Improving the management of Atrial Fibrillation in General Practice: protocol for a mixed method study (Preprint) (original) (raw)
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Prevalence and treatment of atrial fibrillation in UK general practice from 2000 to 2016
Heart, 2018
ObjectiveAtrial fibrillation (AF) is the most common cardiac arrhythmia and an important risk factor for stroke. Treatment with anticoagulants substantially reduces risk of stroke. Current prevalence and treatment rates of AF in the UK as well as changes in recent years are not known. The aim of this analysis was to determine trends in age–sex specific prevalence and treatment of AF in the UK from 2000 to 2016.Methods17 sequential cross-sectional analyses were carried out between 2000 and 2016 using a large database of electronic primary care records of patients registered with UK general practitioners. These determined the prevalence of patients diagnosed with AF, the stroke risk of those with AF and the proportion of AF patients currently receiving anticoagulants. Stroke risk was assessed using CHA2DS2-VASc score.ResultsAge–sex standardised AF prevalence increased from 2.14% (95% CI 2.11% to 2.17%) in 2000 to 3.29% (95% CI 3.27% to 3.32%) in 2016. Between 2000 and 2016, the propor...
Improving anticoagulation in atrial fibrillation: observational study in three primary care trusts
British Journal of General Practice, 2014
Background Atrial fibrillation (AF) is a cause of stroke, and undertreatment with anticoagulants is a persistent issue despite their effectiveness. Aim To increase the proportion of people with AF treated appropriately using anticoagulants, and reduce inappropriate antiplatelet therapy. Design of study Cross-sectional analysis. Setting Electronic patient health records on 4604 patients with AF obtained from general practices in three inner London primary care trusts between April 2011 and 2013.
Heart, 2006
Objectives: To examine trends in the prevalence of diagnosed atrial fibrillation (AF), its treatment with oral anticoagulants between 1994 and 2003, and predictors of anticoagulant treatment in 2003. Methods: Analysis of electronic data from 131 general practices (about one million registered patients annually) contributing to the DIN-LINK database. Results: From 1994 to 2003 the prevalence of ''active'' AF rose from 0.78% to 1.31% in men and from 0.79% to 1.15% in women. The proportion of patients with AF taking anticoagulants rose from 25% to 53% in men and from 21% to 40% in women. Most others received antiplatelets. The likelihood of receiving anticoagulants was greater for men and with increasing stroke risk. It decreased sharply with age after 75 years. Socioeconomic status, urbanisation and region had no influence. Non-steroidal anti-inflammatory drugs, antiplatelet drugs and ulcer healing drugs were associated with reduced likelihood of receiving anticoagulants, as were peptic ulcers, chronic gut disorders, anaemias, psychoses and poor compliance. Anticoagulant treatment was associated with several cardiovascular co-morbidities and drugs, possibly due to secondary care treatment. Nevertheless, only 56.5% of patients at very high risk of stroke were taking anticoagulants in 2003, whereas 38.2% of patients at low risk of stroke received anticoagulants. Conclusions: This study confirms previously observed trends of increasing AF prevalence and warfarin treatment. Many patients who may benefit from anticoagulation still do not receive it, whereas others at lower risk of stroke do. The lower likelihood of women receiving anticoagulants is of particular concern.
Atrial fibrillation in a primary care practice: Prevalence and management
2002
Background: Atrial fibrillation is a common serious cardiac arrhythmia. Knowing the prevalence of atrial fibrillation and documentation of medical management are important in the provision of primary care. This study sought to determine the prevalence of atrial fibrillation in a primary care population and to identify and quantify the treatments being used for stroke prevention in this group of patients.
Current management of atrial fibrillation: an observational study in NHS primary care
BMJ open, 2013
To describe National Health Service (NHS) resource use and pharmacological management of atrial fibrillation (AF) in routine UK primary care. Multicentre retrospective study. Seven primary care practices in England, one in Wales. Patients with AF were identified and approached for consent. Data were collected on the first 12 weeks post-diagnosis ('initiation') and, for established patients, up to the most recent 3 years of management ('maintenance'). Data collected on 825 patients with AF, 56% men. Mean age (at diagnosis) 70.5 years. Mean 2.4 (SD 2.2) visits to primary care per patient during the initiation phase; 1.5 (SD 1.8) per patient-year during the maintenance phase. Mean 0.4 (SD 0.6) inpatient admissions for AF per patient during the initiation phase and 0.1 (SD 0.3) per patient-year during the maintenance phase. The mean length of hospital stay per admitted patient was 5.6 days during initiation and 6.4 days per patient-year during maintenance. During the ini...
BMJ Open, 2015
Stroke-risk in atrial fibrillation (AF) can be significantly reduced by appropriate thromboembolic prophylaxis. However, National Institute for Health and Care Excellence estimates suggest that up to half of eligible patients with AF are not anticoagulated, with severe consequences for stroke prevention. We aimed to determine the outcome of an innovative Primary Care AF (PCAF) service on anticoagulation uptake in a cohort of high-risk patients with AF in the UK. Methods: The PCAF service is a novel cooperative pathway providing specialist resources within general practitioner (GP) practices. It utilises a four-phase protocol to identify high-risk patients with AF (CHA 2 DS 2-VASc ≥1) who are suboptimally anticoagulated, and delivers Consultant-led anticoagulation assessment within the local GP practice. We assessed rates of anticoagulation in highrisk patients before and after PCAF service intervention, and determined compliance with newly-initiated anticoagulation at follow-up. Results: The PCAF service was delivered in 56 GP practices (population 386 624; AF prevalence 2.1%) between June 2012 and June 2014. 1579 high-risk patients with AF with suboptimal anticoagulation (either not taking any anticoagulation or taking warfarin but with a low time-in-therapeutic-range) were invited for review, with 86% attending. Of 1063 eligible patients on no anticoagulation, 1020 (96%) agreed to start warfarin (459 (43%)) or a non-vitamin K antagonist oral anticoagulant (NOAC, 561 (53%)). The overall proportion of eligible patients receiving anticoagulation improved from 77% to 95% (p<0.0001). Additionally, 111/121 (92%) patients suboptimally treated with warfarin agreed to switch to a NOAC. Audit of eight practices after 195 (185-606) days showed that 90% of patients started on a new anticoagulant therapy had continued treatment. Based on data extrapolated from previous studies, around 30-35 strokes per year may have been prevented in these previously under-treated high-risk patients. Conclusions: Systematic identification of patients with AF with high stroke-risk and consultation in PCAF consultant-led clinics effectively delivers oral anticoagulation to high-risk patients with AF in the community.
