Quarter of at-risk patients still being treated with a medicine that is no longer recommended, latest figures reveal.
Wide differences in access to medicines to reduce the risk of strokes in people with the heart rhythm disorder atrial fibrillation (AF) are revealed today (9 May) in a new report.1
The chance of receiving these treatments varies 16-fold across England, the report says.
In one part of England 69.3% of patients receive these treatments – in another part just 4.2% are prescribed them. This is despite them being approved as clinically and cost effective by the National Institute for Health and Care Excellence (NICE).
The report highlights innovative case studies where local services are championing new models of care, but there remains a significant postcode lottery across the country. Research shows that some 7,000 strokes and 2,000 deaths could be avoided each year in the UK with effective management of AF. The therapies involved are from a class of blood-thinning drugs known as Non-Vitamin K Antagonist Oral Anti-Coagulants (NOACs).
They are approved for the commonest type of AF (non-valvular AF) to reduce the risk of stroke in patients at high risk. They are an alternative option to warfarin, which is an effective treatment but one which requires routine monitoring of blood levels and whilst appropriate for some patients may not be appropriate for all. . The heart rhythm disorder caused by AF can lead to blood clots forming inside the heart, which can then travel to the brain and cause a stroke. Patients with AF are five times more likely to suffer a stroke than those without the condition.
In 2014, NICE recommended that patients with AF at high risk of stroke should, unless otherwise indicated, receive an anticoagulant - drugs that work to prevent the coagulation (clotting) of blood - and that NOACs should be considered as an alternative option to warfarin for doctors to discuss with patients at risk of stroke from non-valvular AF.
In addition, in a significant change to established practice, NICE stated that aspirin (an antiplatelet drug) should not be used on its own to prevent AF-related stroke, due to being ineffective in preventing this condition.
Despite this, data over one year later show that less than half of patients admitted to hospital with a stroke were taking anticoagulants (despite being known to have AF) and over a quarter were still taking aspirin.
These data come from the Sentinel Stroke National Audit Programme (SSNAP). The authors' state: "These data reveal that there are still major issues in primary and secondary care about ensuring that patients have effective stroke prevention. Over one fifth of patients are in atrial fibrillation (AF) on admission. Only 45.6% of patients in AF on admission are taking anticoagulants with 27.9% taking only antiplatelet drugs which are considered ineffective for patients in AF."
In 2012/13, a year after approving NOACs, NICE estimated that these new medicines should make up approximately 20% (as a percentage of all oral anticoagulants) of the medicines used by patients. But, by June 2015 almost three quarters of Clinical Commissioning Groups in England were below 20%, with many substantially lower.
As well as regional variation, the report also highlights that UK patients have poorer access to NOACs than patients in most other European countries: In a table of 21 European countries together with Turkey, the UK appears fourth from the bottom. Large countries such as France and Germany, and also small countries such as Romania, Denmark, Portugal and Greece all appear above the UK in terms of NOAC use.
Commenting on the report's findings Professor Martin Cowie, Professor of Cardiology at Imperial College London, said: "It is worrying that despite the NICE guidance of June 2014 on NOAC use for AF just a handful of CCGs have a third or more of patients using these therapies.
"We need this alternative to warfarin. Warfarin can be an effective stroke prevention therapy for some AF patients, but not for all, and it imposes restrictions on food and drink intake as well as needing regular blood level monitoring, which is not the case with the newer therapies." Professor Cowie added: "The other disturbing fact from this report concerns the continuing use of aspirin for AF. Aspirin is poorly effective against AF related stroke and it increases the risk of bleeding. Some doctors seem to have a low awareness of this issue and this needs to improve."
The new report, called One year on – why are patients still having unnecessary AF-related strokes?, comes from the Association of the British Pharmaceutical Industry's (ABPI) Stroke in Atrial Fibrillation Initiative (SAFI).2,3
It is being launched today at the House of Commons.
Speaking at the launch, Dr Berkeley Phillips, Medical Director of ABPI SAFI said: "We need to understand why variation exists across the NHS when it comes to using new and innovative medicines which help to prevent stroke. Through the use of these medicines as part of optimising anticoagulation treatment, we have an opportunity to improve patient health and prevent thousands of patients from dying needlessly. We can do this through sharing experience and best practice so that all patients benefit from consistently high standards of care".
Mr Barry Sheerman, chairman of the All Party Parliamentary Group on Atrial Fibrillation and MP for Huddersfield, said: "It is unacceptable that in one part of the country around 70% of patients with AF receive the newer therapies yet in another part fewer than 5% do."
The total cost of stroke to the UK, including lost productivity and benefits payments as well as direct NHS costs, is estimated at £11.3 billion a year.
Notes to Editors
The report uses data published by the end of 2015.
About Atrial Fibrillation
AF affects around 1 in 50 (or 2.4%) people in England.
The risk of developing AF increases with age and it is estimated to affect up to 1.4 million people in England.
Some 7,000 strokes and 2,000 premature deaths could be avoided each year with effective management of AF.
AF-related strokes are more severe and more likely to be fatal than non-AF-related strokes.
There were over 16,000 strokes in patients with AF in the 12 months to June 2015. Mortality at 30 days is estimated at 25% so applying this estimate, these strokes would result in an estimated 4,000 deaths at 30 days.
People with AF who suffer a stroke have greater mortality, more disability, more severe strokes, longer hospital stay and a lower rate of discharge to their own homes compared to those without AF.
1 One year on – why are patients still having unnecessary AF-related strokes? Published by the Stroke in Atrial Fibrillation Initiative, 9 May 2016.
2. The ABPI SAFI is collectively funded by its five members, all research-driven pharmaceutical companies that have developed and gained regulatory approval for a NOAC. The members are Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo and Pfizer.
3. One year on – why are patients still having unnecessary AF-related strokes is supported by AF Association, Arrhythmia Alliance, Stroke Association, Anticoagulation Europe (UK).
Telephone during work hours (9am to 5pm Monday to Friday): +44 (0) 20 7747 7147 or +44 (0) 20 7747 1441
Telephone out of hours (5pm to 9am and weekends): +44 (0) 20 7747 1445
About the ABPI
The ABPI represents innovative research-based biopharmaceutical companies, large, medium and small, leading an exciting new era of biosciences in the UK.
Our industry, a major contributor to the economy of the UK, brings life-saving and life-enhancing medicines to patients. We represent companies supplying around 90 per cent of all medicines used by the NHS, and are researching and developing the majority of the current medicines pipeline, ensuring that the UK remains at the forefront of helping patients prevent and overcome diseases.
The ABPI is recognised by government as the industry body negotiating on behalf of the branded pharmaceutical industry, for statutory consultation requirements including the pricing scheme for medicines in the UK.