Download AF Final Rapid July 2016

Public Health Wales
1000 lives + Atrial Fibrillation Rapid Guide
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
July 2016
Author; Primary Care Quality
Date; Jul 2016
Status: Final
Version: 1
1
Intended audience: Public (Internet) NHS
(Intranet) Public Health Wales (Intranet) PCQ
Public Health Wales
1000 lives + Atrial Fibrillation Rapid Guide
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
Author; Primary Care Quality
Date; Jul 2016
Status: Final
Version: 1
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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
Author; Primary Care Quality
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Driver
Aim
‘What should we be doing?’
Care Bundle 1; Patients Diagnosed with AF in last 12 Months
AF; New Cases
Assessment &
Stroke Risk Reduction
 Identify those with a recent diagnosis of AF (last 12M)
 Perform CHA2DS2-VASc assessment on all patients with a
diagnosis of AF
 Assess Anticoagulation Risk (HAS-BLED)
 All patients with CHA 2DS2-VASc score of ≥2 (men ≥1) are
assessed / considered for anticoagulation.
 Patients with AF who are at risk of stroke, and
Anticoagulation Risk assessed as acceptable are anticoagulated or have a Contra-Indication.
Care Bundle 2; Patients Diagnosed with AF ever
To reduce
the risk of
Stroke
occurring
in patients
with Atrial
Fibrillation
AF; All Cases
Assessment &
Stroke Risk Reduction
 Identify those with a diagnosis of AF ever
 Perform CHA2DS2-VASc assessment on all patients with a
diagnosis of AF
 Identify all patients with AF who are at risk of stroke but
who are not receiving treatment
 Identify all AF patients not receiving treatment, and who
have not had a Stroke risk assessment
 Identify any patients taking an anti-platelet as monotherapy for their AF
Care Bundle 3; Rate, Rhythm and INR Control
Ongoing Management


 Patients with AF have had their Pulse taken and recorded
(Rate / Rhythm)
Patients with AF and taking Warfarin have had their Time
in Therapeutic Range calculated / recorded
Author; Primary Care Quality
Date; Jul 2016
Status: Final
Version: 1
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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.
2.
3.
What are we trying to accomplish?
How will we know when we have accomplished what we set out to do?
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:
Author; Primary Care Quality
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 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.
Author; Primary Care Quality
Date; Jul 2016
Status: Final
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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 criteria
Statement - 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
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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.
A further consideration is that the diagnosis of AF could have been made in a
hospital setting and potentially a CHA2DS2-VASc assessment also. This information
would hopefully have been relayed to the practice, yet the possibility is that it was
not recorded at the practice using the prescribed READ code.
Anticoagulation Risk (Bundle 1)
Statement – All patients with AF and a CHA2DS2-VASc score of ≥2 (≥1 for men)
have undergone an anticoagulation risk assessment within 6 months of diagnosis
and annually thereafter
Evidence - NICE recommends use of the HAS-BLED Risk Scoring Calculator to
assess modifiable bleeding risks to those identified.
In Wales The All Wales Medicines Strategy Group (AWMSG) also endorses the use of
HAS-BLED to assess bleeding risk but also that it is supports consideration of the
correctable risk factors for bleeding, e.g. uncontrolled hypertension, concomitant use
of aspirin/NSAIDs, labile INRs, etc as well as other clinical and social factors e.g.
Whether the patient has a GP, are they being investigated or treated for cancer,
active venous thrombo-embolism, OTC medications or frequent antibiotics,
evidence of trips or falls, sensory visual or literacy impairment, mental health
factors, whether the patient is of child-bearing age. Other factors include;
 Compliance (check time in therapeutic INR range (TTR) if on warfarin)
 Thrombo-embolic events
 Bleeding events
 Other side effects
 Co-medications and over the counter drugs
 Check renal function - if impaired it may constitute a contraindication or
recommendation not to use the anticoagulant or may require a dose reduction;
recommendations differ for warfarin, dabigatran, apixaban and rivaroxaban
NICE recommends that when discussing benefits / risks of anticoagulation,
clinicians explain that for most people the benefits outweigh the risks. For others
this may not be so and careful monitoring of bleeding risk is important.
