Joining the dots: A new gold standard for anticoagulation
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UKXAR08160221 Date of Preparation: August 2016 The roundtable was funded and organised by Bayer plc. The report reflects opinions that were shared by attendees and does not necessarily represent the views of Bayer or ACE.
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Joining the dots: A new gold standard for anticoagulation August 2016 This report is based on a roundtable policy discussion ‘Preventing and treating blood clots: How can the NHS innovate to save lives?’, which took place in Parliament on Tuesday 3 November 2015. It was hosted and cochaired by Barry Sheerman MP and Eve Knight, Chief Executive of AntiCoagulation Europe (UK) (ACE). T he roundtab le w as funde d and organ is ed by Bayer plc. T he report reflects opinions t hat w ere s hared by att endees a nd does not neces s arily represent t he view s of Bayer or ACE.
1. Foreword Barry Sheerman MP Ten years ago the House of Commons Health Select Committee estimated that over 25,000 people in England were dying each year from venous thromboembolism (a blood clot in a vein) contracted in hospital1. Since then significant progress has been made in preventing and treating blood clots, including the introduction of new risk assessments, clinical guidelines, and National Institute for Health and Care Excellence (NICE) recommended treatment options. Through the experience of people close to me I know that despite these improvements, to date the promise of policy in this area is not being matched by action on the ground. We are extremely grateful to the clinical and policy experts who took the time to share their insight and experience of the realities of anticoagulation during the development of this report and hope the insight will serve to act as an important call to action.
Eve Knight, Chief Executive of AntiCoagulation Europe (UK) The first half of this report highlights the key existing initiatives from the past ten years which have been aimed at preventing and treating blood clots, before moving on to outline the main discussion points from the roundtable meeting, namely, identifying the barriers facing effective anticoagulation, and setting out a vision for a distinctive and unified anticoagulation service for the future. Anticoagulation needs to be prioritised in its own right and should not be seen as a subset to other conditions. As such, we call on individuals and organisations across the health and social care sector to support the recommendations in this report, in order to deliver a step change in the prevention and treatment of blood clots in England and a new gold standard for anticoagulation.
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2. Background Introduction Thousands of hospital patients every year are diagnosed with a blood clot or blockage caused by a blood clot in their arteries, veins, or lungs1. Separately, Atrial Fibrillation (AF), a common heart rhythm condition, affects around one million patients in the UK2. These conditions can be treated through anticoagulation. The most commonly prescribed anticoagulant is warfarin and newer types of anticoagulants are also available known as NOACs (Newer Oral Anticoagulants) or DOACS (Direct oral anticoagulants). For the purposes of this report the term NOACs will be used as this is what they are most commonly referred as.
Anticoagulation to treat AF •
About AF: AF is a heart condition that causes an irregular and often abnormally fast pulse rate2. People with AF are four to five times more likely to have a stroke3, caused when blood clots formed in the heart enter the circulation and block arteries in the brain3.
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Num bers affected: It is estimated that 1.4 million people are living with AF4 and 12,500 strokes each year are thought to be a consequence of AF5
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Anticoagulation for AF: Depending on a patient’s risk of stroke, NICE guidance recommends that anticoagulants should be used to stop blood from clotting in people with a confirmed diagnosis of AF6
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Anticoagulants prescribed: The latest Sentinel Stroke National Audit Programme (SSNAP) clinical audit for October to December 2015 revealed that, on admission to hospital, only 48.9 per cent (4200) of AF patients with a stroke, were on anticoagulants prior to admission7
Anticoagulation to prevent DVT and treat and prevent the formation of blood clots •
About DVT and PE: When a blood clot forms in one of the deep veins in the leg, thigh, pelvis or arm, it is known as deep vein thrombosis (DVT). If part of the blood clot comes loose it can be carried in the blood to another part of the body8. If the blood clot reaches the lungs, it is known as a pulmonary embolism (PE); this is a serious condition and can be fatal. Venous thromboembolism (VTE) is the umbrella term for DVT and PE
•
Numbers affected: Estimates show that every year one in every 1000 people in the UK is affected by DVT8. These could be developed in hospital (‘hospital associated DVT’, incurred due to often long periods of immobility) or in the community. Risk factors for developing DVT can include a history of DVT, recent surgery, immobility, obesity and cancer treatment8
•
Anticoagulation for DVT and PE: NICE guidance recommends that anticoagulants should be used to stop blood from clotting in people with a confirmed diagnosis of DVT, or those with risk factors of developing a DVT. Anticoagulation can prevent DVT from developing in the first instance, treat existing cases and prevent recurrent cases
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Over the past ten years a number of incentives and levers have been introduced with the aim of improving anticoagulation treatments for these conditions. More detail on these policy levers can be found in appendix one.
