Darzi Fellowship accepts pharmacy-led project to improve care of AF patients
Patients with atrial fibrillation who take new oral anticoagulants to reduce their risk of stroke need a smooth transition of care from hospital to community, Asha Fowells finds
ATRIAL fibrillation (AF) is the most common heart rhythm abnormality, affecting some 800,000 people in the UK. Compared with the statistics for a disease like diabetes, which is thought to affect nearly three million people, this number may not seem terribly significant. However, for further comparison, over 331,000 people in the UK were diagnosed with cancer in 2011, which is over 900 cases a day. With AF coming in at more than twice that incidence, and affecting around 10% of people aged over 75 years at a time when the population is ageing, the scale of the problem becomes apparent.
The Pharmaceutical Journal, 24/31 May 2014, Vol 292, 7811/7812
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Part of the treatment plan for AF involves anticoagulant therapy to reduce the risk of stroke, one of the main complications of the disease. Although warfarin is the chief anti-clotting agent used, an increasing number of patients are not suitable for this treatment so instead are prescribed one of the newer oral anticoagulants (rivaroxaban, dabigatran and apixaban), often known as NOACs. There are pros and cons to this; the NOACs have fewer drug interactions than warfarin and do not require frequent blood tests, but they are considerably more expensive and — in community settings, at least — are sometimes not as well understood.
Sotiris Antoniou, consultant pharmacist in cardiovascular medicine at Barts Health NHS Trust in London, explains that there are two real areas of concern in terms of stroke prevention for AF patients. “The first is that 40% of those who are suitable for anticoagulant therapy are not anticoagulated. The second is that across all long-term conditions, we know that anything from one third to half of all medicines are not taken as prescribed. When you consider that NOACs have a shorter half-life than warfarin, not taking a NOAC as prescribed can have serious consequences,” he says.
Clearly there is a need to up-skill community pharmacists in this clinical area so they feel confident in dealing with patients on NOACs during new medicine service (NMS) consultations and medicines use reviews (MURs), but while exploring how this could be remedied, Antoniou realised that — unlike warfarin — no specific care pathway existed for patients on these drugs. When a newly formed multidisciplinary steering group — including a GP specialist in AF, a cardiologist, a haematologist and Antoniou himself — started to look into the issue, it soon became obvious that improving stroke prevention in AF was complex, with many workstreams required. One priority identified was the need for someone who could work full time with others to design and develop a referral pathway for NOAC patients into community pharmacy.
This is where the Darzi Fellowship comes in (see Panel). The funding that is attached to the award has been matched by the academic health science partnership UCL Partners, meaning that a senior pharmacist can be recruited to work across hospital and community pharmacy to get the pathway right and then pilot it through some 50 pharmacies. Antoniou describes the ideal: “While still in hospital, patients put onto a NOAC will be asked which community pharmacy they usually go to, so we can organise a clinical appointment for them around a week or 10 days after being discharged. The pharmacist will be able to check their compliance and answer any questions they might have.” In providing information and support in this way, medication adherence is more likely to be maintained, he says.
The collaboration with UCL Partners is an integral part of the project. Amanda Begley, the partnership’s director of innovation and implementation, says: “A good way to describe UCL Partners would be as an enabler — finding ways to support front-line staff to work in partnership to improve outcomes and save lives. We enable different groups to come together around common aims, from commissioners to practitioners and academics. For example, Rob Horne, leading expert on medication adherence who works at the UCL School of Pharmacy, is involved in this project. So the Darzi fellow will be supported to tap into a range of resources and expertise from across the partnership to assist in co-designing the service but also overcoming the messiness of implementation.
“We will also make sure that future adopters are involved,” explains Begley. “The aim is to develop something that is scaleable and replicable. We are keen to both learn from others and to openly share our lessons learnt.” At the other end of the AF care pathway development plan sit the community pharmacists who will be delivering the new service to patients, so Michael Levitan, secretary and chief executive of the Middlesex Pharmaceutical Group, which supports four local pharmaceutical committees in North West and North London, is also part of the team.
Levitan’s involvement stems from some NMS training he commissioned on anticoagulation, including the use of warfarin and NOACs. The benefits went beyond the advice and support that newly knowledgeable pharmacists were able to offer patients by facilitating closer working between pharmacists in different sectors, he says. “Between secondary care and community pharmacy, there is often no collaboration and precious little communication, when as a profession we should be trying to unite for the benefit of patients.” The upside for secondary care professionals was that empowering their community colleagues helped them to work towards their target of trying to prevent people being readmitted to hospital within 28 days of discharge, he adds.
The NHS Outcomes Framework lists “preventing people from dying prematurely” as one of five domains designed to support commissioners in planning how to improve quality and outcomes at a local level. AF — which increases the risk of blood clots and therefore stroke, and also causes the heart to become inefficient and may lead to heart failure — is a prime clinical area within this. The award of a Darzi Fellowship illustrates just how seriously the condition, and pharmacy’s role within it, is being taken by people who influence the direction of the healthcare system.
Panel: The Darzi Fellowship Programme
The Darzi Fellowship programme is designed to help clinicians develop the skills to become a leader in their chosen field. Individuals who are appointed Darzi fellows are seconded for a year from their usual role to work on a major project (or number of smaller projects) under the guidance of a sponsor who is usually a medical or clinical director. The fellows also undertake a leadership development programme — which leads to a postgraduate certificate — provided by the Centre for Innovation in Health Management at the University of Leeds.
The Darzi Fellowship programme started in 2008 and recruitment for the sixth wave of fellows is now in progress. To date, more than 130 fellowships have been awarded, with a further 41 fellows enrolled onto the 2013–14 programme. Pharmacy only became eligible for inclusion in the fourth wave, but has had a number of successes, including a Newham Clinical Commissioning Group project to reduce drug spend and prescription variability, a Bexley CCG initiative to improve cost-effective dressings prescribing in primary care, and the establishment of a near patient pharmacy and medicines support unit at Moorfields Eye Hospital.
Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.11138537
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