Dashboard for raising the quality of care in atrial fibrillation, pilot study in a primary care sentinel network

Problem

Atrial fibrillation (AF) is a common cardiac arrhythmia which has globally increasing incidence. AF leads to strokes, transient ischemic attacks and peripheral embolisms. The correct management of AF can reduce the risk of thromboembolic complications. Studies have shown that the number of patients being treated for has increased. However, guidance in different localities is high variable particularly for the use of direct oral anticoagulants (DOACs).

Approach

We developed an online dashboard for reporting metrics related to managing AF patients in primary care. The data for the dashboard are obtained from the Royal College of General Practitioners (RCGP) Research and Surveillance database (RSC) in real time. The dashboard is accessible to all practices in the RCGP RSC primary care sentinel network and individual practices are able to view metrics related to their management of AF compared with other network practices. The dashboard displays four groups of information: (1) Incidence and prevalence of AF (2) Risk scores using CHADVASc and HASBLED scores (3) Prescribing of anticoagulants and (4) Suboptimal prescribing of anticoagulants. In addition to these metrics, the dashboard also provides additional indicators corresponding to potential earnings according to the Quality and Outcomes Framework (QOF) business rules. In parallel to building the dashboard we also conducted a retrospective analysis of AF cases between 2007 and 2017.

Findings

We identified 415,517 patient with a diagnosis of AF between 2007 and 2017. We have observed an increase in AF and an increase in stroke risk by CHAD and by CHA₂DS₂-VASc Score over ten year period. We are currently conducting an evaluation study by involving various stakeholders in the general practice setting to provide feedback about the usability of the dashboard. Usability feedback is captured during a think-aloud session where the participants narrate their user experience while navigating the dashboard. The feedback allows us to build a cognitive model which highlights sections of the dashboard with usability issues.

Consequences

If implemented in practice this dashboard could improve quality. Whilst nearly all the RCGP RSC practices are high achievers in QOF this dashboard has highlighted gaps in their management. In particular, cases could be identified outside those flagged by QOF, CHA₂DS₂-VASc Score often not coded, even when all the component data are recorded. Incident cases are most often started on DOAC, though there are gaps in monitoring and patients on inappropriate low doses.