3. The reality on the ground – continued challenges to effective anticoagulation. The roundtable discussion While the introduction of national incentives has led to a reduction of hospital associated VTE and the number of policy initiatives and incentives has been significant, the impact shows that more needs to be done. • •
•
•
We need to ensure that all patients who are assessed to be at risk of developing a blood clot receive appropriate preventative treatment Under-diagnosis – Conservative estimates claim around 700,000 cases of undiagnosed atrial fibrillation exist9, so we know it is a significant problem and not having an established diagnosis means that it is difficult to treat patients appropriately It is estimated under half (48.9 per cent) of stroke patients with known atrial fibrillation were on anticoagulant treatment on admission to hospital in England, Wales and Northern Ireland up to December 201510 The Medicines Optimisation Dashboard demonstrates that the average uptake of non-Vitamin K anticoagulants across all CCGs, as a percentage of all anticoagulant prescriptions, is just 16.5 per cent11
According to a report by the by the Association of the British Pharmaceutical Industry (ABPI) Stroke in Atrial Fibrillation Initiative (SAFI), under-anticoagulation represents “a huge unmet clinical need, and one which places a significant preventable burden (both clinically and financially) on patients, their families and carers, and the NHS”12. This theme emerged during the discussion at the roundtable. Despite their varied areas of expertise, attendees identified broadly similar challenges to effective anticoagulation. These can be grouped together under the following issues: • • • •
There is a lack of integration between primary and secondary care anticoagulation services There is not a standardised care pathway for anticoagulation services, which means there is inequitable access to treatment across the country Inconsistent training and education can lead to misconceptions around anticoagulation, and a clinical reluctance from Health Care Professionals (HCPs) to prescribe Issues with budgets and resource means that there is not the time, nor the incentive, for GPs to appropriately manage anticoagulation appointments
Primary and secondary care barriers Discussions highlighted that primary and secondary care in some areas is disjointed, which often leads to a bottleneck where patients referred to anticoagulation services by their GP face delays in accessing those services. Attendees also highlighted that in some areas, primary care is not initiating treatment because anticoagulation services in hospitals say that it has to be secondary care that prescribes. This differs from NICE guidance which states “the initiation, monitoring and reviewing of anticoagulation therapy UKXAR08160221 Date of Preparation: August 2016 UKXAR08160221 Date of Preparation: August 2016
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for people with AF, VTE and other conditions can take place in a number of settings across the healthcare system, including hospital outpatient, primary care and community settings”13.
Care pathways and access to treatment Linked to the issue of disjointed primary and secondary care is the fact that there are currently different pathways for anticoagulation services across localities. The lack of continuity and standardisation of patient care leads to a disparity in access for patients and is seen as a significant barrier to effective anticoagulation services. GPs have to be confident to prescribe; however the lack of a pathway in many Clinical Commissioning Groups (CCGs) means that many do not feel confident about diagnosing AF and managing the condition, and therefore do not always feel competent to prescribe. This is exacerbated by fragmented patient records as people travel between different services in primary and secondary care, which use different processes and IT systems to record data. A particular software programme is used by Health Care Professionals (HCPs) in secondary care to support the management of anticoagulation in a patient, but this cannot be accessed by GPs, and a lack of communication between the two professions often leads to this data not being shared. Additionally, due to the fact that patients who are being treated with Non-Vitamin K Oral anticoagulants (NOACs) need to be monitored less frequently than those being treated with warfarin, many patients are not being reviewed in a formal way. Instead, they are only receiving repeat prescriptions which places an onus on the patient to be proactive in seeking a discussion about their ongoing treatment needs. In terms of access to treatment, despite NICE guidance recommending NOACs as a treatment option for both VTE and AF, in many areas across the country, patients are not informed about, or given access to, these anticoagulants - creating a “postcode lottery”. Also, anticoagulation rates have only improved marginally, indicating that more action is needed to drive progress. This can have a detrimental effect on both the treatment and management of their condition, and to their quality of life. It is important to note that although access to new treatments is important, there should also be continuance of existing patients engaging in managing their warfarin treatments through selfmonitoring. We need to prevent a postcode lottery in terms of prescribing strips or withdrawing access to existing anticoagulation management which has kept patients safe in avoiding clots and understanding AF.
