Primary Care
Atrial Fibrillation
Rapid Improvement Guide
This guide has been produced to enable GP Practices and their teams to successfully implement a series of care bundles in a timely manner and apply the Model for Improvement when identifying, diagnosing and managing patient’s with Atrial Fibrillation
The former Public Health Wales Primary Care Quality Team, now incorporated within the Primary and Community Care Development and Innovation Hub, developed a series of quality improvement toolkits to assist practices in collating and reviewing information. From information received, practices still find these toolkits useful, therefore they will remain on this webpage for your ease of reference. Please note, however, that the date of publication is clearly stated in the toolkit and that the evidence within may have changed since publication.
July 2016
The purpose of this guide
This Rapid Guide has been developed by Primary Care Quality Public Health Wales to support general practices working, where appropriate with secondary care colleagues in reviewing their current processes for identifying and managing patients with AF.
Evidence has shown that timely management benefits patients 2,3,4,5 yet patient management is known to be sub-optimal. The National Screening Committee stated in their report of 2014 the following; numerous studies have demonstrated that, among people with AF, compliance with currently recommended anti-thrombotic treatments is poor. Many people who, according to the 2006 NICE guideline, should be on anticoagulants are not; many people who should not be on anticoagulants are on anticoagulants; and among those who are taking warfarin the level of anticoagulation is often too high or too low. (Screening for Atrial Fibrillation in People aged 65 and over; National Screening Committee; May 2014)
How do practices get involved?
This Quality Improvement development is a voluntary subscription to undertake the interventions described in this improvement guide
In order to filter data from the Audit + software in practice, to feed back to practices who have subscribed to the collaborative (s), Primary Care Quality will need to identify who has subscribed to which collaborative
Therefore, PCQ have set up an online registration process for practices who wish to engage in any of the quality improvement topics, please click on the following webpage to register your interest:
http://howis.wales.nhs.uk/sitesplus/888/page/34030
http://www.wales.nhs.uk/sitesplus/888/page/45127
This document is not intended to be a complete reference manual. This guide should be
used alongside the ‘How To’ Guides to support the successful implementation of the programme’s interventions
1. What are we trying to accomplish?
Achieving a reduction in the risk of Stroke in patients with AF
Atrial fibrillation (AF) is an arrhythmia 1,2,3,4 resulting from irregular, disorganised electrical activity in the atria of the heart. AF commonly occurs in association with risk factors, such as hypertension, diabetes and ischemic heart disease.
For patients in whom antithrombotic therapy is indicated, such treatment should be initiated with minimal delay including offering immediate heparin 1 and this guide will suggest an approach that will enable practices to measure processes against a series of evidence based interventions (‘what should we be doing’?). Timely and effective management reduces the risk of stroke 2,3,4,5
2. What should we be doing?
There is much evidence to support the understanding that AF is poorly managed currently, and this seems to be the case nationally. The National Screening Committee was referencing NICE in stating the following; numerous studies have demonstrated that, among people with AF, compliance with currently recommended anti-thrombotic treatments is poor. Many people who, according to the 2006 NICE guideline, should be on anticoagulants are not; many people who should not be on anticoagulants are on anticoagulants; and among those who are taking warfarin the level of anticoagulation is often too high or too low7. It is clear that this should not continue and Primary Care has a lead role in addressing the situation in Wales. Primary Care Quality (PCQ) has used the evidence gathered to produce an AF driver diagram (See page 4) to summarise desired outcomes and how they can be achieved. These outcomes will focus on the key areas of patient’s management, rather than seeking to implement all aspects of management of people with Atrial Fibrillation. These “Drivers” will assist practices to deliver a high level improvement aim through a logical set of underpinning goals.
This Guide therefore seeks to assist practices to assess the quality of the service people with Atrial Fibrillation receive by focusing on key aspects of the relevant guidance, notably the 2014 NICE document (CG180) http://www.nice.org.uk/guidance/CG180 . The NICE guidance offers comprehensive advice to those tasked with managing patients with Atrial Fibrillation. This guide will focus on the central features of Stroke Risk, Anticoagulation Risk and Treatment, with some further reporting around ongoing management.
3. How will we know that change is an improvement?
In order to answer this practices will need a defined process (such as compliance with all elements of a care bundle) which is evidently linked to an outcome (such as an increase in the numbers of CHA2DS2 – VASc assessments undertaken). Both process and outcome data, which are linked, are essential to evaluate the effectiveness of change.
The data the practice collects in real time can be used to tell the improvement story and build the case and/or argument to change practice in order to improve outcomes.
Practices may wish to allocate their own standards to the recommended process measures following a review of their baseline data from PCQ
4. What changes can we make, to the way that we manage
Atrial Fibrillation, that will result in improvement?
The PDSA (Plan, Do, Study, Act) process is a generic set of principles to assist decision making and the quality of a provided service. By examining current practice and comparing against the relevant guidance, variations can be identified by assessing the effectiveness of actions as expressed in the Driver Diagram (p4). Underpinning the PDSA Cycle are three essential questions forming the basis of the Model for Improvement:
1. What are we trying to accomplish?
2. How will we know when we have accomplished what we set out to do?
3. What will we test/try in order to produce the improvement we aim to achieve?
By following PDSA (Plan, Do, Study, Act) cycle practices can test, implement and replicate each intervention within the driver diagram.
Plan; what you are going to do differently? Practices can choose an area where it is thought there may be a gap between current activity and evidence based guidance. Where accepted guidance and current practice differ there may be value in exploring these areas in more detail. Work out (i.e. plan) how and what could be tested so that these differences are reduced.
