Identifying undiagnosed atrial fibrillation can help prevent strokes by giving timely treatment before a catastrophic health event, such as a stroke, occurs. An Atrial Fibrillation Detection pilot aims to find those patients. Fosseway PCN clinical director, Dr Arshad Khalid, and PCN transformation and development manager, Sian Sykes, explain more.
A pilot in Fosseway PCN is seeking to improve the cardiovascular disease (CVD) outcomes for people in Leicester, Leicestershire and Rutland (LLR) by identifying undiagnosed atrial fibrillation (AF).
Based on the Public Health England prevalence estimates and 20/21 Quality Outcome Framework prevalence data, it is thought that there are approximately 6,000 patients across LLR who may have undiagnosed AF.
While AF can be difficult to cure or convert to sinus rhythm, treatment can manage symptoms and anticoagulation can ease the risk of stroke. But for treatment to be initiated, patients must first be identified.
Clinical director of Fosseway PCN, Dr Arshad Khalid, and Liz Wharton, senior pharmacist in LLR integrated care board (ICB) medicines optimisation team, have launched the Atrial Fibrillation Detection pilot to do just that.
Aim
The pilot aims to identify undiagnosed AF across LLR and ensure patients receive appropriate treatment to prevent adverse health events, such as stroke.
Funded by a pharmaceutical company and led by the ICB, the scheme uses a handheld diagnostic tool – MyDiagnostick – which an individual holds for 30 seconds. The device signals whether the pulse is regular or irregular. The latter group will then have a 12-lead ECG in primary care. Practices are paid for this work as part of their cardiorespiratory activity.
The project focuses mainly on patients aged over 65, as the risk of AF increases steeply with age, particularly after 75. However, we hope to expand our testing to include other groups, such as people with long-term conditions, those under 65, and patients who may only visit their GP for NHS health checks or vaccinations. The ease of use makes the device an ideal way to capture a diverse patient cohort.
Method
MyDiagnostick is very simple to use. As there are no buttons or parameters to be set, the device does not require a healthcare professional to administer the test. That means non-clinical staff can use it, which saves clinician time.
For example, as soon as the device is turned on, it is ready for use. After one minute of recording, the device lights green for regular and red for irregular, which indicates AF may be present. The device will then switch off.
This is in contrast with current Holter and event recorders, which require electrodes on the skin and a wired connection to the recording device worn on the patient’s belt. These devices require setup by a clinician, making them less practical for widespread opportunistic use.
Approach
The pilot is led by the ICB, with all PCNs across LLR invited to participate. Each of the 12 practices in our federation - Hinckley and Bosworth Medical Alliance - along with the PCN’s enhanced access hub, is involved.
We received one device per practice, plus one for our Enhanced Access service – 13 in total. The device is used at a variety of locations across the PCN with each practice using it in a way that best suits their needs.
For example, at Orchard Medical Practice, where Dr Khalid is senior GP partner, patients were seen when their spring Covid booster was delivered. Other practices have used the device in the waiting room and clinical examination rooms.
One challenge has been clinician concern over liability when results indicate an irregular pulse. Another has been unexpectedly high patient uptake, which has at times outstripped initial planning. We also underestimated how popular the service would be among patients. The uptake has been overwhelming.
Outcomes
The pilot began in January and, so far, several clinics have been run across the PCN’s 12 member practices. Testing is often carried out in NHS Health Check clinics by healthcare assistants. They have also been done by administrative staff during vaccination sessions.
For example, at Orchard Medical Practice, 590 patients attended a Covid clinic for their vaccine. About half of these patients were already on the AF register and, therefore, ineligible for the test.
Almost 300 were eligible and the device was used to test them while they were waiting in line for their vaccination. There were 19 patients who had a red light, and they went on to have a 12-lead ECG recording. Of the 19, a mixed variety of problems were uncovered, including AF and excess ectopic activity.
Future
Although the pilot runs for 12 months, practices will keep the devices afterwards. But, for the project to achieve its full potential, it would need to be rolled out more widely.
Another next step would be to introduce more advanced reporting tools to focus on areas of LLR with the greatest discrepancy between reported incidents of AF and expected AF.
Current searches on practice systems rely on manual coding and may underestimate prevalence. So, for example, if a patient is seen in A&E and diagnosed with AF, the code has to be added to the GP record by a member of the practice team. Population health management tools such as Aristotle and Fingertips offer some insights but are based on year-old data, meaning true AF numbers are likely higher.
In future, the team would like to see the devices become as routine as blood pressure machines, available in waiting rooms or health hubs for patients to use without appointment or supervision.