GP
General practitioner
GRASP-AF
Guidance on Risk Prevention in Atrial Fibrillation
HSCIC
Health and Social Care Information Centre
INR
International normalised ratio
JHWS
Joint health and wellbeing strategy
JSNA
Joint strategic needs assessment
LES
Locally enhanced service
NHS
National Health Service
NHS IQ
NHS Improving Quality
NIC
NICE Implementation Collaborative
NICE
National Institute for Health and Care Excellence
NOAC
Non-Vitamin K antagonist oral anticoagulant
NPSA
National Patient Safety Association
PbR
Payment by Results
PCT
Primary care trust
PE
Pulmonary embolism
PROMs
Patient reported outcome measures
QOF
Quality and Outcomes Framework
SSNAP
Sentinel Stroke National Audit Programme
SUS
Secondary Uses Service
VTE
Venous thromboembolism
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References – Report of findings 1
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National Institute for Health and Care Excellence, Costing Report: atrial fibrillation - Implementing the NICE guideline on atrial fibrillation (CG180), June 2014. Available at: http://www.nice.org.uk/guidance/cg180/resources/cg180-atrial-fibrillation-update-costing-report2 29 National Institute for Health and Care Excellence, Costing Report: atrial fibrillation - Implementing the NICE guideline on atrial fibrillation (CG180), June 2014. Available at: http://www.nice.org.uk/guidance/cg180/resources/cg180-atrial-fibrillation-update-costing-report2 30 National Institute for Health and Care Excellence, Atrial fibrillation: the management of atrial fibrillation, 18 June 2014. Available at: http://www.nice.org.uk/nicemedia/live/14573/68045/68045.pdf 31 National Patient Safety Agency, Patient Safety Alert. Actions that can make anticoagulation therapy safer, 2007 32 NHS Improvement, Commissioning for Stroke Prevention in Primary Care. Accessed on 18 September 2014 via: http://www.nhsiq.nhs.uk/media/2335814/af_commissioning_guide.pdf 33 National Institute for Health and Care Excellence, Support for commissioning: anticoagulation therapy, May 2013. Accessed on 18 September 2014 via: http://www.nice.org.uk/guidance/cmg49/resources/non-guidancesupport-for-commissioning-anticoagulation-therapy-pdf 34 AntiCoagulation Europe, Commissioning effective anticoagulation services for the future: a resource pack for commissioners, November 2012 35 NHS Commissioning Board (NHS England), Commissioning fact sheet for clinical commissioning groups, August 2012. Accessed via: http://www.england.nhs.uk/wp-content/uploads/2012/09/fs-ccg-respon.pdf 36 Bayer HealthCare, From prevention to treatment: deep vein thrombosis and pulmonary embolism – Taking the pulse of NHS services, November 2013 37 Atrial Fibrillation Association and AntiCoagulation Europe, The AF Report, Atrial Fibrillation:Preventing a stroke crisis, 2011 38 NHS Lincolnshire CCG, Response to Freedom of Information audit on file 39 NHS Central Manchester CCG, Response to Freedom of Information audit on file 40 National Institute for Health and Care Excellence, Support for commissioning: anticoagulation therapy, May 2013. Accessed on 18 September 2014 via: http://www.nice.org.uk/guidance/cmg49/resources/non-guidancesupport-for-commissioning-anticoagulation-therapy-pdf 41 AntiCoagulation Europe, Commissioning effective anticoagulation services for the future: a resource pack for commissioners, November 2012 42 NHS Hull CCG, Response to Freedom of Information audit on file 43 Stewart S, et al. Heart, 2001; 86(5):516-21 44 National Institute for Health and Care Excellence, Support for commissioning: anticoagulation therapy, May 2013. Available at: http://publications.nice.org.uk/support-for-commissioning-anticoagulation-therapy-cmg49/ 45 GMC, Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study, May 2012 46 Bayer HealthCare, From prevention to treatment: deep vein thrombosis and pulmonary embolism – Taking the pulse of NHS services, November 2013 47 Bayer HealthCare, From prevention to treatment: deep vein thrombosis and pulmonary embolism – Taking the pulse of NHS services, November 2013 48 National Institute for Health and Care Excellence, Support for commissioning: