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Evaluation case study: an evaluation of the Don’t Wait to Anticoagulate project

What was the aim of the project?

The West of England AHSN have been working in collaboration with Gloucestershire Clinical Commissioning Group (CCG) and Bayer Healthcare on the Don’t Wait to Anticoagulate project (DWAC). DWAC has been helping to prevent strokes amongst patients with atrial fibrillation.

The aim of the project was to improve anticoagulation treatment for patients with a diagnosis of atrial fibrillation in Gloucestershire CCG. Atrial fibrillation (known as AF) is an abnormal heart rhythm. Effective anticoagulation has been shown to reduce the risk of stroke for patients with atrial fibrillation. Anticoagulation is the process of hindering the clotting of blood; especially the use of an anticoagulant medicine to prevent the formation of blood clots.

Who was involved with the project?

The West of England AHSN worked with Gloucestershire CCG, Bayer HealthCare (a pharmaceutical company), Interface Clinical Services, Royal United Hospital Bath NHS Foundation Trust, University of the West of England (UWE), GPs in Gloucestershire and Medicines Optimisation Pharmacists in Gloucestershire.

What was the aim of the evaluation?

The evaluation aimed to:

  • collate quantitative data over a 12 week period for each of the 51 GP practices that completed the project to measure the impact of the intervention
  • evaluate the role of the quality improvement team at the West of England AHSN
  • gain insight into the experience of undertaking a quality improvement project in primary care.

What resources and people were involved with the evaluation?

Sarah White, Quality Improvement Lead at the West of England AHSN worked with the Faculty for Health and Applied Sciences at the University of the West of England on the evaluation.

What did they do?

Sarah collected quantitative data through audits of the clinical systems, focusing on current anticoagulation status pre- and post-intervention. The quality improvement team also collected qualitative data through regular meetings with each GP practice to determine how the project was going, the reflective diaries kept by the team were later analysed for themes using specialist software called Nvivo.

The West of England AHSN commissioned UWE to undertake a realist evaluation of the project with a specific focus on the impact of the quality improvement team work. UWE also held focus groups with key stakeholders to determine their experience of working in partnership with the CCG, West of England AHSN and Bayer HealthCare.

What did they find?

The evaluation data showed that the project had a positive effect on rates of anticoagulation in Gloucestershire CCG in the 12 week period within which it was measured. During this time 2,228 patients with atrial fibrillation were reviewed in line with NICE CG180 guidance, and an additional 654 patients with atrial fibrillation were identified and added to the AF register. Of these, 265 achieved a favourable level of blood thinning (optimally anticoagulated) as a result of the project.

Modelling shows that during the second 12-week programme DWAC potentially saved 13 strokes.

Overall, the GP practices involved expressed positive comments on the project and found that the support from the quality improvement team was useful. The clinical skills training that was provided was well received, however the quality improvement training needed to be more specific and focused on the outcomes of the project.

The role of the Clinical Champion was essential to the project as this provided peer support for participating GPs as well as providing support for the project as a whole.

The role of the quality improvement team was to keep the project on track. Joint working with Bayer HealthCare was well received. The resources provided through the bespoke website were used but not to the full extent. The patient risk sheets received mixed reviews with some practices making full use of them and finding them useful while others found them confusing for their patients.

The evaluation found that patient feedback was difficult to ascertain and a learning point might be that patient groups are engaged much earlier in the project.

Who was the evaluation shared with and why?

The evaluation was shared with key stakeholders involved with the project and informed the roll out of phase three of DWAC.

What next?

DWAC received national recognition and a number of AHSNs around the country now have plans to run the scheme across their regions.

What has changed as a result?

There is a positive change in anticoagulation processes for patients with atrial fibrillation resulting in a number of strokes prevented. There is variation in the extent of the change in participating GP practices.

Phase three of DWAC was rolled out in partnership with Bristol CCG to all their primary care practices. Completed in March 2017, the full evaluation of this latest phase will be available in the autumn.

In addition, the Bristol, North Somerset and South Gloucestershire (BNSSG) Sustainability and Transformation Partnership (STP) is considering DWAC as part of their stroke prevention pathway, which is hoped would form phase four of the local rollout.

Each new phase is tailored to meet the specific needs of the CCG or AHSN that undertake it, using the learning from this evaluation.

Successes and challenges

Successes

During phases one and two of the project’s roll-out in Gloucestershire, DWAC has potentially prevented 21 strokes amongst people with atrial fibrillation, representing a potential saving of around £460,000 by optimising medicines management in primary care.

Challenges

Challenges included the timing of the project – training was provided prior to Christmas but most practices weren’t able to start until afterwards which resulted in a lack of momentum for some.

Training on quality improvement needed to be more in-depth and specific to the project to ensure full commitment and success.

References

  • UK Medicines Information. Common Questions and Answers on the Practical Use of Oral Anticoagulants in Non-Valvular Atrial Fibrillation. 2015