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Research and Development

AbstractAtrial fibrillation is the most common heart rhythm disturbance. It is

associated with a five-fold increase in stroke. Warfarin is an effective

anticoagulant for the prevention of stroke but is underused.

This article describes a pilot which found that providing generalpractices with expert advice and education from an arrhythmia nurse

increased the numbers of patients with atrial fibrillation being

prescribed warfarin to reduce their risk of stroke.

Closer links were forged between primary and secondary care and

the pilot also demonstrated savings both financially and in terms of

strokes prevented

Key words

wAtrial fibrillation wStroke prevention wArrhythmia nurse

specialist wSavings wPrimary care

Submitted for review 9 July 2012. Accepted for publication 28 August 2012.

Conflict of interest: None declared

Atrial fibrillation (AF) is the most common heartrhythm disturbance, occurring in 12% of thepopulation. In South London primary care trusts

(PCs), the observed prevalence of AF ranged from 0.7%to 1.2% over the years 20072010 (NHS InformationCentre for Health and Social Care, 2011). It is estimatedthat due to silent undetected AF, the true prevalence ofAF may be closer to 2% of the population. Because theprevalence of AF increases with age, we can expect to seea rise in the future, as the population ages.

AF increases the risk and severity of stroke and peoplewith AF are five times more likely to have a stroke thanpeople with a normal heart rhythm (Camm et al, 2010).Strokes caused by AF result in far greater morbidity andmortality compared with strokes due to other causes.Overall death rates are doubled by AF and only antithrom-

botic therapy has been shown to reduce AF-related deaths.Te costing report produced to accompany the NationalInstitute for Health and Clinical Excellence (NICE) guid-ance on AF (NICE, 2006) concluded that warfarin wasunderused: it was estimated that 46% of patients whoshould have been on warfarin were not receiving it.

Te benefits of warfarin, particularly for an elderlpopulation, were confirmed by the BAFA (BirminghamAtrial Fibrillation reatment of the Aged) trial (Mant et al2007), which importantly showed no increase in bleedincompared with aspirin.

Since the publication of the European Society oCardiology guidelines on AF (Camm et al, 2010), there iclear guidance on stroke risk stratification in this group opatients. However, despite evidence of its benefits andefforts to increase usage, anticoagulation in patients withAF remains underutilised.

Te risk of stroke can be assessed using the CHADS2o

CHA2DS

2-VASc stroke risk stratification schemes. At th

time of the pilot NICE was consulting on the use of thCHADS

2score for potential new AF Quality and Outcome

Framework (QOF) indicators (the incentives scheme fo

GP practices, introduced as part of the General MedicaServices Contract), so this was this scheme selected for usin our pilot. Subsequently the CHADS

2score (Table 1) ha

been incorporated into the new QOF indicators fo2012/13 (NHS Employers, 2012).

Previous workTroughout 2010 the South London Cardiovascular andStroke Network (SLCSN) participated in a Heart andStroke Improvement Programme National Priority Projec

Stroke prevention in primary care:optimising management of AF

through nurse specialist supportGillian Fox-Wilson is Senior Project Manager, South London Cardiovascular and Stroke Network, 84 Kennington

Road, London, SE11 6NL; Stephanie Cruickshankis BHF Arrhythmia Nurse Specialist, St Helier Hospital, Surrey.

Email: [email protected]

Clinical risk factor for stroke Score

Congestive heart failure 1

Hypertension 1

Age > 75 1

Diabetes 1

Stroke/transient ischaemic attack (TIA)

(previous history)

2

Warfarin indicated when CHADS2score >1

(adapted from Gage et al, 2001)

Table 1.

