Why is Atrial Fibrillation a problem in Hounslow borough?
Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia in the UK. 1.4 million people are affected with AF in England, with up to 425,000 people undiagnosed and untreated, 4,949 of which are based in Hounslow borough, West London . AF Prevalence in Hounslow during 2015/2016 was lower than expected at approximately 0.95% rather than the expected prevalence of approximately 1.62%. Patients with AF are 5 times more likely to suffer strokes.
Atrial Fibrillation-related Stroke
Hounslow has a higher than average AF-related stroke rate in its population of 304,686 residents. SSNAP 2014 data for Hounslow CCG, shows that for AF patients not anticoagulated before their stroke, after discharge there was 47% mortality and severe disability in 20% of cases. These statistics in conjunction with the forecasted 3% increase in the Hounslow population over the age of 45 by 2021 and additional 3160 residents over the age of 75, reinforce the need to address the problem of undiagnosed AF the borough.
The estimated cost per AF-related stroke is £12,228 in the first year excluding social care costs. Without preventative treatment, 5% of patients with AF will have a stroke each year.
A health economic evaluation of community based screening in Australia reported that the AliveCor system was cost effective in detecting AF and preventing stroke, with an ICER of £2,799 when compared with standard diagnostic assessment for AF, which included consultation with a GP and a specialist, and a 12 lead ECG (NICE.org.uk).
Hounslow Atrial Fibrillation Quality Improvement Project Screening
The Quality Improvement (QI) team focussed on their aim of improving the quality of care and healthcare outcomes (including stroke prevention) for people with or at risk of AF in Hounslow CCG by April 2017. Using the NIHR CLAHRC NWL’s systematic approach, interventions included:
- A primary care clinical template to improve compliance with NICE guidance and patient-centred anticoagulation choices;
- Deployment of the AliveCor Kardia mobile Electrocardiogram (ECG) device (AliveCor, Mountain View, CA) within 52 Hounslow GP practices coupled with the creation of an AF “at risk” register and patient status alert on the GP practice information system (SystmOne, The Phoenix Partnership, Hosforth, UK) to identify those at high risk of AF to facilitate opportunistic screening;
- Community awareness and screening campaigns were also held in areas where Geographical Information Systems mapping of observed versus expected AF prevalence indicated greater numbers of undiagnosed AF patients.
- Digital postcards have been produced, as a resource for patient education.
Using routinely collected data on registered patients, from 2016 to 2017, the percentage of ‘at risk’ patients screened increased from 5.1% to 13.7%, diagnosed AF prevalence increased to 1%, 479 patients were newly diagnosed with AF, representing an estimated additional 138 patient diagnoses each year. Based on a 5% risk of stroke in AF patients without anticoagulation, if the additional 138 AF patients were not anticoagulated, 10.5 of these patients would be expected to have a stroke within a year. Based on a 64% reduction in the risk of stroke for AF patients on anticoagulation when compared to placebo, it is estimated that if all the 138 additional AF patients were anticoagulated, approximately 6.9 of these patients would have a stroke within a year. The potential additional 4.4 strokes prevented each year (through anticoagulation) in this scenario equates to a yearly potential saving of £54,289.81 (set up and running cost not included).
Improvements have been made to the medication review care pathway for people identified with AF to ensure that evidence-based decisions are made for appropriate use of anticoagulants. The records of 347 patients with AF have been reviewed leading to 33 patients receiving appropriate anticoagulation, who were previously not on the correct medication.
Community champions are patients, religious leaders and other volunteers, which has built capacity in the community for increasing the number of people screened over the last year to 1494 in the community alone.
Several people were identified as having a possible AF and referred to their GP for further consultation. In addition, 22 community champions from various community groups including Age UK and Tesco have volunteered to undertake training using the AliveCor ECG device and to continue screening in the community.
Healthcare Quality Improvement Partnership (HQIP) published a case study (July 2017) sharing this community approach to awareness and screening.