Improving quality and safety - full abstract

Getting It Right First Time – Cemented total hip replacements

Zakir Haider, Shahnawaz Khan, Sirat Khan, Ahsan Sheeraz
Barts Health

Background: Getting It Right First Time (GIRFT) is an NHS programme designed to improve quality of care and following detailed analysis of practices in Orthopaedics nationally produced a number of guidelines to improve efficiency and productivity within the orthopaedic community. One such guideline was to adopt the use of cemented total hip replacements (THR) for patients aged over 65 years old. Nationally, this has already led to a 10% increase in use of cemented femoral stems in total hip replacements with a cost saving of £4.4 million nationally due to a lower cost of cemented femoral prostheses. 

Our aim was to explore the number of total hip replacements being performed using cemented femoral stems across the Barts Health Trust in London.

Methods: Retrospective review of all patients who underwent total hip replacement from 2018 to 2019 at a large multi-centre NHS trust.

Results: In total, 422 patients underwent THRs at Barts Health between 2018 to 2019 of which 151 (36%) hips used cemented femoral stems only.  Calculating the cost of using cemented femoral prosthesis for all THRs performed could mean a potentially cost saving of £156, 096 to the trust per annum.

Implications: Results clearly demonstrate a significant cost saving by strictly adhering to GIRFT guidelines in times of increasing resource and financial constraints within the NHS. However,  there are also other important implications of using this guideline.  By undertaking cemented total hip replacements the trust is demonstrating adherence to a nationally agreed guideline whilst also reducing the risk of potential litigation. Moreover, with increased awareness, local care commissioning groups may begin to probe implant selection with increasing justification for current usage trends. 

To conclude, this study clearly highlights a number of significant cost and safety benefits from adhering to GIRFT guidelines.  We strongly recommend that other trusts also audit their current practice in order to raise awareness of this issue.


Hospital Financial Performance and Quality of Care: Evidence From Portugal

Iryna Sabat
Nova SBE

Background: This paper aims at investigating the relationship between hospital financial performance and quality of hospital care and patient safety indicators using panel data on Portuguese public hospitals for the period of 2008-2017. Additionally, the study addresses the impact of Troika’s regulation period on changes in quality and patient safety areas occurring through financial channels. 

Methodology: We compute a set of financial indicators reflecting financial performance of hospitals using information from hospital monthly financial reports and utilize hospital-level diagnosis-related group (DRG) data to construct quality of in-hospital care measures, including overall and disease-specific mortality rates. We then combine these data with local municipality level variables reflecting market characteristics and hospital-level variables accounting for the case-mix of patients, to develop a model of potential determinants of hospital care quality. Additionally, we compute a range of patient safety indicators distinguishing between nurse- and surgery related adverse events and use them as dependent variables thereby seeking to answer whether worsened hospital financial conditions may compromise patient safety. The study adopts a partial adjustment mechanism thereby accounting for lags in the response of quality to changing conditions and addresses potential endogeneity by employing fixed effects estimation. 

Results: The results suggest that hospital’s transition to lower profitability quartiles may be associated with higher rates of mortality and adverse patient safety events. However, the significance and magnitude of the impact are indicator-specific, which suggests that some measures may not be sensitive enough to reflect the impact. Noteworthy, changes in quality and safety are responsive both to large and small transitions in profitability measures. 

Regarding Troika effect, we find that in the short run Troika period had a more negative impact on hospitals in the lowest profitability quartiles, so that they had higher rates of adverse patient safety events as compared to the most profitable ones. This suggests that hospitals in the lowest quartile were likely becoming more financially fragile during austerity measures, which in turn unfavorably influenced their rates of patient safety indicators. In the long run Troika’s period effect was associated with slightly higher mortality and higher PSI rates in hospitals that transitioned to lowest profitability quartiles. Noteworthy, the results show significance in case of several indicators out of the whole range tested, which on one hand does not let us to make conclusive generalized statements, but on the other hand demonstrates the need to consider a range of quality indicators, since some may not be responsive and show true effect.


