Call to action
AntiCoagulation Europe (ACE), the Atrial Fibrillation Association (AFA), and all those who endorse the recommendations in this report, call for an urgent focus on AF within the National Health Service (NHS), and call specifically for six actions that will improve and extend the lives of UK AF patients. If implemented, these actions will prevent thousands of fatal and debilitating cases of stroke; saving hundreds of thousands from stretched healthcare budgets.
Budgetary pressures within the NHS are ever-present and inevitable. Moreover, financial pressure demands sound reasoning and compelling arguments before policy change or new services. Given the weight of the evidence collated in this report, it is clear that the opportunity exists to make considerable long-term cost savings by implementing policies that today will result in the improved detection, diagnosis and management of patients with atrial fibrillation to prevent stroke.
To achieve these goals, the six actions called for by the AFA and ACE are:
- Targeted screening: The introduction of a targeted national screening programme drawing on routine manual pulse checks and ECG readings
- Guideline adherence: The development and adoption of policies that increase GP motivation to follow international guidelines
- Public awareness, patient empowerment: The use of existing materials to fuel a national public and patient education campaign to improve detection and patient empowerment
- Equity of treatment: The imposition of equal access to AF treatments and services for all patients using the NHS regardless of location
- GP education: An AF education campaign for GPs to illustrate the importance of symptomatic control, appropriate referral and the value of patient empowerment
- AF research: Government support for research into the causes, prevention and treatment of AF
We call for the introduction of a targeted national screening programme drawing on routine manual pulse checks and ECG readings
The prevalence of AF in our society continues to grow, but measures to detect and diagnose these patients remain insufficient. Consequently, there are many hundreds of thousands of patients with AF who are currently unaware, untreated and at substantially elevated risk of suffering a stroke. Moreover, the early diagnosis of AF is associated with an increased range of treatment options, some of which have been demonstrated to eliminate AF permanently.
A simple route to improving early detection and management of AF patients is through the introduction of an effective national AF screening programme. In Chapter 5 of this report, the potential advantages of routine screening methods are clearly outlined. For these to be effective, a nationwide policy change is required, one which requires:
- The audit of all patients in general practice to determine and flag those at AF and stroke risk
- Manual pulse checks for all risk-flagged patients when visiting their local GP surgery
- Immediate access to an ECG for all flagged patients for whom AF is suspected
- Ready access to 24 and 48-hour heart monitoring to secure a diagnosis of intermittent AF
We call for the development and adoption of policies that increase GP motivation to follow international guidelines
Evidence discussed in Chapter 7 of this report illustrates that the following of guidelines is associated with improved patient treatment and a reduction in stroke. Confusingly in the UK, physicians have to draw upon two sets of conflicting guidance: the 2006 guidance from the National Institute for Health and Clinical Excellence (NICE) which all doctors in England and Wales are expected to follow; and the 2010 guidelines from the European Society of Cardiology (ESC) which represent the most current expert consensus on the affective management of patients with AF.
The existing NICE guideline for AF (CG36) is currently under review. The AFA and ACE have formally voiced their support for this review and look forward to engaging in consultation with NICE to ensure a revision that will result in harmony with European guidelines and the effective treatment of as many AF patients as possible. Specifically we call for accelerated review of the NICE clinical guideline on AF and for:
- NICE adoption of the treatment recommendations in the ESC 2010 guidelines
- NICE adoption of patient risk calculations using CHADS2 and CHA2DS2VASc as described in the ESC 2010 guidelines
- NICE recommendation of a national opportunistic screening programme based upon the flagging of suitable patients, routine manual pulse checks and immediate access to ECG checks
- NICE recommendation for early referral to an appropriate specialist when many patients might be suitable for ablation and anti-arrhythmic therapy
- Replacement of the traditional but arbitrary classification of AF (based upon the duration of AF episodes) for treatment decisions
We call for changes to the GP payment system to increase patient treatment in accordance with international guidelines
General Practitioners are also currently poorly motivated by payments through the Quality Outcomes Framework (QOF) to manage AF patients in accordance with guidelines. QOF seeks to reward doctors for the achievement of certain targets. The current system pays extra to doctors if they treat AF patients only with aspirin, despite considerable evidence that a significant additional reduction in risk of stroke is possible with anticoagulation treatment. Importantly, these data also show that the advantages of warfarin over aspirin come without a significant increase in the risk of bleeding. At the time of preparation of this report, a revision to QOF has been proposed. We strongly support the rapid adoption of these revisions:
- Reward for a high proportion of AF patients for whom a formal stroke risk has been calculated
- Reward for a high proportion of AF patients receiving anticoagulation therapy
Public awareness, patient empowerment
We call for the use of existing materials to fuel a national public and patient education campaign to improve detection and patient empowerment
The importance of public and patient awareness and knowledge cannot be over-stressed. Almost anyone can perform a simple pulse check if they want to check for the possibility that they have AF. We have also reviewed evidence in Chapter 8 that greater treatment success is achieved in patients who have sufficient knowledge of their condition to contribute to treatment decisions and targets.