Discussion;
HAS-BLED is the method recommended currently by NICE to assess anticoagulation
risk but until quite recently, formal assessment of bleeding risk was not a routine
feature of anticoagulation management and even now is not a QoF requirement.
A further complication is that there is no READ Code for anticoagulation risk
assessment, although there is one for Warfarin Risk Assessment, and now of course
we have one for HAS-BLED (38G3.)
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Patients with a CHA2DS2 – VASc score of ≥2 assessed in the last 12 months should
have received a HAS-BLED assessment also, but it is possible that bleeding risk was
assessed using a different set of criteria and recorded as “warfarin assessment”
(66Q1. / 66Q2. / 66QB.) Audit+ will search on all of these codes.
Bleeding risks are susceptible to change and can increase with patient’s
circumstances. Equally risks can be addressed and modified making it important to
re-assess anti-coagulation risk annually to ensure a patient’s suitability for
anticoagulation is unaltered.
NICE states that for people who are not taking an anticoagulant because of
bleeding risk or other factors, review stroke and bleeding risks annually, and
ensure that all review’s and decisions are documented. [NICE; CG180]
Similarly for those taking an anticoagulant, ongoing monitoring is appropriate (review
the need for anticoagulation and the quality of anticoagulation at least annually, or
more frequently if clinically relevant events occur affecting anticoagulation or bleeding
risk. [NICE; CG180]
Anticoagulation (Bundle 1)
Statement – All patients with AF, a CHA2DS2-VASc score of ≥2 (≥1 for men)
and have undergone an anticoagulation risk assessment, and found to be
suitable for anticoagulation have been prescribed warfarin or a NOAC.
Evidence - Anticoagulation may be with apixaban, dabigatran etexilate,
rivaroxaban or a vitamin K antagonist. [NICE; CG180]
Consider anticoagulation for men with a CHA2DS2 – VASc score of 1 OR for all people
with a CHA2DS2 – VASc score of 2 or above, after bleeding risk had been considered.
Discussion
Audit+ will search for all anticoagulants used to treat people (in the previous 6
months) with Atrial Fibrillation who have a CHA2DS2 – VASc score of ≥2 and an
acceptable anticoagulation risk.
People suitable for anticoagulation should be in receipt of a prescription for warfarin
or a NOAC, unless there is a record of the patient having a valid reason for not
taking such drugs.
There are potentially a number of coded reasons for non use of warfarin, such as;
Warfarin Declined (8I3E.); Warfarin Not Indicated (8I65.); Warfarin Not Tolerated
(8I71.); Warfarin Contra-Indicated (8I25.); H/O Warfarin Allergy (14LP.); Personal
History of Warfarin Allergy (ZV14A); Adverse Reaction to Warfarin Sodium (TJ421 /
U6042); Warfarin Therapy Stopped (66Q5.) Some entries may have been included
using free-text, confirming the value of a thorough review of the patient’s records.
Patients not taking Warfarin may be in receipt of an anti-platelet in line with earlier
guidance, and it is these people who would also require further consideration and
counselling regarding anticoagulation, possibly by offering a NOAC.
A small number of patients may have an AF Resolved code following diagnosis, and
such patients will not be included in the baseline Audit+ search.
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Treatment (Bundle 2)
Statement – No patients with AF, and suitable for anticoagulation should be
prescribed an antiplatelet alone for their AF
Evidence - Do not offer aspirin monotherapy solely for stroke prevention to people
with atrial fibrillation (NICE CG180)
Discussion
It should be noted that aspirin is appropriate for patients with co-morbidities such
as Coronary Heart Disease and will feature in the medication records of some
patients with atrial fibrillation. However the guidance is now explicit that Aspirin or
Aspirin/Clopidogrel is not recommended as sole therapy for anyone with AF.