CHADS2stroke risk scoring system

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Research and Developmen

(NPP) on Stroke Prevention in Primary Care: AddressingAtrial Fibrillation. Te project aimed to provide a strategicvision for improving and redesigning care for patientswith AF throughout South London by the following keywork areas:

w Increase the observed prevalence of AF by enhancing

the identification of new AF patientsw Optimise treatment for AF by increasing the percentageof patients on anticoagulation, and increase the use ofstroke risk stratification tools

w Review and stock take of existing services i.e. anticoagu-lation services and primary care ECG services

w An educational component for both staff and patients onidentification and management of AF in primary care.Steering groups in four South London PCs were estab-

lished in 2010, with membership drawn from primarycare GPs, information management facilitators, commis-sioners, secondary care cardiologists and arrhythmianurse specialists.

As this NPP drew to a close at the end of 2010, SLCSNlooked to see where the most benefits to patients with AFcould be made, which could be explored further in a sec-ond phase of this stroke prevention work.

Following a review of the lessons learned from the NPPit was decided to further develop the work around opti-mising stroke prevention in AF.

AimTe main aim of this work was to determine if providing GPpractices with specialist support from an arrhythmia nursewould increase the numbers of patients with AF at risk of

stroke (CHADS2 score >1), being prescribed the oral anti-coagulant warfarin to reduce the risk of stroke.

MethodSLCSN approached the south London hospital-basedarrhythmia nurse specialists (ANSs) in September 2010,inviting interest in a secondment to support primary careto optimise treatment of AF. Te ANS awarded the rolewas based in a hospital trust located in one of the PCsparticipating in the NPP. It therefore made sense to pilotthis more intensive work to optimise treatment of AF withpractices in this locality. Te ANS was able to commit aday and a half each week to the project.

A SLCSN-facilitated stroke prevention education event,held in October 2010, attracted 56 GPs from the pilot PC.Presentations at this event focused on AF, including thebenefits of the stroke risk stratification toolGuidance onRisk Assessment and Stroke Prevention for AtrialFibrillation (GRASP-AF)

Following the engagement and outreach work through-out 2010, including the education event, by the end of theyear 20 out of 56 practices in the PC (37%) expressed aninterest in participating in the project. Practices wishing toparticipate in the project and benefit from a visit from thearrhythmia nurse were required to first download theGRASP-AF tool and then upload practice data anony-mously to CHAR-Online.

As previously described by yndall and Holding (2009)GRASP-AF is a free GP database-interrogation tool forimproving the management of AF. Te tool originated inthe West Yorkshire Cardiovascular Network and has beendeveloped and promoted by a dedicated team includingJames Barrett (I manager), Dr Matt Fey (GP), Ian

Robson (senior I analyst) and Richard Healicon (bothNHS Improvement), Keith yndall (arrhythmia nurse)and Dr Campbell Cowan (consultant cardiologist).

GRASP-AF identifies patients with atrial fibrillation then:w Searches for co-morbidities and works out both aCHADS

2and CHA

2DS

2-VASc score

w Searches for current medicationwarfarin, aspirin ornewer oral anticoagulant

w Searches for recorded reasons for not treating withwarfarin

w Gives a simple alert for those at high risk and not onwarfarin (or a newer oral anticoagulant).CHAR-Online is a web-based comparative analysis

tool that allows practices to track their improvements inAF management and compare their results anonymouslywith local practices and with national results.

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Effective team workA team approach was key to the success of this projectwith the following important contributors:

Arrhythmia nurse specialist

Te central and crucial role: providing clinical expertise,

education and advice to general practice and forming alink between primary and secondary care.

GP lead

Strong support from an enthusiastic clinical champion(the PC GP cardiovascular disease lead) promoted thepilot to colleagues and helped engage practices, so wasinstrumental in getting the project off the ground

Commissioning

Commitment from a PC senior commissioning managerassisted in driving the work forward and ensured its legacylocally at the end of the pilot.

South London Cardiovascular and Stroke Network

Instigated and directed the pilot. Background work withthe primary care steering groups during the NPP and edu-cation events raised the awareness of the problem. Teteam also provided project management and data analysisthroughout the project.