Journal of managed care & specialty pharmacy, 2015
A multidimensional approach involving consideration of available resources, individual patient characteristics, patient preferences, and cost of treatment is often required to optimize clinical decision making in the management of atrial fibrillation (AF). In order to bring together varying perspectives on effective tactics and to formulate innovative strategies to improve the management of AF, a think tank consortium of advisors was assembled from across the spectrum of health care stakeholders. Focus groups were conducted and facilitated by a moderator and a notetaker. Participants were asked to comment on preliminary data for the increased prevalence of AF, patterns of treatment, impact of adherence with anticoagulants on clinical and economic outcomes, and opportunities for optimizing treatment.Several recommendations to reach short- and long-term goals in improving AF management emerged from the focus group discussions. These recommendations specifically targeted 3 stakeholder ...
Is treatment of atrial fibrillation in primary care based on thromboembolic risk assessment?
Family Practice, 2003
Background. Antithrombotic treatment in atrial fibrillation should be guided by the risk of thromboembolic events. Although practice studies have shown underutilization of antithrombotics, it is not clear whether physicians make use of thromboembolic risk stratification in their treatment decisions, as recommended in current guidelines. Objective. The aim of the present study was to assess which clinical determinants influence coumarin and aspirin prescription in patients with atrial fibrillation in primary care. Methods. In a cross-sectional study of 15 computerized general practices covering 38 000 patients in The Netherlands, we identified patients with atrial fibrillation using several search algorithms. Determinants of antithrombotic therapy were assessed using polytomous logistic regression analysis. Results. A total of 247 patients with atrial fibrillation were identified among 10 335 patients aged 55 years or over (prevalence 2.4%). Mean age was 77 years (range 55-95); 51% were male. Overall, 52% of the patients used coumarin and 27% used aspirin. About 50% of patients were also treated by a cardiologist. Referred patients were prescribed coumarin more often (63% versus 35%, P Ͻ 0.001). Prior stroke/transient ischaemic attack or systemic embolism [adjusted odds ratio (OR) 5.3, 95% confidence interval (CI) 1.1-24.8], and chronic heart failure (adjusted OR 2.1, 95% CI 0.8-5.1) were independent determinants for coumarin prescription. These associations were less strong for aspirin prescription. However, other established risk factors for future thromboembolic events, such as hypertension and diabetes mellitus, did not lead to higher prescription rates. In contrast, several factors not associated with thromboembolic events, such as chronic (versus paroxysmal) atrial fibrillation (adjusted OR 3.7, 95% CI 1.7-8.2) and longstanding (versus recent) diagnosis (adjusted OR 2.2, 95% CI 1.1-4.5), were also associated with higher coumarin prescription. Conclusion. These results illustrate that physicians' decisions about initiating antithrombotic therapy in atrial fibrillation are not evidence based. They are guided partly by thromboembolic risk stratification, but also by factors insignificant for thromboembolic risk.
The British journal of general practice : the journal of the Royal College of General Practitioners, 2018
Despite improvement in anticoagulation for atrial fibrillation (AF), substantial variation in anticoagulation persists between clinical commissioning groups (CCGs) and regions in England. To identify reasons for variation between English CCGs in anticoagulation for AF. A 4-year observational study from 2012/2013 to 2015/2016, of the national Quality and Outcomes Framework. Multiple regression and Pearson's correlation coefficients were used to analyse anticoagulation for AF in relation to older age, Index of Multiple Deprivation, prescription of non-vitamin K antagonist oral anticoagulants (NOACs), and exception reporting, as well as stroke hospital admission and mortality. The proportion of eligible patients in England prescribed anticoagulants for AF without exceptions for clinical complexity or patient dissent increased from 65.1% in 2012/2013 to 77.9% in 2015/2016. In 2015, 290 920 additional eligible people were anticoagulated in association with use of the CHADSVASc rather...
2018
Background Despite improvement in anticoagulation for atrial fibrillation, substantial variation in anticoagulation persists between Clinical Commissioning Groups (CCGs) and regions in England. Aim We aimed to identify reasons for variation between English CCGs in anticoagulation for atrial fibrillation. Design and setting Observational study based on the national Quality and Outcomes Framework for all CCGs for four years, 2012/13 to 2015/16. Methods Multiple regression and Pearson correlation coefficients were used to analyse anticoagulation for atrial fibrillation in relation to older age, Index of Multiple Deprivation (IMD), prescription of nonVitamin K oral anticoagulants (NOACs) and exception reporting, as well as stroke hospital admission and mortality. Results The proportion of eligible people in England anticoagulated for atrial fibrillation without any exceptions for clinical complexity or patient dissent, increased incrementally from 65.1% in 2012/13 to 77.9% in 2015/16. I...