Audit+ will offer a report indicating those with AF who are in receipt of an
antiplatelet but without an anticoagulant. The practice will have the opportunity to
review the records of these patients and decide if the absence of an OAC is
appropriate i.e. whether the patient has previously declined, been found to be
intolerant of, or contra-indicated to OAC and is concurrently taking an antiplatelet
for a reason unconnected to their AF. A thorough record search should also show
any instances of un-coded entries such as free-text diagnoses of conditions that
would be appropriately treated with an anti-platelet.
Audit + will also identify those patients with AF who are not in receipt of either an
anticoagulant or an antiplatelet. Review will reveal if those patients are perhaps in
receipt of over the counter aspirin, recorded as free text. Such patients may have a
very low stroke risk; without any co-morbidity aspirin use would not be recommended.
Ongoing Management (Bundle 3)
Statement - All patients with AF should have a record of Pulse Rate and Rhythm
Evidence – Establishing pulse rate and rhythm is an essential part of controlling
the pulse of patients with Atrial Fibrillation. Once known the practice can begin to
treat the arrhythmia using the appropriate strategy. Rate control should be
offered as first-line for people with atrial fibrillation, except in people:





Whose atrial fibrillation is reversible
With heart failure thought to be primarily caused by atrial fibrillation
With new-onset atrial fibrillation
With atrial flutter and considered suitable for ablation to restore sinus rhythm
Where rhythm control would be preferred based on clinical judgement (NICE CG180)
In considering ‘Rate versus Rhythm Management, The Atrial Fibrillation
Association recommend that if the heart rate is acceptable, and the patient is
asymptomatic, then only the medication to reduce stroke risk needs be considered.
However if heart rate is rapid or during activity, then a patient will need medication
to reduce it, usually by commencing treatment with either a beta-blocker or a rate
limiting calcium channel blocker (AFA 2009).
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Discussion – Earlier quality improvement (QI) work involving AF, and testing of
the Audit+ module in practice would suggest that pulse rate and rhythm may not
be routinely recorded. Practices who find this to be the case would have to consider
the recording of this aspect of monitoring to be developmental, and consider ways
to increase recording in future.
Statement – All patients taking warfarin for at least 3 months should have their
INR checked periodically and their Time in Therapeutic Range recorded
Evidence - Assessing anticoagulation control with vitamin K antagonists
NICE advocates that when monitoring warfarin use it is essential the responsible
clinicians calculate the person's time in therapeutic range (TTR) at each visit.
When calculating TTR: use a validated method of measurement such as the
Rosendaal method for computer-assisted dosing or proportion of tests in range for
manual dosing exclude measurements taken during the first 6 weeks of treatment
calculate TTR over a maintenance period of at least 6 months (CG180)
Re-assess anticoagulation for a person with poor anticoagulation control shown by
any of the following:
 2 INR values higher than 5 or 1 INR value above 8 within the past 6 months
 2 INR values less than 1.5 within the past 6 months
 TTR <65%
When reassessing anticoagulation, take into account and if possible address the
following factors that may contribute to poor anticoagulation control:





cognitive function
adherence to prescribed therapy
illness
interacting drug therapy
life-style factors including diet and alcohol consumption (NICE CG180)
Discussion – Practices may find this to be another aspect of care where
demonstrating achievement is difficult in terms of accessing the continuous INR
readings necessary to assess Time in Therapeutic Range (TTR). This could be
because the practice utilises a stand-alone anticoagulation management system
such as INR Star or RAT that would NOT relay INR results back into the main
practice computer system. In such circumstances consider a reasonable proxy to
be a record that TTR is calculated and used to assess a patient’s management.
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Further Key Messages from NICE Update (CG 180 June 2014)
The current NICE guidance seeks to place patients at the centre of the care process
and CG180 states; Patients should have the opportunity to make informed
decisions about their treatment, in partnership with their healthcare professionals.
