Atrial fibrillation (AF) affects a million people in the UK and is associated with one in eight strokes (one in three over 80 years). More than half these strokes could be averted by oral anticoagulants (OAC), but the proportion of patients receiving oral anticoagulants varies. Determinants of variation in AF anticoagulation between CCGs were examined. Key outputs and impacts from the work to date include:
National Quality and Outcomes Framework Atrial Fibrillation (AF) anticoagulation: The researchers found that patient complexity as indicated by ‘exception reporting’ is one major factor accounting for variation in AF anticoagulation between CCGs in the region. Population factors such as age and deprivation, however, were not associated with variation between CCGs. There was a decreasing trend of stroke admissions with an increasing use of anticoagulants. Publication: Anticoagulation for atrial fibrillation; explaining variation in English Clinical Commissioning Groups. Robson J et al. (Published June 2018 BJGP)
Pulse checks in people 65 years and older: This study in three east London CCGs (where pulse checks in people 65+ are now implemented routinely) achieved 90% coverage over a three year period. During this time, AF detection improved: AF register size increased by 9.6%, and an additional 790 people were anticoagulated reducing an estimated 45 strokes over three years. This work is now being developed across the remaining four CCGs to cover the whole of North East London STP. Funding has been secured from UCLP to support further implementation across the five CCGs in North Central London STP. There is no current national programme but this work contributes to the literature supporting national implementation. Publication: Opportunistic pulse checks in primary care to improve recognition of atrial fibrillation: a retrospective analysis of electronic patient records Cole J et al. (Published June 2018 BJGP)
The findings are informing the quality improvement programmes for AF in the region developed by the local AHSN, UCLP
Contribution of CLAHRC North Thames
CLAHRC North Thames funded the research assistant and PhD student who examined QOF data and local data on AF improvement. This CLAHRC-funded work has informed colleagues working with the local AHSN, UCLP, to support quality improvement programmes across CCGs both locally and pan-London. The funding and adoption of the AF project by the CLAHRC has also helped raise the profile of the topic, and has assisted with applications for further funding. For example, AF was a case exemplar for the successful MRC HDRUK London bid; was part of a successful Barts Charity REAL-Health bid; and is part of the NHS England Local Integrated Health Care Record Exemplars pan-London bid covering five STP London regions.
What happened next?
The findings are informing the quality improvement programmes for AF in the region developed by the local AHSN, UCLP. The following major initiatives have been associated with the work on AF:
Scaling improvement – Policy: CLAHRC PI John Robson, who is also CVD lead for UCLP, contributed to a pan-London AHSN AF Toolkit, which included promotion of pulse checks. Atrial fibrillation has also been adopted as a priority topic in NE London and NC London STPs.
Scaling improvement – Innovation: Pulse checks in over 65s are now implemented in five CCGs in North East London. Improvement of AF management by in-practice pharmacists is being promoted by UCLP in North Central and East London (in association with the NHSE clinical pharmacist in general practice £100M scheme).
Innovation and devices: A software tool - Active Patient Link AF (APL-AF) - has been developed for all four different GP IT systems to support general practitioners or in-patient pharmacists to improve anticoagulation and AF management, and has been successfully employed in Redbridge CCG (paper in preparation). CLAHRC PI John Robson provided advice for implementation of the AliveCor Kardia AF detection device programme across North Central and North East London and the UCLP footprint.