Impact of a new integrated respiratory services on COPD hospital admissions. An interrupted time series analysis

Martha Elwenspoek(1), Tim Jones(2), Tracey Stone(2), Jonathan Banks(2), James Dodd(3)
(1)NIHR ARC West, (2)NIHR ARC West and Population Health Sciences of University of Bristol, (3)North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust

Background: Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung disease, usually caused by smoking (1). COPD accounts for 1 in 10 emergency hospital admissions in the UK due to its frequent exacerbations, which makes it the second most common reason for unplanned hospital admissions (2). Outcomes are poor and there is a high readmission rate (3). Consequently, COPD admissions represent a high burden for respiratory services.

In 2016, a Clinical Commissioning Group (CCG) in England commissioned a not-for-profit community provider and a respiratory department in a secondary care hospital to design and deliver a new integrated respiratory service to improve patient outcome and experience. The new integrated respiratory service comprised of three additional service pathways that were delivered in collaboration with the community provider: home oxygen assessment, pulmonary rehab, and admissions avoidance pathways. In this study, we show the impacts of the admission avoidance pathway.

Methods: We used interrupted time series analysis with a control group on routinely collected hospital admission data (Hospital Episode Statistics), comparing admissions in the intervention CCG and 10 demographically similar control CCGs in the 2 years before and 1 year after the implementation of the new service. Patient population consisted of all patients admitted to hospital within these CCGs with COPD as primary diagnosis.

The primary outcome was a level and/or trend change in the rate of hospital admissions in response to the implementation of the admission avoidance pathway. Secondary outcomes were a level and/or trend change in mean length of hospital stay in days and proportion of readmissions within 30 days.

Results: Unplanned hospital admissions for COPD exacerbations follow a clear seasonal pattern, peaking in early winter. We found no evidence that the admission avoidance pathway in the intervention region influenced the rate of hospital admissions (Figure 1) or 30-day readmissions. We found weak evidence of a trend change in length of hospital stay following the launch of the Admission avoidance pathway, i.e. the increase in mean length of stay over time, which was observed in the pre-period, halted after the launch of the admission avoidance pathway.

Implications: We found little evidence that the integrated respiratory service had an impact on hospital admissions for COPD. Further investigation is required to understand the reasons why. Given the relatively short time period after the service was introduced, it may be too soon to see some of the potential benefits.


  1. Soriano JB, Rodriguez-Roisin R. Chronic obstructive pulmonary disease overview: epidemiology, risk factors, and clinical presentation. Proc Am Thorac Soc 2011;8(4):363-7. doi: 10.1513/pats.201102-017RM [published Online First: 2011/08/06]

  2. Team MDR. Consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease (COPD) in England. Department of Health and Social Care 2010

  3. Price LC, Lowe D, Hosker HS, et al. UK National COPD Audit 2003: Impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation. Thorax 2006;61(10):837-42. doi: 10.1136/thx.2005.049940 [published Online First: 2006/02/02]

Figure 1. Hospital admissions model fit.


EDQDF: Improving Emergency Care 

Katie Jones, Jo Mower, Julian Baker

Background: Developed and informed by a multi-disciplinary team, the Emergency Department Quality and Delivery Framework (EDQDF) intends to improve emergency care in Wales in light of Welsh government’s quadruple aim for health care, and has been awarded funding to support the implementation of projects with this goal in mind. At last year’s HSR conference, the EDQDF team presented a poster describing “Phase 1” of their project; this year, they are ready to present “Phase 2” and discuss the progress made.

Methods: The EDQDF team has developed a series of Pathway Improvement Projects (PIPs) and National Enabler of Service Improvements (NESIs) in order to deliver on the quad aim, and continues to organise events and workshops across Wales with the aim to build an Emergency Department Network to bring colleagues working in this area together.

Results and Implications: TBC: This presentation will describe the journey so far in a short poster presentation, outlining the Pathway Improvement Projects and the ways in which these are intended to support better health care in Wales.

3 min quick-fire paper: Notes on a Welsh Intervention for Frequent Attenders to ED (presented by Katie Jones)

Background: From patients suffering with chronic conditions and hard to treat, to those with a constellation of medical, social, and psychological complaints, people who frequently rely on emergency services  - or “frequent attenders” – do so for complex reasons. In the social context such patients are often dismissed as “time wasters” or in generally derogatory terms. Despite a widespread knowledge of stigma across the system, and indeed society, it remains nonetheless a shifting and pervasive experience for many, whether perceived or real. This research firstly considers the real stigma attached to these identities and, secondly, how a health initiative in Wales seeks to address these issues.