IT support from PCT information manager

Te information manager was available to help practicesdownload and run the GRASP-AF tool and to encouragethem to upload their baseline data to CHAR-Online

ahead of the ANS visit. Tis role was crucial in helpingpractices prepare their data ready for the visit from thearrhythmia nurse. It maximised the use of the ANSsclinical expertise.

TimescalesTe ANS secondment started at the beginning of 2011.She began contacting the 20 practices that had expressedinterest in participating in the project. Mutually conven-ient times for visits were arranged. Of the 20 practicescontacted 19 were visited as one practice declined. Aer

visits to the practices were completed in April, the ANSthen wrote to practices with both their own individual

results and the anonymised findings across all the partici-pating practices.

Te individual data had been collected during the prac-tice visit, prior to uploading on to CHAR online.Individual practices were not identified to each other tomaintain anonymity. Practices were asked to bring thepatients in for review of treatment and then re uploadtheir data to CHAR-Online to demonstrate the differ-ence from their baseline.

Practices received a further written reminder in Julyfrom the PC (rather than the ANS) to complete theirpatient reviews and re-upload the new data. Te GPs werealso given the opportunity to share their views about theproject via a short online survey.

Role of the arrhythmia nurse specialistTe ANS adopted a flexible approach to the practice visitand tailored the education and support according to thneeds of the individual practice. Te majority of visitinvolved the ANS on a one-to-one basis, giving a brieoverview of AF, the importance of oral anticoagulation in

the reduction of stroke risk, up to a more structuredpractice-based formal teaching session on AF, includinan explanation on how to use CHADS

2to assess risk, and

oral anticoagulation.Scope of the ANS role included:

w Provision of specialist arrhythmia advicew Help practices plan care for AF patientsw Bridge gap between primary and secondary carew Support with stroke risk assessmentw Education including warfarin anticoagulationw Review GRASP results particularlyw Patients identified with CHADS

2>1 not on warfarin.

w Use clinical expertise to conduct a thorough notereview of these at-risk patients then discuss with GP(sreasons for patients not being on warfarin

w Leave practice with list of patients to bring in for faceto-face review with GP to discuss oral anticoagulationwith warfarin

w Evaluate results.

ResultsDespite encouragement from the ANS and the PC, only12 practices of the 19 visited re-uploaded their data toCHAR-Online to allow a comparison with their baselindata. Baseline and post-project data is therefore availabl

for 63% of practices visited.It is worth highlighting that, unlike many other similaprojects around the country (NHS Improvement, 2009)practices were not offered any financial incentive to participate in the project or share anonymised data.

Te data available for evaluation, and presented in Table and Figure 1, refer to the 12 practices that:w Received an education and support visit from the AN

andw Up-loaded anonymised baseline andpost-project infor

mation data to CHAR-Online.

Increase in size of AF register

Although the aim of the project was to optimise treatmenrather than increase the identification of AF, a smaincrease in the numbers of patients on the AF register waobserved. Across the 12 practices with pre and postproject data, the AF register rose from 1405 to 1446, anincrease of 41 patients (in percentages, a change from1.26% at baseline to 1.29% post-project).

Patients identified for revieww 195 patients identified for face-to-face review with GPfollowing ANS visit

w GRASP-AF tool showed these patients had CHADSscore of >1, yet they were not receiving any warfarinanticoagulation to reduce their risk of stroke

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Baseline Post-project Increase

Number of AF patients 1405 1446 41

Number of CHADS2>1

patients on warfarin

445 505 60

Proportion of CHADS2>1

patients on warfarin

57.27% 60.92% 3.65%

National comparator 53.82% 55.33% 2.05%

Table 2.

