Improving anticoagulation in atrial fibrillation: observational study in three primary care trusts

Abstract

Background: Atrial fibrillation (AF) is a cause of stroke, and undertreatment with anticoagulants is a persistent issue despite their effectiveness.

Aim: To increase the proportion of people with AF treated appropriately using anticoagulants, and reduce inappropriate antiplatelet therapy.

Design of study: Cross-sectional analysis.

Setting: Electronic patient health records on 4604 patients with AF obtained from general practices in three inner London primary care trusts between April 2011 and 2013.

Method: The Anticoagulant Programme East London (APEL) sought to achieve its aims through an intervention with three components: altering professional beliefs using new clinical guidance and related education; facilitating change using computer software to support clinical decisions and patient review optimising anticoagulation; motivating change through evaluative feedback showing individual practice performance relative to peers.

Results: From April 2011 to April 2013, the proportion of people with CHA2DS2-VASc ≥1 on anticoagulants increased from 52.6% to 59.8% (trend difference P<0.001). The proportion of people with CHA2DS2-VASc ≥1 on aspirin declined from 37.7% to 30.3% (trend difference P<0.001). Comparing the 2 years before the intervention with the 2 years after, numbers of new people on the AF register almost doubled from 108 to 204.

Conclusions: The APEL programme supports improvement in clinical managing AF by a combined programme of education around agreed guidance, computer aids to facilitate decision-making and patient review and feedback of locally identifiable results. If replicated nationally over 3 years, such a programme could result in approximately 1600 fewer strokes every year.

Keywords: anticoagulants; atrial fibrillation; clinical decision support systems; patterns; prescribing; primary health care; stroke.

Figure 1.

Anticoagulant and antiplatelet use in patients with AF with CHAD₂S₂-VASC ≥1.

Figure 2.

Funnel plot: proportion on anticoagulants by east London practices.