Training and education The fragmented approach to pathways is exacerbated by barriers in training and education for all HCPs. This was seen as an issue across HCPs, commissioners, patients and the public: Health Care Professionals (HCPs) For HCPs, training and education around anticoagulation is lacking, particularly in nursing. It was voiced that a competency framework covering the diagnosis, treatment and management of conditions that require anticoagulation would be useful. There is a misunderstanding among HCPs about the perceived cost of NICE recommended NOACs. This can lead to a clinical reluctance to prescribe, as GPs don’t feel confident enough in their own knowledge around anticoagulation, and information on this issue from different sources can vary. UKXAR08160221 Date of Preparation: August 2016 UKXAR08160221 Date of Preparation: August 2016
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Given advances within anticoagulation treatment there is an opportunity to develop clinics into a holistic service that fits all the needs of patients. This will present a challenge for local health services. Commissioners A lack of understanding around the cost benefits of effective anticoagulation can lead many commissioners to be reluctant to further invest in anticoagulation services. This is despite positive NICE Technology Appraisals, which should be implemented within 90 days of their announcement and NICE guidance for commissioners. Patients/the public Many patients often come forward and state that they are unaware of all of the treatment options available to them, that they have not been informed properly, or have been misinformed about NOACs.
Budgets and staffing resources A final consistent theme of the challenges facing effective anticoagulation was the issue of stretched budgets and resources within the NHS. Undiagnosed AF presents a huge staffing issue for the health service in terms of hours, particularly if advances in technology are not embraced to ease the burden on already overstretched services. The Government estimates that 700,000 people in the UK may have the condition without knowing it14. If all of these individuals were to be found and diagnosed, this would create a huge backlog of appointments to discuss anticoagulation treatment, and would increase the cost of the treatment for CCGs, potentially to unsustainable levels under traditional warfarin based services. Additionally, currently GPs have a ten minute appointment with a patient in order to discuss initiating anticoagulation. If this is to be done comprehensively and properly, a longer consultation time of at least 30 minutes is required. NOACs are both clinically proven and cost effective as outlined by NICE13. Despite this, there is a perceived and inaccurate notion about the cost, based on the acquisition cost of a NOAC alone compared to warfarin, rather than looking at the ‘whole cost’ of warfarin, including the regime of testing that is required to support its use. This lack of insight can impact on prescribing. NOACs can be a shift of cost and are not necessarily ‘more expensive’. For example if a GP refers a patient to an anticoagulation clinic then this comes out of a practice ‘commissioning’ budget. If a GP prescribes directly then it comes from the practice ‘prescribing’ budget. However the funding does not move from one pot to the other. Patients, policy and services have continuously called for care to be delivered closer to home, and the opportunity to deliver effective anticoagulation in a primary care setting is the goal of many. Like many other areas of care, the transition and development of services sometimes requires a movement between secondary and primary care, with the associated necessity of alignment of funding flow and incentives to change. Currently in many areas, arrangements favour the ‘status quo’ of the continuation of traditional warfarin only services. In order to enable the burden on services to be decreased, while ensuring the maximum number of patients receive anticoagulation, it is important that the challenge of aligning funding and incentives is met to enable patients and health systems to benefit from all available treatments. Some areas are UKXAR08160221 Date of Preparation: August 2016 UKXAR08160221 Date of Preparation: August 2016
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achieving success through enhanced payments and others utilise ‘Quality Payments’ to primary care practitioners. The ‘secondary/primary’ shift is seen as a long standing issue that needs resolving. Access to NOACs is also sometimes restricted by the development of local formulary guidance or protocols that state that NOACs should be initiated after the patient has been on warfarin for several months, despite no restriction to a particular line of therapy in their licence or in the NICE Technology Appraisals. Attendees suggested that in some areas, financial incentives are being offered through the Commissioning for Quality and Improvement (CQUIN) programme to adhere to these locally imposed guidelines.
