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Audit. “ a critical systematic analysis of the quality of medical care – including outcomes use of resources and quality of life for the patient”. BASILDON ANTICOAGULANT SERVICE Consultant and Clinical Assistants seeing patients in clinic Prothrombin time measured by MLSO x 2

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Audit

Audit

“ a critical systematic analysis of the quality of medical care – including outcomes use of resources and quality of life for the patient”


Audit

  • BASILDON ANTICOAGULANT SERVICE

  • Consultant and Clinical Assistants seeing patients in clinic Prothrombin time measured by MLSO x 2

  • 600 patients – 3 weekly clinics

  • In control - 50%

  • No patient selection or education


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BASILDON ANTICOAGULANT SERVICE 2002

Nurses see the patient in clinic, on ward and at home

Automated analyser interfaced to computer NPT as required 2,400 patients

New patients seen, others by request


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Benchmarking exercises

If same algorithm - what makes the difference ?

Manual intervention

Patient selection


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% Time in Range Comparison for April 2002 Run, Site 11 and Range 2.50

% Time in Range

This chart shows the time in range for all sites in ascending order.

The bar below the line shows the time below range; the bar above the line shows the time above range.

Your site is highlighted in red. The numbers of patients for each site are shown at the bottom of the chart.


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PATIENT SELECTION

The ideal patient:

is co-operative

can read

has no other illnesses or drugs

remembers what you tell them

doesn’t worry

is stable and temperate in their habits


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Patient selection

SPAF, etc. highly selective

Beyth – multi-component intervention –

9% of older patients randomised

Can we generalise from such a selected group?


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RISK FACTORS FOR THROMBOSIS IN AF – SPAF

3 independent clinical predictors

RR

CCF2.6

MultivarateHypertension2.2

PH of thrombo embolism2.1

Event rate - % pa

Age < 605.7

Univariate61-755.9

> 758.0

Age as a multivariate risk featureRR = 1.2


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RISK FACTORS FOR VTE

Cancer31%

CCF24%

Fracture10%

MI 8%

Obesity 4%


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600

500

400

300

200

100

0

Male Patients

Female Patients

Incidence rate per 100,000

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 >80

Age years


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Evidence based medicine

Like teenage sex

The results are sometimes embarrassing

Everyone thinks everyone else is doing it

Those doing it have enthusiasm

rather than expertise

Old people disapprove of it


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THE EVIDENCE BASE

INCEPTION-COHORT PROSPECTVE COLLABORATIVE STUDY

ITALIAN STUDY ON COMPLICATIONS OF ORAL ANTICOAGULANT TREATMENT (ISCOAT)

Palaretti Lancet 1996 348 p423-8

2745 patients in 34 clinics followed for one year

AGE < 70 1779

AGE > 70 966

Died 102

Died AC comp. 5


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ANTICOAGULANT CONTROL

51566INRs

Mean interval 15 days

Multivarcate Risk Ratios All ranges %controlbelowabove

All patients 68 26 6

141 patients with bleeding 66 24 10

RR

Relative Risk Factors age > 70 1.70

arterial disease 1.7

INR > 4.5 6

Timing – 1st 90 days 2.5


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  • STUDY OBJECTIVES

  • To identify complication of anticoagulant therapy

  • As a basis for improved practice –

  • cf published works

  • To identify patients who would benefit from other treatments


Study methods

Study Methods

Review of 1 year’s patients –2,400

1/4/01 – 31/3/02 search of PAS for events

  • Bleeding + thromboses according to ICD codes Thrombosis DVT,PE TIA

    Search of blood bank needs for episodes GP + FHSA records for conformation/missing patients


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Basildon results

LIH

Target on DAWN 32 1 1

Thromboses5

Bleeds 22 2 5

INR on admission 29/39


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INR for complications

>12


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Outcome:

Recovered and continued warfarin85%

Recovered and stopped 9%

Died 6%

Death related to AC 0%


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Co-morbidities

Cancer18%

Arthritis3%

Heart failure – not stated


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Local cause:

Yes29%

Peptic ulcer 6%

Ca. Colon 3%

Bladder lesion 6%

Bronchitis 3%

Ca. Bronchus 6%


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INTERACTING DRUGS

Yes32%

Simvastatin15%

Aspirin10%

Amioderone 6%

Diclofenac 3%

Prednisolone 3%


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ANTICOAGULANT CONTROL

% in control below above

All ranges

ISCOAT 68 26 6

Basildon 67 22 11


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INCIDENCE OF BLEEDING P.A.

Fatal % Major %Minor %

Levin – experimental studies ’92 0.4 2.4 8.5

Londfield review of similar studies ’93 0.8 4.9 15

Palaretti – prospective cohort study ’96 0.25 1.1 6.2

Watts + Clark retrospective 2002 0.0 0.6


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Have we captured all the events ?

Do clinicians report events to us ?

Review of patients terminated in study period = 252

No. who have had blood transfusions = 13

2 Haemorrhagic deaths

G.U. warfarin stopped 3/12 prior to fatal bleed

post-op switched to IV heparin


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  • PAS identifies admission and ICD code

  • PAS identifies death

  • Out of hospital death not necessarily referred

  • ? Outcomes

  • Check GP records

  • FHSA statistics


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Follow-up of DNAs

All DNAs get a reminder letter

If 3 DNAs – letter from EJW to patient and GP

35 patient disappeared

10 ‘disappeared’ patients attended post 1.4.02

i.e. persistent poor attendees


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  • What can DAWN tell us about our worst patients ?

  • Worst – out of range 90% of the time

  • 197 results from 24 patients

  • i.e. 1% of our patient population provide the 10% worst results

  • Improve patient selection

    Palaretti changed 11% to anti-platelet R,

    Basildon < 1%


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What should we do with the Awkward Squad ?

Educate

Stop warfarin – alternativesaspirin

aspirin + dipyridamole

New R, pentasachoride

DTIs

Agatroban Ximelagatran

Clinical review and explain risks of stopping

? Give all patients an annual review


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Fibrinogen

Melagatran (429,5 Da)

Thrombin

exosite 1 (fibrinogen)

exosite 2 (heparin)

active site


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NEWER ANTITHROMBOTICS WILL BE EXPENSIVE

They will be cost effect for :

Housebound patients

Poorly controlled patients

Patients on interacting drugs

? Discharge to GP now


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CONCLUSION :

This audit has shown a lower incidence of major and fatal bleeding than in previously reported studies.

The retrospective nature of the data collection means some cases of non-fatal bleeding and some thromboses may not have been identified.

Robust systems of data capture are required

Fatal episodes can be identified through FHSA records


The future

The Future


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Technological Trends

INTERNET World-wide

Intranet

or

“NHSnet”

Computer

Telephony

Notebooks

Telemedicine

Web Enabled TV

Video

Voice

Image

Palmtops

Mobile Phones


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Citrix PossibilitiesSeamless Connectivity


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PCGs

GPs

Pharmacies

Community

e.g.Nurses

Dentists

Acute

Hospitals

A Possible New Model

NHSNet or IntraNet

Dawn AC

Web Edition

Security

24 hours

Modem

Browser

Features

Admin

Needs a link for audit data collection


Audit

BASILDON ANTICOAGULANT SERVICE

? 2003 as 2002

+ all patients to have (or be offered) a clinical review

patients treated inappropriately to be terminated

problems patients to be offered alternative R,


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