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Original research
Improving the quality of care for patients with or at risk of atrial fibrillation: an improvement initiative in UK general practices
  1. Yewande Adeleke1,
  2. Dionne Matthew1,2,
  3. Bradley Porter3,4,
  4. Thomas Woodcock1,
  5. Jayne Yap1,5,
  6. Sophia Hashmy6,
  7. Ammu Mathew7,
  8. Ron Grant8,
  9. Agnes Kaba7,
  10. Brigitte Unger-Graeber9,
  11. Sadia Khan7,
  12. Derek Bell2 and
  13. Martin R Cowie10
  1. 1Department of Primary Care and Public Health, Imperial College London, Chelsea and Westminster Hospital, NIHR Collaboration for Leadership in Applied Health Research and Care for Northwest London, London, UK
  2. 2Chelsea and Westminster Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
  3. 3Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
  4. 4St Thomas' Hospital, King's College London, London, UK
  5. 5Clinical Quality, Performance and Technology, Government of Singapore Ministry of Health, Outram, Singapore
  6. 6North West London Clinical Commissioning Groups, London, UK
  7. 7Cardiology Department, West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
  8. 8Upbeat Heart Prevention and Support Group, London, UK
  9. 9Chiswick Health Practice, London, UK
  10. 10National Heart and Lung Institute, Imperial College London, London, UK
  1. Correspondence to Yewande Adeleke; yewande.adeleke13{at}imperial.ac.uk

Abstract

Objective Atrial fibrillation (AF) is a growing problem internationally and a recognised cause of cardiovascular morbidity and mortality. The London borough of Hounslow has a lower than expected prevalence of AF, suggesting poor detection and associated undertreatment. To improve AF diagnosis and management, a quality improvement (QI) initiative was set up in 48 general practices in Hounslow. We aimed to study whether there was evidence of a change in AF diagnosis and management in Hounslow following implementation of interventions in this QI initiative.

Methods Using the general practice information system (SystmOne), data were retrospectively collected for 415 626 patients, who were actively registered at a Hounslow practice between 1 January 2011 and 31 August 2018. Process, outcome and balancing measures were analysed using statistical process control and interrupted time series regression methods. The baseline period was from 1 January 2011 to 30 September 2014 and the intervention period was from 1 October 2014 to 31 August 2018.

Results When comparing the baseline to the intervention period, (1) the rate of new AF diagnoses increased by 27% (relative risk 1.27; 95% CI 1.05 to 1.52; p<0.01); (2) ECG tests done for patients aged 60 and above increased; (3) CHA2DS2-VASc and HAS-BLED risk assessments within 30 days of AF diagnosis increased from 1.7% to 19% and 0.2% to 8.1%, respectively; (4) among those at higher risk of stroke, anticoagulation prescription within 30 days of AF diagnosis increased from 31% to 63% while prescription of antiplatelet monotherapy within the same time period decreased from 17% to 7.1%; and (5) average CHA2DS2-VASc and HAS-BLED risk scores did not change.

Conclusion Implementation of interventions in the Hounslow QI initiative coincided with improved AF diagnosis and management. Areas with perceived underdetection of AF should consider similar interventions and methodology.

  • atrial fibrillation
  • electrocardiography
  • quality improvement
  • risk stratification
  • anticoagulation

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

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Footnotes

  • Presented at This work has been previously presented as an oral abstract at the 2017 Heart Rhythm Congress. This abstract was based on preliminary data of number of newly diagnosed patients with atrial fibrillation over a shorter time period and using univariate analysis. De Vere F, Porter B, Woodcock T, et al. Primary care based opportunistic screening for atrial fibrillation increases detection rates. Europace 2017;19:i6. doi: 10.1093/europace/eux283.023.

  • Contributors SK and BUG conceived the idea for the study. All the authors contributed to the design and planning of the study. YA, DM and TW performed statistical analysis. YA wrote the first draft of the manuscript. All authors revised the manuscript critically and have given their final approval of the version to be published. YA and DM are responsible for the overall content.

  • Funding This article presents independent research in part funded by the National Institute for Health Research (NIHR) under the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) programme for Northwest London (NWL). This study was supported in part by a Medical and Education Goods and Services (MEGS) grant from Pfizer and Hounslow CCG provided technology (ie, KardiaMobile (AliveCor) and mobile devices).

  • Disclaimer The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

  • Competing interests MRC reports grants and personal fees from Bayer, personal fees from Pfizer BMS Alliance, outside the submitted work. SK reports grants from Pfizer, during the conduct of the study.

  • Patient consent for publication Not required.

  • Ethics approval According to policy on activities that constitute research at West Middlesex University Hospital NHS Trust, this work met criteria for operational improvement activities and is exempt from ethics review. Ethical approval was not required for this work as it was part of a service evaluation and improvement activity and not human subjects research. An ethics waiver was granted by West Middlesex University Hospital NHS Trust research executive.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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