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Quality improvement report
Preventing strokes in people with atrial fibrillation by improving ABC
  1. Jagjot Kaur Chahal1,
  2. Sotiris Antoniou1,2,
  3. Mark Earley3,
  4. Shabana Ali4,
  5. Khalid Saja5,
  6. Harjit Singh4,
  7. Peter K MacCallum6,7,
  8. John Robson8
  1. 1Department of Pharmacy, Barts Health NHS Trust, London, UK
  2. 2Academic Health Science Network, UCL Partners, London, UK
  3. 3Department of Cardiology, Barts Health NHS Trust, London, UK
  4. 4Primary Care & Planned Care, NHS Redbridge Clinical Commissioning Group, London, UK
  5. 5Department of Haematology, Barking Havering and Redbridge University Hospitals NHS Trust, London, UK
  6. 6Department of Haematology, Barts Health NHS Trust, London, UK
  7. 7Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
  8. 8Clinical Effectiveness Group, Queen Mary University of London, London, UK
  1. Correspondence to Jagjot Kaur Chahal; jagjot.chahal{at}nhs.net

Abstract

Nationally, anticoagulation for atrial fibrillation (AF) is improving but remains characterised by marked provider variation. Uncontrolled blood pressure and coronary artery disease further increase cardiovascular risk. Redbridge Clinical Commissioning Group (CCG) and local National Health Service (NHS) hospital trusts supported a programme to improve anticoagulation, blood pressure and cholesterol management; the ABC of AF improvement.

The programme was delivered by a clinical pharmacist in 43 general practices, who used Active Patient Link (APL-AF) software to identify and electronically review the records of AF patients potentially suitable for anticoagulation. These patients were invited for a general practitioner (GP)-pharmacist consultation with initiation of anticoagulation where appropriate. Blood pressure and lipid treatment were also optimised.

The university-based Clinical Effectiveness Group (CEG) provided software support using standard data entry templates from which the APL-AF software was enabled. This identified suitable patients (eg, on aspirin monotherapy, no treatment or inappropriate dual treatments) for clinical and treatment review. It also reported real-time overall practice performance. Additionally, GP education on direct oral anticoagulant initiation in general practices, use of software and performance reviews, took place for all practices in Redbridge.

A weekly multidisciplinary team (MDT) video conference discussed complex patients with a cardiologist, haematologist, GP with specialist interest in cardiology, GP coordinator and clinical pharmacist. This enabled sharing of patient records between GPs and hospital specialists with improved communication and learning.

Over 1 year 2016–2017, anticoagulation in eligible AF patients (CHA2DS2-VASc≥2) increased significantly by 6.3% from 77.0% to 83.3% (p<0.0001), in comparison to 2.8% average improvement in England. Exception reporting was also significantly reduced from 10.0% to 5.8%; a reduction of 4.2% in comparison to a reduction in England of 1.5%. Use of antiplatelet monotherapy was approximately halved, from 12.3% to 6.4%.

These methods are being scaled locally in other London CCGs and are potentially scalable nationally, specifically targeting the poorer performing CCGs.

  • pharmacists
  • primary care
  • quality improvement
  • decision support
  • computerised
  • collaborative
  • breakthrough groups

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2019-000783

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    Footnotes

    • Twitter @ChahalJagjot

    • Contributors JKC, SA, SAl, HS, JR, PKM and KS contributed to the multidisciplinary. All authors contributed to the final editing and approval of the manuscript.

    • Competing interests SA declares personal fees from Bayer, Daiichi Sankyo, Pfizer. KS declares personal fees and non-financial support from Bayer AG and Bristol-Myers Squibb Pharmaceuticals Ltd, personal fees from Pfizer Ltd, non-financial support from Daiichi-Sankyo UK Ltd. PKM declares personal fees and non-financial support from Bayer Pharmaceuticals. All these were outside the submitted work.

    • Patient consent for publication Not required.

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

    • Data availability statement All data relevant to the study are included in the article.