Atrial fibrillation: DOACs and Vitamin K antagonists

Indicator type

General practice indicator suitable for use in the Quality and Outcomes Framework.

Rationale

Anticoagulation in patients with atrial fibrillation (AF) can help prevent stroke. This indicator aims to promote the use of DOACs over vitamin K antagonists unless DOACs are declined by the patient or not indicated. Evidence from an analysis of several studies shows that DOACs are more effective than vitamin K antagonists for a number of outcomes and should be used as a first line treatment for people with an increased risk of stroke (NICE's guideline on atrial fibrillation).

For patients already established and stable on a vitamin K antagonist, the benefits of changing to a DOAC need to be discussed with the patient. Therefore, the risks and benefits of changing medication, the person's time in therapeutic range and the person's preferences should be explored at their next routine appointment.

Source guidance

Atrial fibrillation. NICE guideline NG196 (2021), recommendations 1.6.3 and 1.6.5

Specification

This indicator is based on indicator CVD-05 in the Impact and Investment Fund 2022/23.

Numerator: the number in the denominator who are currently prescribed a direct-acting oral anticoagulant (DOAC) if eligible, or a vitamin K antagonist if not eligible for a DOAC or a DOAC is declined or not indicated.

Denominator: the number of patients with atrial fibrillation and a last recorded CHA₂DS₂-VASc score of 2 or more.

Definition: Current treatment is defined as a prescription in the last 6 months of the reporting period.

Exclusions: People with resolved atrial fibrillation.

Using established guidance for existing IIF Indicator CVD-05 this indicator has multiple success criteria that are evaluated sequentially. A personalised care adjustment (PCA) for the first success criterion (DOAC prescribing) moves the patient into the pool for evaluation against the second criterion (vitamin K antagonist prescribing), rather than removing them from the denominator altogether. People with valvular atrial fibrillation are not evaluated against the first criterion and do not require a record of a PCA for DOACs before evaluation against the second criterion. People with recorded antiphospholipid syndrome do not require a record of a PCA for DOACs before evaluation against the second criterion, if a DOAC is not prescribed.

PCAs for success criterion 1 (moves the patient to evaluation under success criterion 2):

PCAs for success criterion 2:

Possible grounds for exception reporting in the traditional sense (removal from the denominator altogether, unless a success is registered) are:

Calculation: Numerator divided by the denominator, multiplied by 100.

Minimum population: The indicator would be appropriate to assess performance at individual general practice level. To be classified as suitable for use in QOF, there should be an average minimum population of more than 20 patients per practice eligible for inclusion in the denominator prior to application of personalised care adjustments. QOF data for 2021/22 for 2020/21 shows that 1.7% of people in England have atrial fibrillation and a last recorded CHA₂DS₂- VASc score of 2 or more: 173 patients for an average practice with 10,000 patients.

ISBN: 978-1-4731-5932-7