Opportunistic pulse checks in primary care to improve recognition of atrial fibrillation: a retrospective analysis of electronic patient records

Why do people take part in atrial fibrillation screening? Qualitative interview study in English primary care

OBJECTIVES

There is insufficient evidence to support national screening programmes for atrial fibrillation (AF). Nevertheless, some practitioners, policy-makers and special interest groups have encouraged introduction of opportunistic screening in primary care in order to reduce the incidence of stroke through earlier detection and treatment of AF. The attitudes of the public towards AF screening are unknown. We aimed to explore why AF screening participants took part in the screening.

DESIGN

Semistructured longitudinal interview study of participant engagement in the SAFER study (Screening for Atrial Fibrillation with ECG to Reduce stroke). We undertook initial interviews face to face, with up to two follow-up telephone interviews during the screening process. We thematically analysed and synthesised these data to understand shared views of screening participation.

SETTING

5 primary care practices in the East of England, UK.

PARTICIPANTS

23 people taking part in the SAFER study first feasibility phase.

RESULTS

Participants were supportive of screening for AF, explaining their participation in screening as a 'good thing to do'. Participants suggested screening could facilitate earlier diagnosis, more effective treatment, and a better future outcome, despite most being unfamiliar with AF. Participating in AF screening helped attenuate participants' concerns about stroke and demonstrated their commitment to self-care and being a 'good patient'. Participants felt that the screening test was non-invasive, and they were unlikely to have AF; they therefore considered engaging in AF screening was low risk, with few perceived harms.

CONCLUSIONS

Participants assessed the SAFER AF screening programme to be a legitimate, relevant and safe screening opportunity, and complied obediently with what they perceived to be a recommendation to take part. Their unreserved acceptance of screening benefit and lack of awareness of potential harms suggests that uptake would be high but reinforces the importance of ensuring participants receive balanced information about AF screening initiatives.

TRIAL REGISTRATION NUMBER

ISRCTN16939438; Pre-results.

Opportunistic atrial fibrillation screening and detection in "self-service health check-up stations": a brief overview of current technology potential and possibilities

Up to a fifth of patients who suffer a stroke had undiagnosed atrial fibrillation (AF). About 30% of AF patients are asymptomatic and remain undiagnosed, so there are no obvious (to the patient) forewarnings. Opportunistic screening for AF applied to the above clinical situation can save lives, since the strokes that occur as a result of AF are often large, severely debilitating or fatal. Today, anyone can buy a good, FDA-approved mobile electrocardiogram (ECG) device/smartwatch for AF detection on Amazon for €100-400, but not very many asymptomatic AF patients, particularly older patients, will do so on their own. In this article, we introduce the concept and potential benefits of opportunistic AF screening and detection in a community setting using the latest generation of affordable digital ECG capture and interpretation solutions integrated into easy-to-use "self-service health check-up stations" installed in public spaces, such as supermarkets and pharmacies. A comprehensive trial of the proposed self-service health check-up stations for AF screening is needed to produce more evidence to convince decision makers to fully buy into the idea of a nation-wide screening programme using these kiosks.

Temporal trends in incidence of atrial fibrillation in primary care records: a population-based cohort study

OBJECTIVES

Atrial fibrillation (AF) is a heart condition associated with a fivefold increased risk of stroke. The condition can be detected in primary care and treatment can greatly reduce the risk of stroke. In recent years, a number of policy initiatives have tried to improve diagnosis and treatment of AF, including local National Health Service schemes and the Quality and Outcomes Framework. We aimed to examine trends in the incidence of recorded AF in primary care records from English practices between 2004 and 2018.

DESIGN

Longitudinal cohort study.

SETTING

English primary care electronic health records linked to Index of Multiple Deprivation data.

PARTICIPANTS

Cohort of 3.5 million patients over 40 years old registered in general practices in England, contributing 22 million person-years of observation between 2004 and 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incident AF was identified through newly recorded AF codes in the patients' records. Yearly incidence rates were stratified by gender, age group and a measure of deprivation.