4. Overcoming the challenges – recommendations for addressing the barriers to effective anticoagulation The ongoing challenges to anticoagulation are clear, but how can these be overcome? The second half of the roundtable discussion looked at recommendations around how to address these barriers and plug the current gaps in anticoagulation policy. Attendees suggested that one potential option is to develop an overarching anticoagulation guideline or “gold standard guideline” in partnership with the Royal Colleges to improve the prevention and treatment of blood clots. This guideline should cover the following areas: • Drawing together existing policies and pathways and highlighting best practice • A connected system between primary and secondary care tied in with new initiatives such as IT systems and care models • Improving training and education for HCPs and commissioners, with a focus on patient safety • Ensuring sustainability of, and ability to deliver, services to tackle already overstretched services • An anticoagulation public awareness cam paign and the need to diagnose and effectively treat these conditions
Drawing together existing policies and pathways Attendees felt that there was a wealth of national policy on anticoagulation, particularly related to VTE and AF, but that it was not drawn together as effectively as it could be. There was a consensus that policy should focus on anticoagulation more broadly rather than on specific conditions wherever possible. This led to calls for setting out the new “gold standard” for anticoagulation, which would simply and concisely outline the requirements for an effective anticoagulation service for the future. This could be supported by case studies, to identify and highlight areas that display best practise - in order to demonstrate to policymakers, HCPs and patients the standards that should be expected from anticoagulation services.
A connected system between primary and secondary care Care pathways need to be aligned to prevent a postcode lottery in anticoagulation services. This would be aided by drawing together the various policies and incentives for anticoagulation. Improved IT systems are integral as HCPs need to be able to share information safely and securely in order to support the effective management of anticoagulation services. This would support GPs in UKXAR08160221 Date of Preparation: August 2016 UKXAR08160221 Date of Preparation: August 2016
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establishing treatment plans, highlighting actions for follow-up appointments, and signposting where to refer patients to if something is wrong. Some attendees suggested that responsibility for outpatient anticoagulation should be completely passed over to primary care practitioners, in order to cut down on the number of services and appointments a patient has to access in order to be anticoagulated, and to ensure more flexible and timely treatment. On the other hand, there is huge expertise in secondary care around initiating and managing patients on anticoagulation and that collaborative working will allow for effective use of this expertise.
Improving training and education for HCPs and commissioners Attendees felt that ensuring HCPs felt confident in their understanding of anticoagulation would result in improved patient access to the full range of treatments available to them, in line with recommendations from NICE. Experts in secondary care should be called upon for training and education as well as providing clinical governance structures to support primary care clinicians to help deliver this service and this will have to be considered as part of commissioning. Attendees also suggested that improving access to the full range of treatments would also be supported by better educating commissioners about anticoagulation, associated health conditions and the services and resources needed to effectively manage these conditions.
Ensuring sustainability of, and ability to deliver, services Attendees highlighted that shaping structures and making changes to how we manage services, as well as how patients and HCPs access services, is key in order to deal with limited budgets, overstretched staffing and a lack of resources. Integrated IT systems will be important to monitor increases in prescribing rates and the impact on clinical outcomes. An effective quality payment is welcomed, to act as an incentive for GPs to prescribe the full range of anticoagulants. It was also suggested that if quality standards around anticoagulation were built into GP contracts, this could have a positive impact on prescribing rates. Another aspect to consider is supporting GPs with the diagnosis of AF and supporting the Atrial Fibrillation Association in their campaign to get GPs to check pulses. If a GP diagnoses AF in a patient and for that patient to get all the treatment they should in that appointment slot means the GP overruns significantly, so there is no incentive for the GP to check the pulse routinely.
An anticoagulation public awareness campaign There needs to be a push to raise awareness of anticoagulation more broadly so that patients and healthcare professionals are fully informed and engaged. Attendees suggested that a national public awareness campaign should be launched about anticoagulation, bringing together conditions so that people understand the treatment as a whole. This could be led by Public Health England and would help improve diagnosis rates, and tackle the lack of patient understanding about the different treatment options. It could also lead to more informed conversations between patients and their GPs about their treatment plan.
