Stark differences in access to new medicines to reduce the risk of strokes in people with the heart rhythm disorder atrial fibrillation (AF) are revealed today in a new report from the Atrial Fibrillation Association.1
The chance of receiving the newer treatments varies 16-fold across England, the report says.
In one part of England 69% of patients receive the newer treatments - in another part just 4% are prescribed them.
The therapies involved are from a class of blood-thinning drugs known as Non-Vitamin K "Novel" Oral Anti-Coagulants (NOACs).
They are used in AF as an alternative option to warfarin to reduce the risk of blood clots. The cardiac disruption caused by AF means clots are more likely to form in the heart, which can then travel to the brain. Patients with AF are five times more likely to suffer a stroke than those without the condition.2
The report, In Pursuit of Excellence in the Prevention of AF-Related Stroke, points out that more than half of Clinical Commissioning Groups (117 or 56%) are at or below the national average for England of 16.5% for NOAC use compared to warfarin. However, within this 56%, 53 CCGs (25%) have NOAC prescribing rates of 10% or less.
Just seven CCGs have reached or exceeded the recommended level of 35% NOAC use as set out by the National Institute for Health and Care Excellence (NICE) in June 2014.3
Trudie Lobban MBE, CEO and Founder of the AF Association, said: "This variation is completely unacceptable. It makes a mockery of the concept of a National Health Service that patients with the same condition living just miles apart receive such dramatically different rates of the newer therapies."
The latest data shows large variations in NOAC use not just in different regions of the country but sometimes between neighbouring CCGs.4
In Havering CCG, in East London, 43% of AF patients receive the newer treatments - the sixth highest in England. In the neighbouring CCG of Thurrock, in Essex, just 4.2% are prescribed them - the lowest level in the country.
In Bradford City CCG, 33.9% of AF patients are prescribed the newer therapies. In nearby Leeds South and East CCG, 5.9% of patients receive them.
Mrs Lobban added: "In the West Country there are four CCGs where more than 30% of AF patients receive the modern therapies. By contrast, in East Anglia there are four CCGS where fewer than 7% receive the newer therapies. The physiology of the human heart doesn't change between Bristol and Ipswich, but the therapies vary dramatically.
"This has nothing to do with good medicine. We need better understanding and information for both healthcare professionals and patients."
The new report looks across the board at the detection and treatment of AF and says more needs to be done to find the estimated quarter of a million people with undiagnosed AF. This could be done with simple pulse checks, carried out either at GP surgeries or at events like annual flu vaccinations.
The report highlights various projects promoting best practice in AF care, including a project in Liverpool where consultants visit GP surgeries to encourage AF detection and another in South Tees where nurses run AF clinics in the community.
The report stems from the findings of a panel of AF experts including cardiologists, GPs, nurses, pharmacists, NHS managers and health service academics.
The chairman of the panel, Professor Martin Cowie, Professor of Cardiology at Imperial College London, said doctors needed to become better at discussing AF therapy options with patients, as although this took time patients were more likely to keep taking the treatment when better informed. He added that there were still some misconceptions about the newer therapies and these needed to be dispelled.
"It is unacceptable if patients are not given the full range of options, or are actively warned against NOACs, because the clinician is uncertain of the facts and figures," he said.
Jane Macdonald, Director of Nursing and Improvement at Greater Manchester Academic Health Science Network, commented: "AF patient care in many areas appears to remain suboptimal. Without targeted or opportunistic screening for AF, considerable numbers of patients remain undetected. Of those detected, the data suggests that some people might not be consistently placed on an anticoagulant, or go without the opportunity to discuss their preferred choice - all of which goes against current recommendations set out by NICE (clinical guideline 180) and the benefits or outcomes this approach may gain."
Trudie Lobban concluded: "While we have come a long way, and there are many championing quality care of AF patients, there remain thousands of AF patients needlessly suffering an AF-related stroke, which may kill them or leave them disabled for life. This situation needs to change, and it is critical that all individuals involved in the AF patient pathway strive to take patient care from good to excellent, to ensure AF patients and those around them are protected from the devastation of AF-related stroke."