RESULTS

Incidence rates were stable before 2010 and then rose and peaked in 2015 at 5.07 (95% CI 4.94 to 5.20) cases per 1000 person-years. Incidence was higher in males (4.95 (95% CI 4.91 to 4.99) cases per 1000 person-years vs 4.12 (95% CI 4.08 to 4.16) in females) and rises markedly with age (0.58 (95% CI 0.56 to 0.59) cases per 1000 person-years in 40-54 years old vs 21.7 (95% CI 21.4 to 22.0) cases in over 85s). The increase in incidence over time was observed mainly in people over the age of 75, particularly men. There was no evidence that temporal trends in incidence were associated with deprivation.

CONCLUSIONS

Changes in clinical practice and policy initiatives since 2004 have been associated with increased rates of diagnosis of AF up until 2015, but rates declined from 2015 to 2018.

The Cost-Effectiveness of One-Time Opportunistic Screening for Atrial Fibrillation in Different Age Cohorts of Inhabitants in Denmark Aged 65 Years and Above. A Markov Modelled Analysis

AIM

The objective was to evaluate the cost-effectiveness of one-time opportunistic screening for AF in general practice in citizens aged ≥65 years in Denmark compared to a no-screening alternative following current Danish practice.

METHODS AND RESULTS

A decision tree and a Markov model were designed to simulate costs and quality-adjusted life years (QALYs) in a hypothetical cohort of citizens aged ≥65 years equivalent to the Danish population (1 M citizens) over the course of 19 years, using a healthcare and societal perspective. Share of detected AF patients following opportunistic screening was retrieved from a recent Danish screening study, whereas the risk stroke and bleedings in AF patients were based on population data from national registries and their associated costs was obtained from published national registry studies.The present study showed that one-time opportunistic screening for AF was more costly, but also more effective compared to a no-screening alternative. The analysis predicts that one-time opportunistic screening of all Danes aged ≥65 years potentially can identify an additional 10,300 AF patients and prevent 856 strokes in the period considered. The incremental cost of such a screening program is €56.4 M, with a total gain of 6,000 QALYs, resulting in an incremental cost-effectiveness ratio of €9,400 per QALY gained.

CONCLUSION

Opportunistic screening in general practice in citizens aged ≥65 years in Denmark is cost-effective compared to a willingness-to-pay threshold of €22,000. The study and its findings support a potential implementation of opportunistic screening for AF at the general practitioner level in Denmark.

GP incentives to design hypertension and atrial fibrillation local quality-improvement schemes: a controlled before-after study in UK primary care

BACKGROUND

Financial incentives in the UK such as the Quality and Outcomes Framework (QOF) reward GP surgeries for achievement of nationally defined targets. These have shown mixed results, with weak evidence for some measures, but also possible unintended negative effects.

AIM

To look at the effects of a local intervention for atrial fibrillation (AF) and hypertension, with surgeries rewarded financially for work, including appointing designated practice leads, attendance at peer review workshops, and producing their own protocols.

DESIGN AND SETTING

A controlled before-after study comparing surgery performance measures in UK primary care.

METHOD

This study used published QOF data to analyse changes from baseline in mean scores per surgery relating to AF and hypertension prevalence and management at T1 (12 months) and T2 (24 months) for the intervention group, which consisted of all 58 surgeries in East Lancashire Clinical Commissioning Group (CCG), compared to the control group, which consisted of all other surgeries in north-west England.

RESULTS

There was a small acceleration between T0 (baseline) and T2 in recorded prevalence of hypertension in the intervention group compared to the controls, difference 0.29% (95% confidence interval [CI] = 0.05 to 0.53), P = 0.017, but AF prevalence did not increase more in the intervention group. Improvement in quality of management of AF was significantly better in the intervention group, difference 3.24% (95% CI = 1.37 to 5.12), P = 0.001.

CONCLUSION

This intervention improved diagnosis rates of hypertension but not AF, though it did improve quality of AF management. It indicates that funded time to develop quality-improvement measures targeted at a local population and involving peer support can engage staff and have the potential to improve quality.