This commitment is recommended stating that people with AF should be offered a
personalised package of care to include;
 stroke awareness and measures to prevent stroke
 rate control (pulse regular/irregular)
 assessment symptoms for rhythm control;(syncope / dizziness / dyspnoea /
palpitations / chest discomfort / TIA)
 who to contact for advice if needed
 psychological support if needed
 up-to-date education / information, to include; cause, effects, complications,
management of rate / rhythm, advice on anticoagulation and support networks
Referral for specialised management; NICE recommends referral to specialist
management for people with AF whose treatment fails to control the symptoms
When assessing anticoagulation control with vitamin K antagonists, calculate
the person's time in therapeutic range (TTR as a percentage) at each visit.
Use computer-assisted dosing / proportion of tests in range for manual dosing
(exclude measurements taken during the first 6 weeks of treatment) calculate TTR
over a maintenance period of at least 6 months.
Reassess anticoagulation for a person with poor control i.e. any of the following:
 2 INR values higher than 5 or 1 INR value higher than 8 within the past 6 months
 2 INR values less than 1.5 within the past 6 months
 TTR less than 65%
Proportion of tests in range for manual dosing (exclude measurements taken in the
first 6 weeks of treatment) calculate TTR over a maintenance period (≥6 months)
When poor anticoagulation control cannot be improved, evaluate the risks/benefits
of alternative stroke prevention strategies and discuss these with the person
When reassessing anticoagulation, consider and where possible address;
●
●
Cognitive function ● Adherence to prescribed therapy ● Illness
Inter-acting drug therapy ● Lifestyle factors (e.g. diet and alcohol consumption)
If poor anticoagulation control persists evaluate the risks and benefits of
alternative stroke prevention strategies and discuss these with the person
Patient Information; There are many patient information sources relating to the
use of anticoagulants. Patient.Co.UK provides a comprehensive set of guidance.
Recent guidance from the National Screening Committee Report, in their report
- Screening for Atrial Fibrillation in People aged 65 and over; A report for the
National Screening Committee (May 2014) questions the validity of screening
people for atrial fibrillation in the absence of symptoms.
http://www.screening.nhs.uk/atrialfibrillation
A Summary of Recommendations includes;
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 A national AF screening programme (≥65) may be more beneficial than harmful
but cost-effectiveness is unknown at population level
 Current NHS management of AF, detected through routine clinical practice is
known to be frequently poor.
 The NHS should greatly improve management of AF before considering a National
Screening Programme. A screening programme in the absence of this is unjustified.
 The quality of anticoagulation in patients, taking warfarin is not routinely reported.
 New oral anticoagulants could lead to better NHS management of patients with
AF, but this has yet to be demonstrated in practice;
Full explanations of the Committee’s conclusions are to be found at;
http://www.screening.nhs.uk/policydb_download.php?doc=447
References
1 NICE; CG180; Atrial Fibrillation The Management of Atrial Fibrillation June 2014
2 European Society of Cardiology (ESC) Guidelines for the management of
atrial fibrillation 2012
3 National Service Framework for Wales Cardiac Disease : Standard 5 Arrhythmias
2009 http://wales.gov.uk/docs/dhss/publications/090706cardiacNSFen.pdf
4 National Assemble for Wales Health and Social Care Committee; Inquiry into
follow up inquiry 2013
5 The Stroke Prevention in Atrial Fibrillation Expert Report (SAFE) 2012
6 European Heart Rhythm Association;
European Heart Rhythm Association et al. Guidelines for the management of atrial
fibrillation: the Task Force for the Management of Atrial Fibrillation of the European
Society of Cardiology (ESC). European Heart J. 2010 (19):2369-429
7 The UK NSC policy on Atrial Fibrillation screening in adults 2014
http://www.screening.nhs.uk/atrialfibrillation
8 The Atrial Fibrillation Association ; Rate versus rhythm management (2009)
http://www.atrialfibrillation.org.uk/files/file/141105-cjw-Fin%20%20%20Rate%20vs%20Rhythm%20Management%20PFS.pdf
Author; Primary Care Quality
Date; Jul 2016
Status: Final
Version: 1
13
Intended audience: Public (Internet) NHS
(Intranet) Public Health Wales (Intranet) PCQ
Public Health Wales
1000 lives + Atrial Fibrillation Rapid Guide
Process Measures
To assess the application of the interventions, use the following search criteria (as per audit+ software) which will be collected and
analysed by PCQ and reported back to individual practices.