Results from the 12 practices uploading data

w 195 patients identified for review, of these 60 patientsstarted on warfarin, or a 31% conversion rate

w Variation between practices for the proportion of theirCHADS

2>1 patients on warfarin at baseline, which

ranged from 27% to 68%w Post-project variation still seen with range 3975%

w Both at baseline and post-project the results from thepilot practices were above national average.Reasons for not using warfarin varied considerably

between practices. Tese ranged from those who werereluctant to prescribe to the elderly, or patients who livedalone, or had a recent fall, to those who were deemedunable to be safely monitored due to confusion, having

vision problems (with warfarin being a variable daily dose,there were concerns about being able to distinguishbetween the different tablets) or those who lived in a nurs-ing home.

Saving potential for South London (allboroughs extrapolated)If the pilot were extended to cover the entire SouthLondon region there is the potential each year to prevent73 strokes and save 95 608:

w Pilot (97 499 population) saved 3,020w South London (2 971 467 population) could potentiallysave 95 608

w Pilot (97 499 population) prevented 2.4 strokesw South London (2 971 467 population) could potentiallyprevent 73 strokes

ANS evaluation

Te ANS found her role to be both varied and challenging.Her primary role was to support GP practices to clinically

review their AF registers and to provide education andadvice on the management of patients with AF. Her prin-ciple concern was to reduce the risk of stroke, so a thor-ough discussion on warfarin usage and the risks andbenefits was the key focus.

Te ANSs role was to go into practices once theGRASP-AF tool had been run, and to review the resultswith a clinician. Many GPs had reviewed their patientsprior to the ANSs visit, and in these practices she was ableto help decision making in their challenging patientsforinstance, patients with prior bleeds or presumed contrain-dications to warfarin. Other practices benefitted from theANS going through the list, patient by patient, and dis-cussing them on an individual basis.

It was found that some GPs were withholding warfarinin the belief that patients would refuse therapy or be non-compliant. In one study comparing doctor and patient

preferences, patients had a lower threshold for acceptingwarfarin (Man-Song Hing et al, 2007). Decision aids have

80%

70%

60%

50%

40%

30%

20%

10%

0%

Figure 1. Change in proportion of patients with CHADS2score > 1 who were on warfarin, by GP practice

Baseline

Post-project

A B C D E F G H I J K L Total National

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also been shown to be useful in selected situations to assistpatients in making treatment decisions (Holbrook et al,2007). Other concerns included drug interactions, poly-pharmacy, and unstable international normalized ratios(INRs). Another long-held concern is the risk of bleeding,especially in those with frequent falls, despite strong evi-

dence that the risk of falls and bleeding is over-estimatedagainst the risk of stroke, especially in the elderly. Man-Son-Hin et al (1999) stated that a person taking warfarinmust fall about 295 times in one year for warfarin not tobe considered the optimal therapy.

Simple steps to improve AF stroke prevention that couldbe instigated include adding manual pulse check to alltemplates including chronic diseases. Te ANS found insome practices that healthy people were having manualpulse checks, but not those on the chronic disease register.Instigating this would allow opportunistic and routinescreening for high-risk patients.

Facilitating improved access to warfarin testing in pri-mary care will also be key to improved anticoagulationuptake. As the ANS and GP cardiovascular disease leadpointed out, this stroke prevention work targets elderlypopulations, some of whom are housebound, perhaps liv-ing alone, who find it more difficult to access these serv-ices. Careful scrutiny of domiciliary phlebotomy servicesand improved access to home testing is also vital.

Important outcomes from the ANSs perspective werebridging some of the gaps between primary, secondaryand tertiary care, increasing awareness of the risk ofstroke, promoting the use of risk stratification tools toevaluate risks, and optimising prescribing oral anticoagu-

lation in those patients.Continuing to provide this service in primary care willhelp to make the best use of valuable NHS resources, as itcosts a lot less to prevent a stroke, than it does to treatsomebody aer a stroke.