Yet, today, not only are there many thousands of patients unaware that they currently have AF, many of those who have been diagnosed are unaware of what is wrong with their heart or why they are taking medication.
ACE and the AFA have developed a wealth of patient information, much of which could provide source material for a national public and patient awareness and education campaign. We call for Department of Health engagement in and support of these campaigns to:
- Increase patient awareness of AF, its signs and how they can check for AF and their risk of stroke with simple checks and tests
- Increase routine supply of educational material at the point of diagnosis, and from then on, so that patients can gain sufficient knowledge to engage in treatment decisions
Equity of treatment
We call for the equal access to AF treatments and services for all patients using the NHS regardless of location
The simple presence of conflicting clinical guidelines leads inevitably to the unequal treatment of AF patients within the NHS. This is by no means the only cause of inequity for AF patients; many are reviewed in Chapter 8 of this report. By having the NHS, a single body responsible for almost all UK healthcare, we have an unparalleled opportunity to ensure that efficient and effective treatments and services are provided to all UK citizens regardless of local circumstances. Constant vigilance is required to identify and eliminate inequities for patients in the NHS but several targets for attention can easily be identified. We call for government policy and medical practice that ensures:
- Equity of guideline adherence among doctors
- Equity of access to services such as anticoagulation clinics
- The definition and implementation of minimum standards to eliminate or improve services and treatments that fall short of what patients deserve
- Equity of treatment decisions based on clinical status not arbitrary definitions or timing
- Equity of access to anticoagulation treatment regardless of location of the patient or the availability of local anticoagulation services
- Equity of access to ideal referral opportunities regardless of the location of the patient or the availability of local heart rhythm specialists
We call for an AF education campaign for GPs to illustrate the importance of symptomatic control, appropriate referral and the value of patient empowerment
In Chapters 7 and 8 of this report, we document many instances where doctors over-look symptoms, under-use treatments and where they fail to interpret correctly the amount of risk that a patient is willing to accept for a given benefit.
Patients suffering from the symptoms of AF can benefit significantly from early diagnosis and referral for treatments that can have a significant positive impact. It is important that GPs develop an understanding of how significant these symptoms are for the patient, and how effectively they can be helped once diagnosed and referred for specialist treatment.
We have also reviewed extensively, in Chapter 7 of this report, the discrepancies between the theoretical benefits of anticoagulation treatment and the actual benefit achieved in routine clinical practice. Much of this difference can be accounted for by deviation from guidelines founded on a misunderstanding among physicians of how their patients view the risks and benefits of treatment.
The above challenges can be met with educational efforts and tools that:
- Improve GP understanding of the impact that AF symptoms have on quality of life
- Improve GP understanding of the benefits of patient education and engagement in decisions
- Help GPs improve patient understanding of the risks and benefits of treatment
- Improve GP understanding of the potential benefits of early referral
We call for government support for research into the causes, prevention and treatment of AF
Many of the challenges faced by healthcare policy makers and doctors today arise from inadequate access to the necessary data to make effective decisions. This report and the document upon which it is based aim to help increase access to vital information. However, some data simply doesn’t yet exist, highlighting an urgent need for continued research into AF so that services and policies can be developed with a firm confidence of success and cost effectiveness for the NHS. To this end, we call for government support for:
- An assessment of the burden and severity of disease for all patients with AF, based on patient experience and the impact on their quality of life
- Research to identify patients at risk of AF and AF-related stroke, and the likely impact of existing and new therapeutic approaches to the management of AF
- Multi-national registries and monitoring studies to evaluate the effect of interventions to manage AF and prevent AF-related stroke.