AF; with regard to the management of Atrial Fibrillation, research would suggest that there is considerable variation between accepted guidance (e.g. NICE) and common practice with regard to management and treatment. Specifically ensuring patients with AF, and with a CHA2DS2 – VASc score of ≥2 (Men=1) and an acceptable bleeding risk are suitably anti-coagulated (in the absence of contra-indications) by use of warfarin or one of the suite of new oral anti-coagulants.
Simultaneously patients with AF are recommended NOT to take an antiplatelet as sole treatment and should only take an anti-platelet if they also have a separate condition where use of this class of drug affords a degree of evidence based protection. These areas of management form the basis of this Quality Improvement Toolkit and are detailed in the Driver Diagram on page 4.
Do; Carry out the plan and collect information on what worked well and what hasn’t worked so well when looking at patients with Atrial Fibrillation.
Continuous data collection will be collected mainly via the Audit+ software. Data will be analysed and fed back to practices and local networks by Primary Care Quality (PCQ). See data measures on Page 14-15.
The first collection of your data will provide a ‘baseline’ of current performance. Thereafter running and reviewing the data collection at an agreed frequency will give you a more regular idea of how well you are doing.
Practices may be able to develop their own run charts from Audit + data at the practice which will be available more frequently than the PCQ reporting
Further information on the construction, interpretation, displaying time series data and analyses of run charts can be found at ‘How to Improve’ Guide
Some key messages:
· Plot data over time; Tracking a few key quality markers, such as completion of Stroke risk assessments (CHA2DS2 – VASc) or anticoagulation risk assessments (HAS-BLED) over time is the single most powerful tool a team can use.
· Seek usefulness, not perfection; Remember, improvement not measurement is the goal. In order to move forward to the next step, a team needs just enough data to know whether changes are leading to improvement. Identifying appropriate people with AF to treat will lead to risk assessment and effective management.
· Use sampling? Where sampling is appropriate it is an efficient way to help teams understand system effectiveness. However with regard to AF management full coverage would be required to maximise the required improvements
· Integrate measurement into the daily routine. Useful data are often easy to obtain without relying on information systems. Practices will find that effective recording of routine data will provide the required information to review and reflect on the management of people with AF.
· Use qualitative and quantitative data. To assess whether quality improvements have been made it is important to consider accessing and reviewing both qualitative and quantitative data
· Understand the variation that lives within your data. Don’t overreact to a special cause and don’t think that random movement of your data up and down is a signal of improvement.
For example
The practice may find the information / data needed is not currently being collected in an easily retrievable format (or coding). If so, you may wish to use standard coding or use a template as your first test of change.
Study; Gather relevant team members as soon as possible after the test (Do) for a short informal meeting. Analyse the information gathered and review the expected outcome the new process or technique against what actually happened. Questions that will help you include the following:
‘What is the information telling us?’
‘What worked and what didn’t work?’
‘What should be adopted, adapted, or abandoned?’
Act; Use this new knowledge (information, data and study) to plan the next test. Agree the changes. If you feel the outcome measures are no longer appropriate, please contact PCQ.
Continue testing in this way, refining the new procedure or technique, Once all the interventions are being applied to 95% of eligible patients, share your ideas and actions with other practices.
The Enquiry Process
The following quality statements describe passages of care that the guidance states will result in effective management of patients with Atrial Fibrillation. The findings, from the audit reports these questions generate will provide useful information about your patients, and how closely the management of these patients relates to the stated guidance.
Care Bundles One, Two and Three will include themes that describe elements of the care process for patients with Atrial Fibrillation. Each bundle will comprise of a set of questions that when answered will together form an outline of the numbers and percentages of patients in the affected cohort that meet the expected standard set by the relevant guidance.
Data to support these statements will be provided electronically by viewing the AF Module within Audit+, accessible to all practices in Wales.
As each patients situation is highly individual it is expected that some of those reviewed will present a treatment history that differs from the central tenants of that guidance, and when this happens it is recommended that the practice investigate further to seek to establish the context surrounding these divergences. Only by taking this extra step of the enquiry process would it be possible to establish fully if that patient’s care could have been more effective, and suggest how it can be improved.
Diagnosis and Stroke Risk (Bundles 1&2)
Statement - All patients with Atrial Fibrillation, diagnosed in the last 12 months have been assessed for Stroke Risk using the CHA2DS2-VASc – VASc criteriaStatement - All patients diagnosed with Atrial Fibrillation ever have been assessed for Stroke Risk using the CHADS 2 or CHA2DS2-VASc – VASc criteria
Evidence – The National Institute of Health and Clinical Excellence currently recommends use of CHA2DS2-VASc (CHF, Hypertension, Age≥75, Age 65-74, Diabetes, Stroke/TIA, Vascular Disease, Female) to assess stroke risk those with: symptomatic / asymptomatic paroxysmal, persistent or permanent AF; atrial flutter/ continuing risk of arrhythmia following cardio-version (NICE; CG180; June 2014)
Furthermore as CHA2DS2-VASc score increases the rate of thromboembolic event within 1 year in non-anti-coagulated patients with non-valvular AF increases also (American College of Cardiology 2015).
Discussion; It should be noted that the adoption of CHA2DS2-VASc is a relatively recent development and previously CHADS2 would have been the recommended guide to stroke risk including within the Quality and Outcome Framework (QoF)
Audit+ will only search for CHA2DS2-VASc recorded in the last 12 months but on review practices may find patients assessed using the earlier model and appropriately recommended for anticoagulation on the basis of that assessment
Practices should be aware, when reviewing patients whose CHA2DS2-VASc assessment was initially below the level where anticoagulation would normally be offered i.e. ≥2 (or considered i.e.1 for a man) that they may have found that their risk factors have increased subsequently and their “score” following this change would suggest a need to repeat the CHA2DS2-VASc assessment at the earliest opportunity. A CHA2DS2-VASc assessment should be completed annually for patients with AF and not anti-coagulated.