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Next steps AntiCoagulation Europe (UK) and the wider AF community are calling on the Department of Health, NHS England and Clinical Commissioning Groups to take forward the recommendations in this report and drive real change in policy, with a view to setting a new gold standard for anticoagulation. To support our campaign, or for further information, please contact Eve Knight on anticoagulation@ntlworld.com AntiCoagulation Europe (UK) would like to thank the following participants at the roundtable discussion for their input in to this report Nam e Dominic Brand
Dr Anja Drebes Diane Eaton Trudie Lobban MBE
Role Director of External Affairs and Marketing Committee member RCN Critical Care and In-Flight nursing forum Consultant Haematologist Project Manager ACE Founder and CEO
Janet Lock
Pharmacist
Professor John Pasi
Co-Chair
Suman Shrestha
Dr Jecko Thachil
Committee member RCN Critical Care and In-Flight nursing forum Clinical Nurse Specialist in Thrombosis & Anticoagulation Consultant Haematologist
Dr James Uprichard
Consultant Haematologist
Alexis Wieroniey
Deputy Director, Policy and Influencing Consultant Pharmacist, Cardiovascular
Stuart Cox
Sue Bacon
Helen Williams
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Organisation Stroke Association Royal College of Nursing
Royal Free Hospital AntiCoagulation Europe (UK) Atrial Fibrillation Association and Arrhythmia Alliance Basingstoke and North Hampshire UK Thromboprophylaxis Forum Royal College of Nursing
North Bristol NHS Trust Central Manchester University Hospitals St George’s University Hopsitals NHS Trust Stroke Association NHS Southwark
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Appendix one Ten years of landmarks in VTE and the prevention of AF-related stroke Over the last ten years, several incentives have been developed for the identification, prevention and treatment of hospital-associated VTE, and for the identification and anticoagulation of people with AF and DVT in the community. These are:
2005 Health Select Committee Investigation of Venous Thromboembolism in Hospitalised Patients A 2005 investigation by the Health Select Committee prompted a new interest in blood clots, and on the impact of VTE on patients. The Committee found that, “each year over 25,000 people in England die from venous thromboembolism (VTE) contracted in hospital. This is more than the combined total of deaths from breast cancer, AIDs and traffic accidents, and more than twenty-five times the number who die from MRSA”15. In addition to drawing attention to the scale of the problem, the Health Select Committee concluded that there were structural problems in the identification of people with VTE; amongst them that patients typically experienced problems after being discharged from hospital and with the result that the original attending physician might not be aware that VTE had developed and the lack of national guidelines to ensure doctors considered the risk of VTE and the availability of treatments. The Health Committee concluded that all patients should undergo a risk assessment on admission to hospital with the aim to identify patients who would potentially benefit from prophylaxis, and introduced the idea of tracking at risk patients after discharge, with attending physicians informed if they then went on to develop VTE15.
2007 NICE Guideline CG46: Venous Thromboembolism (surgical) Following the 2005 Health Committee inquiry, a NICE review of guidelines for the identification and treatment of blood clots was published in 2007 as NICE clinical guideline 46: Venous Thromboembolism (surgical)16. Amongst other priorities for implementation, the NICE guidelines took the Health Committee recommendations forward, calling for a risk assessment for patients at risk of thromboembolism17.
2009 – 2015 Health Technology Appraisals From 2009, NICE has issued single technology appraisals for dabigatran, rivaroxaban▼, apixaban and edoxaban▼ 18 19 20 21, a group of medicines known as Non-Vitamin K Oral Anti-coagulants (NOACs) in several indications. These anticoagulants must therefore be made available for prescribing in line with NICE technology appraisal guidance22. The NHS Constitution mandates that all patients have a right to medicines recommended by NICE, if clinically appropriate23.
2010 – 2015 NHS Standard Contract The NHS Standard Contract is mandated by NHS England for use by commissioners for all contracts for healthcare services other than those within primary care. The 2015/16 NHS Standard Contract imposes a financial penalty on all hospital trusts that fail to risk assess 95 per cent of inpatients for their risk of developing VTE in hospital24. UKXAR08160221 Date of Preparation: August 2016 UKXAR08160221 Date of Preparation: August 2016
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2010 NICE Guideline CG92: Venous thromboembolism: reducing the risk for patients in hospital NICE guidelines on thromboembolism were substantially expanded in 2010 under the title, Venous thromboembolism in adults admitted to hospital: reducing the risk, and then revised again in 201425. The guideline covered hospital treatment for all adults, including in-patients, and was issued shortly after non-Vitamin K oral anticoagulants (NOACs) were licensed for use in hip and knee surgery patients26. Progress was recognised, including the implementation of risk assessment on admission to hospital and the use of preventative measures. However, the 2010 guidelines were clear that more could be done. Then Clinical Director of NICE, Dr Fergus Macbeth commented: “There is a real clinical need for this guideline. It has been reported that measures to prevent VTE in hospital patients are used inconsistently, and in many cases patients at significant risk of developing a blood clot don’t get any preventative treatment at all”27. These guidelines are now going through a consultation process with the new guidelines due out in 2018.