AF; Stroke Risk Reduction.1
Total
Care Bundle 1
Diagnosed in the last 12 Months
Audit+ Descriptor
1A
All patients with a confirmed diagnosis of AF recorded in the last 12 months
1B
Of 1A Patients with CHA2DS2-VASc recorded within 6 months of diagnosis
1C
Of 1B Patients with CHA2DS2-VASc score ≥ 2 (males=1)
1D
Of 1C Patients have had an Anticoagulation Risk Assessment
1E
Of 1D Patients have had a HASBLED assessment
1E
Of 1D Patients are currently in receipt of an anticoagulant or Non Compliant (see below)
Stroke Risk Assessed
Anticoagulation Risk Assessment
Anticoagulation Therapy
Recorded Non-Compliance; Warfarin Declined; Warfarin Not Indicated; Warfarin Not Tolerated; Warfarin Contra-Indicated;
H/O Warfarin Allergy; Personal History of Warfarin Allergy; Adverse Reaction to Warfarin Sodium; Warfarin Therapy Stopped
Author; Primary Care Quality
Version: 1
Date; Jul 2016
Status: Final
14
Intended audience: Public (Internet) NHS
(Intranet) Public Health Wales (Intranet) PCQ
Public Health Wales
AF; Stroke Risk Reduction.2
Care Bundle 2
Diagnosed ever
Stroke Risk
1000 lives + Atrial Fibrillation Rapid Guide
Total
Audit+ Descriptor
2A
All patients with a confirmed diagnosis of AF recorded ever
2B
Of 2A Patients with CHA2DS2-VASc recorded within last 12 Months
2C
Of 2B Patients with CHA2DS2-VASc score ≥ 2 (males=1)
2D
Of 2C Patients at risk of stroke but NOT on anticoagulation therapy
2E
Of 2D Patients who are currently taking an anti-platelet as mono-therapy
2F
Of 2A Patients NOT taking an anticoagulant and have not had CHA2DS2-VASc assessed
Recorded Non-Compliance; Warfarin Declined; Warfarin Not Indicated; Warfarin Not Tolerated; Warfarin Contra-Indicated; H/O
Warfarin Allergy; Personal History of Warfarin Allergy; Adverse Reaction to Warfarin Sodium; Warfarin Therapy Stopped
Care Bundle 3
AF; Ongoing Management
Pulse Rate and Rhythm
INR Control
Total
Audit + Descriptor
3A
Patients that have a diagnosis of AF recorded ever (and not later resolved)
3B
Of 3A Patients who have had a pulse rate recorded in the last 13 months
3C
Of 3A Patients who have had a pulse rhythm recorded in last 13m
3D
Of 3A Patients taking Warfarin and whose Time in Therapeutic Range (TTR) is recorded
Author; Primary Care Quality
Version: 1
Date; Jul 2016
Status: Final
15
Intended audience: Public (Internet) NHS
(Intranet) Public Health Wales (Intranet) PCQ
Public Health Wales
1000 lives + Atrial Fibrillation Rapid Guide
Practice Reflection Sheet
What did the practice learn from carrying out this quality improvement review?
What changes, if any have the practice agreed to implement as a result?
What collective strengths and weaknesses did the practice recognise that would
enable the practice to enhance the service it provides to patients?
What collective strengths and weaknesses did the practice recognise that would
enable the practice to develop the skills of others?
Author; Primary Care Quality
Date; Jul 2016
Status: Final
Version: 1
16
Intended audience: Public (Internet) NHS
(Intranet) Public Health Wales (Intranet) PCQ