anticoagulation therapy, May 2013. Available at: http://publications.nice.org.uk/support-for-commissioning-anticoagulation-therapy-cmg49/ 49 NICE Implementation Collaborative, Consensus – Supporting local implementation of NICE guidance on use of the novel (non-vitamin K antagonist) oral anticoagulants in non-valvular atrial fibrillation, June 2014 50 NICE Implementation Collaborative, Consensus – Supporting local implementation of NICE guidance on use of the novel (non-vitamin K antagonist) oral anticoagulants in non-valvular atrial fibrillation, June 2014 51 West Yorkshire Cardiovascular Network, Recommendations for the Introduction of New Oral Anticoagulants, July 2012 52 National Institute for Health and Care Excellence, Atrial fibrillation: the management of atrial fibrillation, 18 June 2014. Available at: http://www.nice.org.uk/nicemedia/live/14573/68045/68045.pdf 53 NHS Sheffield CCG, Sheffield Guidelines for the Management of Atrial Fibrillation, Date unknown. 54 Hart RG, Pearce LA, Aguilar MI, ‘Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta analysis’, Ann Intern Med, 2007;146:857-67 55 National Institute for Health and Care Excellence, Atrial fibrillation: the management of atrial fibrillation, 18 June 2014. Available at: http://www.nice.org.uk/nicemedia/live/14573/68045/68045.pdf 56 National Institute for Health and Care Excellence, Atrial fibrillation: the management of 26
atrial fibrillation, 18 June 2014. Available at: http://www.nice.org.uk/nicemedia/live/14573/68045/68045.pdf 57 NICE Implementation Collaborative, Consensus – Supporting local implementation of NICE guidance on use of the novel (non-vitamin K antagonist) oral anticoagulants in non-valvular atrial fibrillation, June 2014 58 NICE Implementation Collaborative, Consensus – Supporting local implementation of NICE guidance on use of the novel (non-vitamin K antagonist) oral anticoagulants in non-valvular atrial fibrillation, June 2014 59 NHS Brent CCG, Response to Freedom of Information audit on file 60 AntiCoagulation Europe, Commissioning effective anticoagulation services for the future: A resource pack for commissioners, December 2012 61 NHS Wyre Forest CCG, Response to Freedom of Information audit on file 62 NHS South Worcestershire CCG, Response to Freedom of Information audit on file 63 NHS Newcastle West and NHS Newcastle North East CCGs, Response to Freedom of Information audit on file 64 Department of Health, Cardiovascular Disease Outcomes Strategy – Improving outcomes for people with or at risk of cardiovascular disease, March 2013 65 AntiCoagulation Europe, Patient experience of anticoagulation services: ACE survey, October 2013 66 AntiCoagulation Europe, Patient experience of anticoagulation services: ACE survey, October 2013 67 Department of Health, Innovation, health and wealth – Accelerating adoption and diffusion in the NHS, December 2011 68 NHS Commissioning Board (NHS England), Catalogue of potential innovations – Innovation, health and wealth, March 2013 69 National Institute for Health and Care Excellence, Support for commissioning: anticoagulation therapy, May 2013. Available at: http://publications.nice.org.uk/support-for-commissioning-anticoagulation-therapy-cmg49/ 70 AntiCoagulation Europe, Commissioning effective anticoagulation services for the future: a resource pack for commissioners, November 2012 71 NHS Luton CCG, Response to Freedom of Information audit on file 72 NHS Oxfordshire CCG, Response to Freedom of Information audit on file 73 NHS Durham Dales, Easington and Sedgefield CCG, Response to Freedom of Information audit on file 74 NHS North, East, West Devon CCG, Response to Freedom of Information audit on file 75 NHS Gloucestershire CCG, Response to Freedom of Information audit on file 76 NHS Gloucestershire CCG, Response to Freedom of Information audit on file 77 National Institute for Health and Care Excellence, Atrial fibrillation: the management of atrial fibrillation, 18 June 2014. Available at: http://www.nice.org.uk/nicemedia/live/14573/68045/68045.pdf 78 NHS Chiltern CCG, Response to Freedom of Information audit on file
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