PRIMIS GRASPs the opportunity to improve stroke prevention

West Yorkshire 2009

PRIMIS has produced a new CHART query set, Guidance on Risk Assessment and Stroke Prevention in Atrial Fibrillation (GRASP AF). This query set helps practices to identify patients with Atrial Fibrillation who are at risk of stroke and highlights the benefits of warfarin.

The need for a query to extract primary care data was the result of the West Yorkshire Cardiovascular Network and Leeds Arrhythmia team working together to contribute towards a National AF project. The data analysis set was produced in conjunction with PRIMIS in order to create a tool that could be used nationally on any GP practice IT System.

Recent studies have found that AF currently affects 1.2% of the UK population, causing between 15% and 20% of all thrombo-embolic strokes. There is also evidence to suggest that the condition is associated with the worst strokes in terms of subsequent morbidity and mortality.

Despite these findings, the National Institute for Health and Clinical Excellence (NICE) estimate that 40% of patients for whom warfarin may be beneficial are not being prescribed it (possibly on the basis of sound medical judgement), which if remedied could prevent 6,000 strokes per year, saving the lives of 4,000 people.

As well as identifying those patients within their own practice in need of warfarin, practices can also compare their results with the pseudonymised data from other practices using PRIMIS software, CHART Online.

GRASP AF in practice

The CHART query set was originally commissioned by the WYCN, and practices in West Yorkshire have access and support to it via their local cardiac network. The tool has recently become available nationally via the NHS Improvement Team and can be accessed via their website, www.improvement.nhs.uk.

All 24 of the practices that make up the York Health Group took part in the initial roll out of the query, covering a population of 228,500, of which 3,572 patients have been diagnosed with AF, a prevalence of 1.56%.

Of these, the GRASP query identified almost 2,000 patients as having a CHADS2 score of two or more, of which over 50% were already taking warfarin. As a result 775 reviews were undertaken (114 face-to-face and 661 note reviews).

Adele Graham, who led the project for the WYCN, is delighted by the results seen in West Yorkshire following the initial roll out and is now looking forward to seeing the findings across the country.

She revealed: "The project was led by the WYCN, and supported by all the practices of the Practice Based Commissioning Cluster. As part of the project these practices had to sign up to participate, produce baseline data, do the reviews and re-run data by a specific date.

They also had to agree to attend an interactive educational session with the local clinical lead GP, which covered the diagnosis and management of AF and the guidelines for the use of anticoagulation. In particular the local practitioners were unaware of the results of the BAFTA trial ***, which demonstrated the safety of warfarin in the treatment of AF, even in elderly patients.

"The GPs completed a pre and post project questionnaire and results were favorable. Those who attended the educational programme reported an increase in confidence in diagnosing and managing AF. All respondents said they had now started to use the CHADS2 scoring system."

Adele also revealed the questionnaire had shown that:

• 90% of clinicians felt GRASP AF produced information in a format that was easy to read, digest and act upon.

• 50% of practice staff felt the GRASP library was easy to download and administer. However, half did require a facilitator to come in and help them download and run the query.

She continued: "After the preliminary results were shared with the practices, the GPs attending did say they would re-run the query. But more importantly, after participating in this project, they would use a scoring system to identify patients at risk of stroke on diagnosis of AF and manage the patient with warfarin if appropriate."

Helping practices install and run GRASP AF

Ursula Farrington and Paul Wood, Primary Care Information Specialists at North Yorkshire and York PCT, were available to support and assist practices to run the GRASP AF query in CHART.

Although all of their practices had used the PRIMIS+ data analysis tool CHART before for the IM&T DES, many still needed support due to differences in the download process.

Rather than downloading the query, practices were emailed a link to the library and Ursula and Paul were on hand to support them with installing and running it. Ursula explained: "Following refresher training, most practices found it a good query which was quick to run."

The Priory Medical Group in York was one of the first practices to use the query library, and staff were impressed with the ease in which it could be run.

Information Systems Manager Margaret Moore said: "We found the documentation easy to follow, with plenty of screen shots to show you what to do and reassure you that things were working as they should. As we are a large site, I had some concerns that the queries would take a long time to run but this wasn't the case.

"The process became even easier to use once we could send the anonymised data electronically, rather than emailing the summary sheet. I also found it useful to use CHART to drill down to the individual patient details so I could provide our clinicians with the lists that they wanted."

GP Stephen Billsborough was also impressed with the query set, explaining that he would recommend its use to others and highlighting the line by line patient list as a particularly useful CHART feature.

He said: "Using the tool, we reviewed all patients with AF who had a CHADS2 score of two or more. This provided an opportunity to review our records and refine the disease register.

"About 50% of our patients had a CHADS2 score of two or more but weren't on warfarin. After reviewing the notes and calling in some patients, we only revised prescriptions for two patients. All others were deemed to be on the best possible medication for their symptoms."

A CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with nonrheumatic atrial fibrillation (AF). It considers a history of congestive heart failure, hypertension, diabetes, a prior stroke or Transient ischemic attack and age. For more information, please visit http://circ.ahajournals.org/cgi/content/full/110/16/2287