2012 The NHS Safety Thermometer The NHS Safety Thermometer is the measurement tool designed to record the prevalence of patient harms, and to record the information and analysis needed to support the delivery of harm-free care across acute hospitals, community hospitals, care homes and district nursing services28. Introduced in 2012, the NHS Safety Thermometer collects the data of around 200,000 UK patients every month, collecting data on four key harms, including VTE29. By measuring treatment of new cases of VTE, the NHS Safety Thermometer is designed to assess whether cases of VTE are being appropriately identified, and preventative measures taken. The implementation of the Safety Thermometer marked a new recognition of VTE acquired in the community. Questions asked under the Safety Thermometer include whether the patient has a documented VTE assessment and whether they have started appropriate prophylaxis, and also distinguishes between cases where anticoagulation was initiated before admission (old VTE), or after (new VTE). It was therefore designed to be complementary to, but not to replace, the national VTE CQUIN, which rewards providers who risk assess 90 per cent or more of adult inpatients for their risk of developing VTE.
2013 First publication of the Innovation Scorecard The 2011 report, Innovation Health and Wealth (IHW) identified the need to strengthen compliance with Health Technology Appraisals, in order to increase access for patients and Health Care Professionals (HCPs) to medicines and technologies, including the publication of an Innovation Scorecard to benchmark progress. The scorecard, first published in 2013 and showing data for 2011, is published quarterly by the Health and Social Care Information Centre (HSCIC)30. The Innovation Scorecard covers selected innovative NICE approved medicines, including NOACs, and provides data sourced at CCG and hospital trust level.
NICE Guideline CG180: Atrial fibrilliation: management NICE Guideline CG180 covers the care and treatment of people with atrial fibrillation31. CG180, published in 2006 as an update of NICE Clinical Guideline 36, added new recommendations for a UKXAR08160221 Date of Preparation: August 2016 UKXAR08160221 Date of Preparation: August 2016
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personalised package of care and information, referral for specialised management, stroke prevention and rhythm control, and the management of acute fibrillation.
Sentinel Stroke National Audit Programme (SSNAP) The SSNAP is a web-based audit tool which measures stroke services against evidence based standards, and national and local benchmarks32. Under the SSNAP dataset, information is collected for every stroke patient, including content on standards in acute care, rehabilitation, follow up of care and outcomes. Detailed individual hospital level reports with national benchmarking were added in 2014. All results are available via the SSNAP Results Portal.
2014 NICE Implementation Collaborative (NIC) Consensus Statement on the use of NOACs (NIC NOAC Report)
The NIC was set up in 2012 to identify barriers to the implementation of NICE guidance, with the aim of ensuring patients get quick and more consistent access to approved treatments33. The NIC NOAC Report – developed by a range of health care professionals and patient groups including the Royal College of Physicians and the Royal College of Nursing, identifies factors inhibiting the prescription of NOACs, and ways to overcome those barriers.
Incentives in VTE and the prevention of AF-related stroke 2015/16 Quality and Outcomes Framework (QOF) The 2015/16 (QOF) contains three AF-related indicators (AF001, AF006 and AF007)34 These QOF indicators offer GP practices a financial reward for developing a register of people with AF, assessing people with AF for their stroke risk, and treating people with anticoagulation, if they are at risk of an AF-related stroke. Together, the measures are designed to incentivise GP practices to develop more robust information on unmet need, and prevent more AF-related strokes through early identification and treatment.
2015/16 NHS Outcomes Framework Domain 5 of the 2015/16 NHS Outcomes Framework includes an indicator on deaths from VTE-related events due to hospital admissions35, providing a national measure of the number of patients who have been admitted to hospital with any cause and die within 90 days of their last discharge. The indicator aims to reduce mortality from VTE developed in hospitals by driving efforts to improve the prevention, detection and treatment of VTE at a national level36.
2009 – 2010 Commissioning for Quality and Innovation (CQUINs) The CQUIN payments framework was established in 2009/10 to encourage service providers to improve the quality of care provided to patients37. CQUINs allow commissioners to reward excellence, providing financial incentives for the achievement of national and local quality improvement goals. From 2010 national CQUIN goals included reducing death, disability and chronic ill health from VTE – a goal retired in 2014/15.
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