23 April 2015

Increasing identification and delivery of evidence-based care for people with known atrial fibrillation

Atrial fibrillation (AF) affects around 1 million people (though around 250,000 of these are undiagnosed) in the UK; it causes irregular or abnormally fast heart rate and is responsible for around 1 in 8 strokes. It is believed that more than half of the strokes due to AF could be prevented by the appropriate use of oral anti-coagulation (OAC) treatments.

The Anticoagulation Programme East London (APEL) was developed to address this issue. In three north east London boroughs, 145 practices had their AF registers reviewed. Patients were risk assessed and stratified and were targeted for appropriate clinical management. This programme was developed and successfully implemented in North East London by the Clinical Effectiveness Group (CEG) and an 8% increase in anticoagulation was achieved over 3 years.

Camden CCG also recognised that too many patients in their region were receiving inappropriate treatment for AF and wanted to urgently address this issue. Through support from UCLPartners and the Clinical Effectiveness group, Camden CCG translated the lessons learnt from the successful implementation of the APEL programme across 35 practices. In just 6 months, Camden CCG reported a 7.5% increase in anticoagulation, which resulted in 132 extra people with atrial fibrillation taking appropriate anticoagulation drugs; and leading to the prevention of 5 strokes and saving 2 lives – a result that has taken other boroughs 2-3 years.

In terms of wider diffusion, the success of this initiative in Camden has generated significant interest from other local CCGs in UCLPartners’ region. The project has been replicated by Enfield CCG (with joint Public Health funding) and three others (Barnet, Haringey and Islington) have taken learning from Camden’s success to embed the approach and develop their own models.

The quality standards element (outlined below) is being co-developed and tested in 10 CCGs across UCLPartners. We are also collaborating with other AHSNs to enable diffusion between networks.

If the results achieved by Camden CCG were replicated across the other 19 CCGs in UCLPartners, we would prevent 108 strokes, save 30 lives, and avoid around £1.3m in clinical care costs every year. Replicating the rate of uptake would mean that the partnership would reach the NICE recommended levels within 18 months.

UCLPartners has developed a whole pathway AF Quality standards dashboard for continuous measurement and also set up an AF community of practice with engagement from 12 CCGs to share learning and enable CCGs within the partnership to increase detection and management of AF to support the predicted 26,000 people in the region who are living with AF, but do not know it.

The AF programme of work includes:

The UCLPartners AF Community of Practice

The AF community of practice aims to provide a platform for stakeholders to engage and share learning form ongoing AF interventions and approaches to optimal management within the UCLPartners geography. These include the following:

AF primary care interventions

The primary care interventions aims to support GP practices across the UCLPartners geography to increase the number of AF patients receiving appropriate treatment and reduce the incidence of AF related stroke. 6 CCGs are currently supporting their GP surgeries in reviewing AF registers.

Quality Standards

AF quality standards were co-developed to help measure outcomes of AF care across the whole AF pathway: Screening and detection, initiation, treatment and ongoing monitoring and support. Initially this will be utilising primary care data.

Primary care education GP initiation

UCLPartners supported Barts Health NHS Trust to secure Health Education England funding to deliver a CVD primary care education programme (with a focus on AF) to 12 CCGs.  This has also included targeted training to support GP initiation of anticoagulation.

Patient information platform

UCLPartners is working with the AF Association to develop patient networks across the UCLPartners geography to support patient information, education and peer-to-peer support.

Adherence

Co-designing and testing a new community pharmacy referral pathway to optimise and support adherence with oral anticoagulants (especially NOACs), for patients diagnosed with AF in primary care.

Orange Study

Led by Barts Health NHS Trust, the aim is to expand the national anticoagulation Bleeding Registry to build detailed knowledge of bleeding risks and outcomes.

Consensus statement re asymptomatic screening

Identify gaps in evidence and resolve through appropriate registries and research development. Provide guidance on opportunistic screening of paroxysmal AF in the over 65s through consensus of UCLPartners clinicians while additional evidence is growing.

UCLPartners continues to work with the AF Association, NICE Implementation Collaborative, devices companies and ABPI Stroke and AF Group to enable national diffusion once local implementation has delivered improved local health outcomes.  We are also collaborating with Interdisciplinary group for Stroke Prevention in Atrial Fibrillation (iSPAF) a sub group of the stroke SCN in adopting a pan-London approach to AF management and stroke prevention.

As we formally recognise the closure report for the Atrial Fibrillation project I wanted to extend my thanks to the UCLPartners team, on behalf of the programme and the CCG, for your role in improving the identification and management of AF for our patients in Camden.  As you have evidenced, this has potentially prevented seven people resident within Camden from having a stroke and improved healthcare for hundreds more.  We will continue to maintain and progress this work through our Long Term Conditions Locally Commissioned Service.  Collectively, we have also learnt significant volumes through our partnership approach and I look forward to our continued interaction through the other cardiovascular work streams.

Dr Lance Saker, GP Hampstead Group Practice, Camden CCG Board

By increasing identification and delivery of evidence-based care for people with known AF to the level that NICE recommends, we could prevent approximately 700 strokes per year, save 210 lives and avoid around £8.4m in costs across the partnership.