Atrial fibrillation: review of anticoagulation

Indicators

The percentage of patients with atrial fibrillation, currently treated with an anticoagulant, who have had a review in the preceding 12 months which included: assessment of stroke/venous thromboembolism (VTE) risk; assessment of bleeding risk; assessment of renal function, creatinine clearance, full blood count (FBC) and liver function tests (LFTs); any adverse events related to anticoagulation; assessment of compliance; choice of anticoagulant.

Introduction

Atrial fibrillation (AF) is a condition of the heart causing it to beat rapidly and irregularly. People with AF are at increased risk of blood clots and stroke. The risk of these complications can be minimised through appropriate use of anticoagulation therapy.

This statement covers a new indicator that is part of the NICE menu of indicators for general practice, following the recommendations of the NICE indicator advisory committee in June 2017.

This statement considers the likely resource impact of the proposed indicator in terms of the number of extra reviews and blood tests carried out.

Resource impact

There are around 54.8 million people in England (see Office for National Statistics data 2016). The latest data available (NHS Digital, 2016) indicate that the diagnosed prevalence of AF is 1.71%, equivalent to around 937,000 people in England and that of these people, nearly 78% (730,000) are currently treated with an anticoagulant.

Pilot data (University of Birmingham and York Health Economics Consortium) showed that of people currently treated with an anticoagulant, around 29% have had a review of their anticoagulant therapy in the previous 12 months.

Assuming that achieving the indicator will need a GP appointment lasting 17 minutes (see Unit Costs of Health and Social Care 2016), 5 minutes of practice nurse time to take blood samples for testing and 3 blood tests (see the Department ofHealth and Social Care NHS reference costs 2015/16), the total unit cost per person is £63.60. Costs will differ when healthcare professionals other than GPs carry out the review needed to achieve the indicator.

Table 1 shows estimated cost at achievement levels of 40% to 80%.

Table 1 Estimated annual cost of implementing indicator IND169

	Proportion	Population	Unit cost (£)	Total (£)
England population		54,786,327
Prevalence of diagnosed AF (all ages)	1.71%	936,846
Proportion treated with an anticoagulant	78%	729,709
Current practice (proportion that have annual review of anticoagulant therapy)	29%	213,667	63.60	13,589,200
Total cost of current practice				13,589,200
Future practice at 40% (achievement of indicator)	40%	291,884	63.60	18,563,800
Total cost of future practice				18,563,800
Resource impact at 40% (cost of future practice less cost of current practice)				4,974,600
Future practice at 80% (achievement of indicator)	80%	583,768	63.60	37,127,600
Total cost of future practice				37,127,600
Resource impact at 80% (cost of future practice less cost of current practice)				23,538,400

The annual resource impact of implementing indicator IND169, compared to a baseline achievement of 29.3%, is estimated to be approximately £5.0 million at 40% achievement and approximately £23.5 million at 80% achievement. This does not include any savings which may be made as a result of reduced adverse events associated with AF such as stroke and blood clots.