GP evaluationGPs were given the opportunity to evaluate the project viaa short online survey.

w 100% found the GRASP-AF tool useful and easy to use,

with half responding very easy and half moderately easyw All would recommend GRASP-AF to colleaguesw 80% thought that I support was important to assiswith downloading GRASP-AF

w Te education and support visit from the ANS wafound to be very useful or quite useful by 83% of GP

w Improved links between primary and secondary carand advice and education about management of patientwith AF were the most highly valued aspect of the ANintervention, followed by advice and education abouanticoagulation

w 100% felt the project had raised their practices awareness of AF and stroke risk and all planned to use thCHADS

2score to review AF patients in the future.

w All practices indicated that they would be interested inattending future education events about arrhythmimanagement including stroke prevention.

DiscussionTe pilot demonstrated that intervention from an ANSproviding education and advice to general practice, didincrease the numbers of patients at risk of stroke beingprescribed warfarin. Comparing this pilot with the national picture using CHAR-Online, shows a greater percentage increase in patients converted to warfarin. o thauthors knowledge there is no other published literaturto date demonstrating the impact of taking highly-experienced hospital-based ANS expertise out into primary care

Feedback from practices indicated a desire for a pathway for the management of AF in primary care. Concurrento this pilot work, the SLCSN brought together relevan

clinicians from primary and secondary care to developsuch a pathway, to be used in conjunction with an arrhythmia traffic light referral system (www.slcsn.nhs.uk/af).

Following on from the success of the pilot, educationevents have taken place across South London and planare in place to use the lessons learned to facilitate locaANSs to support primary care in their AF managemenacross all south London boroughs.

New challenges from the introduction of new oral anticoagulant drugs, an increasing elderly population andchanges to the way care is commissioned will mean thapractitioners will need to be flexible in their approach tstroke prevention and AF management.

Te new QOF indicators in AF should result in increaseengagement from primary care and renewed focus on AFstroke prevention. Ongoing education will be an important role for SLCSN.

Recently several new oral anticoagulants have beenlicensed for stroke prevention in AF. Dabigatran and rivaroxaban were recommended as options for AF stroke pre

vention by NICE earlier this year. Tese have a more predictable anticoagulant effect so do not need regular bloodtests to monitor treatment and may be suitable for patientunable to take warfarin. However, the additional costs othese new agents mean that health economies will need tolook at pathway redesign and realignment of anticoagulant services involving all stakeholders.

Key Pointsw Atrial fibrillation is the most common sustained heart rhythmdisturbance

w Atrial fibrillation is associated with a 5-fold increase in stroke

w Warfarin is effective in reducing the risk of stroke but is underused

w A pilot using arrhythmia nurse support to primary care led to an

increase in numbers of patients at risk of stroke being prescribed

warfarin

w The pilot demonstrated cost savings as well as preventing strokes

w Taking hospital-based arrhythmia nurse exper tise out into general

practices promotes joined-up working between primary and secondary

care.

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Although the new oral anticoagulants are now a possibletreatment to prevent stroke in some people with AF, theimplications from the pilot are that ANS support to pri-mary care will still be valuable, particularly in the next fewyears as more alternative oral anticoagulants becomeavailable. Different areas are taking varying approaches to

their introduction, with some favouring a phased imple-mentation. Te initiation of new oral anticoagulants willmostly still lie with clinicians with expertise in initiatingoral anticoagulant therapy for stroke prevention in AF.

Te focus of AF management remains identification ofpatients with AF at risk of stroke using a risk-stratificationtool (such as GRASP-AF) followed by a consideration ofthe most suitable anticoagulation therapy for each indi-

vidual patient.

ConclusionsAF is a leading cause of stroke but there remains a reluc-tance to prescribe warfarin to reduce risk, especially inelderly patients.

Tis primary care pilot using an ANS to offer specialisteducation and advice on AF management led to increasedawareness of risk-stratification tools and an increasednumber of patients prescribed warfarin to reduce the riskof stroke. Results compared very favourably with a nation-al comparator. Savings of cost and lives, in terms of strokesprevented, were demonstrated.

