Improving diagnosis and treatment for atrial fibrillation

Around a million people in the UK suffer from atrial fibrillation, an irregular heartbeat associated with coronary heart disease, which causes dizziness, tiredness and shortness of breath. Without appropriate treatment, people with atrial fibrillation are up to five times more likely to suffer strokes, with the risk of severe disability and early death.

In 2014, NICE estimated that around 250,000 people in the UK have undiagnosed atrial fibrillation. Meanwhile a huge proportion of those who have been diagnosed are not receiving the correct anti-coagulation medicine to prevent stroke. Based on these numbers, better diagnosis and treatment could prevent around 7,000 strokes, avoid more than 2,000 people suffering severe disability, and prevent 2,000 premature deaths each year.

In 2014, the Innovation Agency (the AHSN for the North West Coast) launched a major programme to improve diagnosis and treatment for people with atrial fibrillation, with the aim of cutting the region’s higher than average number of strokes each year. This has included a particularly wide range of projects including awareness-raising campaigns, support for the introduction of new mobile technology, the implementation of a more effective stroke prevention pathway, and rigorous benchmarking of local systems’ performance in improving outcomes. 

As Julia Reynolds, Head of Programmes, explained, the initial challenges were to raise awareness of the problem and support more effective early diagnosis of atrial fibrillation. The team ran public-facing campaigns with charities and other partners and events for clinical staff to raise awareness of the importance of checking for abnormal heart rate. It also invested in introducing new, relatively low-cost diagnostic tools, MyDiagnostick and the Kardia AliveCor, into 150 GP practices and community services so that they could rapidly and accurately identify irregular heart rhythm in the community. In a single year, this potentially enables 180,000 new screenings that may have prevented 70 or more strokes per year, with savings of £1,680,000 in NHS and social care costs.

Since then, the team has pursued opportunities for a broader range of services to check people’s heart rate in different settings, including pharmacies and adult social services. In one area, the clinical commissioning group is training the fire and rescue service to carry out heart-rhythm checks as part of their ‘safe and well’ visits, which focus on helping older people prevent domestic fires. So far, more than 1,000 screens have been carried out with 29 people identified with irregular pulses, potentially avoiding one to two strokes this year. In total it is estimated that the Innovation Agency has prevented around 256 atrial fibrillation-related strokes since it started its work in 2014.

As part of the programme, the Agency has worked closely with more than 25 external partners including pharmaceutical firms, charities and clinical bodies. For example, it has secured more than £250,000 in match funding from pharmaceutical firms and device manufacturers that have an interest in effective diagnosis and adoption of good treatment practice. As Julia explained, some NHS organisations in the region were nervous of partnership working with private providers, in particular for fear of creating conflicts of interest. The AHSN played an important role brokering and overseeing these alliances between private providers and NHS organisations so that the NHS could benefit from financial support and expertise from the private sector while managing perceived risks.

With increasing numbers of patients diagnosed with atrial fibrillation, a second major challenge was to improve treatment and address variations between services, in particular ensuring that people were taking the right doses of anti-coagulation drugs and that their blood clotting times remained within an appropriate range. While warfarin is a cheap and effective anti-coagulant, patients respond differently to the drug, in part because of adherence to their medication plan, lifestyle choices and genetic make-up. Part of the AHSN’s approach has been to support a new commissioning toolkit and pathway for treatment of atrial fibrillation, with the focus on using available technology and making better initial routine assessment of patients with atrial fibrillation, better approaches to calibrating warfarin doses, use of alternative drugs for some patients, and more effective support for patients to manage their conditions on their own. It has also shared with GPs the North East and North Cumbria AHSN’s Atrial Fibrillation Card Deck, a user-friendly guide to effective management of atrial fibrillation in primary care.

For Julia, there is an important role for awareness-raising activities and investment in materials that synthesise the evidence and explain good practice. However, there also needs to be active engagement with clinicians to persuade them of the need for change and win them over to new approaches, and practical support for providers to make purposeful changes to systems and processes, ‘Otherwise, there is a risk that only the most “sticky” innovations get adopted or only the most enthusiastic individuals are able to introduce them effectively and sustainably.’ (As Julia notes, the publication of NICE guidance in 2014 was not, in itself, sufficient to drive rapid changes in how services are delivered.)

As the programme has developed, the Innovation Agency has therefore provided hands-on support to make it easier for providers to improve care pathways. For example, it is working with a collaborative of clinical commissioning groups and more than 100 GP practices in Cheshire and Lancashire to implement changes to preventive services for people with atrial fibrillation. In doing so, it is drawing on the West of England’s quality improvement programme, ‘Don’t wait to anti-coagulate’, which includes tools for assessing performance and testing changes to anti-coagulation services.  Alongside this, the Agency has adopted the Greater Manchester AHSN’s Atrial Fibrillation Data Landscape Tool, which brings together existing data on service performance and provides a basis for comparing services and identifying opportunities for improvement. 

One notable feature of the project has been the degree of joint working across the large numbers of AHSNs that are focusing on atrial fibrillation as a priority. Julia highlighted the opportunities to share learning and adopt tools and approaches developed by other AHSNs, while individual AHSNS remained responsible for supporting implementation in their regions, drawing on strong links with local organisations and their understanding of the local context. 

Like other interviewees, Julia emphasised the challenges of supporting adoption and spread of innovation in highly fragmented local systems. It was particularly difficult to make rapid progress when she needed to engage with individual clinical commissioning groups and providers. Conversely, it was possible to work much faster when there were established forums bringing together commissioners and the providers of specific services across the region, particularly if there was a degree of shared governance and administrative infrastructure to set shared objectives and monitor progress. The partnerships responsible for delivering the two sustainability and transformation plans for the North West Coast might provide a basis for making progress across the whole region in future. 

Like other projects we looked at, the Innovation Agency’s atrial fibrillation programme is fast moving and continuing to evolve. Current projects include genotype-guided dosing for patients using warfarin in anti-coagulation clinics so that they can be prescribed the right dose of warfarin or consider alternative drugs faster if a sensitivity is identified. The AHSN is also exploring scope for patients to play a more active role in monitoring their conditions. (There is evidence that supporting patients to monitor their own blood-clotting times helps to improve management of the condition and their time in therapeutic range). This means that the evidence base needs to evolve too, and much more quickly than it is currently. The Innovation Agency is evaluating the impact of introducing new diagnostic tools, genotype-guided dosing, and self-monitoring as well as other digital innovations.