Reducing AF-related strokes and saving lives

The Challenge

Atrial fibrillation (AF) affects around one and a half million people in the UK; 500,000 of whom are undiagnosed. It causes an irregular or abnormally fast heart rate and is estimated to be responsible for approximately 15-20% of all strokes nationally.

It is estimated that more than half of AF-related strokes could be prevented if people with the condition were taking the appropriate anticoagulation therapy. This is supported by guidance (CG 180) from the National Institute for Health and Care Excellence (NICE), which highlights the need to ensure people with AF are offered the right treatments to reduce their chance of an AF-related stroke.

Facing the challenge

UCLPartners worked with 12 of their Clinical Commissioning Groups (CCGs) in the development and implementation of new models of care for people with atrial fibrillation.

Through engaging a variety of key stakeholder groups, including charities, clinicians and industry partners, UCLPartners identified areas of improvement along the care pathway for people with AF to improve outcomes. This involved looking at existing good practice across the local health economy in north east London and beyond, which could be adapted and spread across the region.

The programme primarily involved UCLPartners facilitating the adoption and spread of the model of care developed by the north east London Clinical Effectiveness Group (CEG). Specifically, UCLPartners worked directly with Camden CCG to improve the number of people with AF recorded on their GP registers over a period of six months using an AF dashboard.

This included:

• Integration of a clinical decision support tool into each GP practice
• Promoting screening initiatives in GP practices to identify and target specific at-risk populations for AF screening
• Providing all GPs with best practice information on the management of AF and the appropriate local anticoagulation pathways
• Conducting workshops and 1:1 educational sessions for clinicians and practice staff on the AF pathway

In addition to local improvements, UCLPartners worked collaboratively with the Health Innovation Network, Imperial College Health Partners, the London Clinical Network and charities to develop a pan-London AF programme. The aim of the programme being to reduce mortality and morbidity by preventing 1500 – 2000 AF-related strokes across London, saving between 350 – 450 lives over five years. Whilst also generating projected cumulative net savings of up to £5 million over the same period to the local health economy.

The objectives of achieving this were to:

• Increase the detection of people with undiagnosed AF
• Increase the proportion of people with known AF and at high risk of stroke who are receiving anticoagulation therapy
• Improve the quality of anticoagulation services
• Create a pan-London AF programme series of community of practice events, to support spread and adoption of best practice and optimal management of patients with AF.

The outcome of this collaboration has been creation of an online interactive toolkit (LINK) to guide and support commissioners, clinicians and the wider AF network through steps and resources to improve the detection and treatment of people with AF.

PROGRESS HIGHLIGHTS

• Driven improvement and research across the AF pathway in north east and central London including increased detection, anticoagulation and medicines optimisation
• A pan-London AF toolkit has been developed as an interactive repository for all resources and best practice relating to AF which launched in June 2017
• Barts Health and UCLPartners is supporting the Care City Test Bed in its early detection research across a population of one million people in north east London. Through support from UCLPartners and the NHS Innovation Accelerator, Care City are using the digital health solution AliveCor’s Kardia to detect AF in at risk groups.
• During Heart Rhythm Week (5-11 June 2017) and Global AF Aware week (20-26 November 2017) the pan-London AF programme ran a series of events providing free 30 second pulse checks for the general public. Over 1500 people within the UCLP geography were screened for AF and taught how to check their own pulse manually. Ongoing events are planned.
• During 2016-17 UCLPartners, as part of the pan-London AF programme, delivered a series of community of practice events, to provide a platform for stakeholder engagement, spread and adoption of best practice and optimal management of patients with AF. These collaborative events will continue to be held bi-annually to support stakeholders working in stroke prevention.

Impact/outcomes

• Our work with Camden CCG resulted in 204 new patients with AF taking the appropriate anticoagulation drugs over a six-month period, which is expected to prevent five strokes per year.
• From 2013 to 2016 anticoagulation rates have increased by 11.8% against the 2012/13 baseline data, resulting in 3767 more people with AF being anticoagulated.
• Over the coming five years, this will result in 360 fewer strokes, which equates to a cost saving of £4.4 million based on a conservative estimate by NICE of £12,228 for the first year of NHS care for an AF related stroke.

Expanding the reach

The success of this work to date has encouraged the adoption of tools and practices for improvement in AF treatment and care across the UCLPartners geography, London, and nationally.

Four out of 18 nationally recognised AF related AHSN initiatives to improve AF management were developed by, or in partnership with, UCLPartners. These include the London Toolkit, AF quality standards and AF dashboard, community pharmacist support with AliveCor’s Kardia to detect AF, and GP referrals to a pharmacist once a GP has identified and started anticoagulation so pharmacists can monitor patients.