|Atrial Fibrillation: Clinical Indicators|
|Register of patients with atrial fibrillation||Register||5|
|Atrial fibrillation diagnoses after 1 April 2006 with ECG or specialist confirmed diagnosis||90||10|
|Patients receiving anticoagulant or antiplatelet therapy||90||15|
- Prevalence rates for England and Northern Ireland for 2006/7 were 1.29 and 1.25 respectively. Age-specific prevalence is rising, affecting 5 per cent of over-65s and 9 per cent of over-75s. AF is associated with a five-fold increase in risk of stroke and the indicator set is designed to encourage treatments that lower this risk.
- The indicator set requires practices to produce a register of patients with AF, to confirm future diagnoses and to treat patients with warfarin or aspirin. Future diagnoses should be confirmed by a specialist or with an ECG.
- AF is one of three indicator sets in the QoF covering aspects of CHD. The original CHD disease area remains, with its subset of indicators for left ventricular dysfunction moved in 2006/7 to a new indicator set covering heart failure.
Step 1: Setting up the register
- The register is worth five points and should list all patients with AF. It should include all patients with an initial event, paroxysmal, persistent and permanent AF.
- Begin by running a search on Read codes used by the practice and make sure the preferred Read codes are entered. You may also need to inspect notes manually and/or do searches based on relevant medications, such as digoxin.
- Once you are happy with your register, it can be useful to make a rough check against expected national prevalence rates, taking into account your patient profile.
Step 2: From now onwards
- The second indicator, worth 10 points, aims to make sure patients put on the register from 1 April 2006 have an ECG or specialist confirmed diagnosis. The guidance says AF is often inaccurately coded and the aim of the indicator is to compile a more accurate register, so treatments are properly targeted.
- All patients with suspected AF will need to be referred for an ECG or specialist opinion, and diagnosis must be confirmed within 12 months of patients going on the register. The practice may also report patients who have been diagnosed or had an ECG up to three months before being added to the register.
- Points will only be earned after confirmation from the specialist or by ECG. It is not enough to make a referral to earn the points.
- The last indicator in this disease area requires patients on the register to be treated with anticoagulant or antiplatelet drug therapy. The guidance says there is strong evidence that stroke can be substantially reduced with warfarin (less so with aspirin) but the choice has been left to the doctor and patient because of the higher risk of haemorrhage with warfarin, particularly in older people.
- Acceptable anticoagulation agents are warfarin and phenindione and acceptable antiplatelet agents are aspirin, clopidogrel and dipyridamole.
- Run a search for patients on your register who are already on these drug therapies and set up a system to see those who are not currently prescribed the relevant treatments.
- The guidance says anticoagulation or antiplatelet therapy would not necessarily be indicated if the episode of AF was an isolated event not expected to recur, such as one-off AF with a self-limiting cause.
- Records need to show patients on the register have been prescribed anticoagulant or antiplatelet therapy in the past six months.
- Remember that over the counter drugs must be re-entered in patients’ records every year to count towards the QoF.
Step 3: September to March
- Consider running a report each month to identify patients with a recent diagnosis of AF with no record of being referred for specialist opinion or an ECG, or no record of the result of that referral.
- Regular searches also need to be carried out to cover patients not on anticoagulation and antiplatelet therapy. Issue fresh invitations to those who still need to be seen. Remember patients can be exception reported after three invitations in 12 months.