Te future for AF stroke prevention is challenging, how-ever as this pilot showed there are exciting opportunitiesto develop new services to optimise management.

Acknowledgments

Te authors wish to thank all the team who contributed to the successof the pilot: Vasa Gnanapragasam GP NHS Sutton and Merton, AnnetteBunka Senior Commissioning Manager NHS South West London,

Richard Whitfield South London Cardiovascular and Stroke Networkand Lizanne Baldwin former I Information Manager NHS Sutton andMerton.

Camm AJ, Kirchhof P, Lip GY et al for the ask Force for theManagement of Atrial Fibrillation of the European Society ofCardiology (ESC) (2010) Guidelines for the management of atrial

fibrillation. Eur Heart J 31: 2369429Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford

MJ (2001) Validation of clinical classification schemes for predictingstroke: results from the National Registry of Atrial Fibrillation.

JAMA285: 286470Holbrook A, Labiris R, Goldsmith CH, Ota K, Harb S, Sebaldt RJ

(2007) Influence of decision aids on patient preferences for anticoag-ulant therapy: a randomized trial. CMAJ176: 15837

Man-Son-Hing M, Nichol G, Lau A, Laupacis A (1999) Choosing anti-thrombotic therapy for elderly patients with atrial fibrillation whoare at risk for falls.Arch Intern Med159: 67785

Man-Son-Hing M, Gage BF, Montgomery AA, Howitt A, Tomson R,Devereaux PJ, Protheroe J, Fahey , Armstrong D, Laupacis (2005)Preference-based antithrombotic therapy in atrial fibrillation: impli-cations for clinical decision-making.Med Decis Making25: 54859

Mant J, Hobbs F, Fletcher K et al (2007) Warfarin versus aspirin for strokeprevention in an elderly community population with atrial fibrillation

(the Birmingham Atrial Fibrillation reatment of the Aged Study,BAFA) a randomised controlled trial. Lancet370: 493-503

NHS Employers (2012) Changes to QOF 2012/13. http://www.nhsem-ployers.org/PayAndContracts/GeneralMedicalServicesContract/QOF/Pages/ChangestoQOF2013.aspx (accessed 28 August 2012)

NHS Improvement (2009)Atrial Fibrillation in Primary Care: Making anImpact on Stroke Prevention. National Priority Project Final Summaries.October. http://tinyurl.com/yjz8vvw (accessed 28 August 2012)

NHS Information Centre for Health and Social Care (2011) QOF prev-alence data tables 2010/11. http://www.ic.nhs.uk/statistics-and-data-collections/supporting-information/audits-and-performance/the-quality-and-outcomes-framework/qof-2010-11/qof-2010-11-data-tables/qof-prevalence-data-tables-2010-11 (accessed 28 August 2012)

National Institute for Health and Clinical Excellence (2006)AtrialFibrillation. e Management of Atrial Fibrillation: Costing Report.Implementing NICE guidance in England[ool to complement CG36]http://guidance.nice.org.uk/CG36/CostingReport/pdf/English

(accessed 28 August 2012)yndall K, Holding S (2009) Guidance for risk assessment and stroke

prevention for AF. British Journal of Cardiac Nursing4(12): 5945

Answer to ECG of the month

Key features of this ECG

w Rate 48 beats per minute, sinus arrhythmia.w Short PR interval, broad QRS complex with up sloping R wave (delta wave pattern)w Positive QRS complex in lead V1

Tis ECG is typical of Wolff-Parkinson-White type A, which may well explain the history of palpitations. Te ECG was passed onto one of the electrophysiology consultants, to discuss with the orthopaedic team.

NEW WAYS OF WORKING TO SHARE?The British Journal of Cardiac Nursingwould like to hear from patients, support groups, charities

and others interested in sharing ideas with health professionals involved in cardiovascular care.

To discuss your ideas please contact the editor: [email protected]

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