Methods: Observational analysis of the WEDFAN interdisciplinary team.

Results and Implication:  

This research is in its early stages.


Implementation of research evidence in orthopaedics: a tale of three trials

Katharine Reeves(1), Samuel Chan(1), Alastair Marsh(1), Suzy Gallier(1), Catrin Wigley(2), Kamlesh Khunti(3), Richard Lilford(4)
(1)University Hospitals Birmingham, (2)Bristol Medical School, University of Bristol, (3)College of Life Sciences, University of Leicester, (4)University of Birmingham

Background: Evidence-based healthcare relies on clinical trials to inform practice and policy. In England, the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme reports the findings of clinical trials. The uptake of the results of surgical trials in clinical practice can be inexpensively monitored by means of routinely collected hospital data(1). Over the past decade, there have been three large, multicentre randomised trials in musculoskeletal trauma in the UK funded by the NIHR HTA programme: Distal Radius Acute Fracture Fixation Trial (DRAFFT)(2), Proximal Fracture of the Humerus: Evaluation by Randomisation (ProFHER)(3) and Ankle Injury Management (AIM)(4). Our objective was to examine the implementation of evidence in orthopaedic practice following publication of the results of these three pivotal clinical trials.

Methods: Case studies based on three orthopaedic trials funded in sequence by the National Institute for Health Research Health Technology Assessment (HTA) programme. These trials dealt with treatment of fractures of the humerus, radius and ankle, respectively. For each case study, we conducted time-series analyses to examine the relationship between publication of findings and the implementation (or not) of the findings.

Results: The results of all three trials favoured the less expensive and less invasive option. In two cases, a change of  practice, in line with the evidence that eventually emerged, preceded publication. Furthermore, the upturn in use of the intervention most supported by each of these two trials corresponded to the start of recruitment to the respective trial. The remaining trial failed to influence practice despite yielding clear-cut evidence.

Figure 1 - DRAFFT


Figure 2 - DRAFFT


Figure 3 - ProFHER


Figure 4 - ProFHER


Figure 5 - AIM


Implications: Implementation of results of all three HTA orthopaedic trials favoured the less expensive and less invasive option. In two of the three studies, a change in practice, in line with the evidence that eventually emerged, preceded publication of that evidence. A trend or a change in practice, at around the start of the trial, indicates that the direction of causation opposes our hypothesis that publication of trial findings would lead to changes in practice. Our results provide provocative insight into the nuanced topic of research and practice, but further qualitative work is needed to fully explain what led to the pre-emptive change in practice we observed and why there was no change in the third case.



1 Lilford R. Why the CLAHRC WM director loves orthopaedic trials. NIHR CLAHRC West Midlands News Blog, 2018.

2 Costa ML, Achten J, Plant C, et al. Uk DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess 2015;19:1–124.

3 Handoll H, Brealey S, Rangan A, et al. The ProFHER (proximal fracture of the humerus: evaluation by randomisation) trial—a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-BMJ effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults. Health Technol Assess 2015;19:1–280.

4 Keene DJ, Mistry D, Nam J, et al. The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years. Health Technol Assess 2016;20:1–158.


Routine feedback on patient-reported outcomes to healthcare providers and patients in clinical practice

Ian Porter(1), Chris Gibbons(2), Daniela Gonçalves-Bradley(3), Stanimir Stoilov(1), Ignacio Ricci-Cabello(4), Elena Tsangaris(5), Jaheeda Gangannagaripalli(1), Antoinette Davey(1), Elizabeth Gibbons(6), Anna Kotzeva(7), Philip Van der Wees(8), Evangelos Kontopantelis(9), Joanne Greenhalgh(10), Peter Bower(11), Jordi Alonso(12), Jose Valderas(1)
(1)University of Exeter, College of Medicine and Health, (2)Harvard Medical School, Boston, MA, USA, (3)Nuffield Department of Population Health, University of Oxford, (4)Primary Care Research Unit, Instituto de Investigación Sanitaria Illes Balears, Palma de Mallorca, Spain, (5)Department of Surgery, Harvard Medical School, Boston, USA, (6)PROM Group, Nuffield Department of Population Health, University of Oxford, (7)Health Technology Assessment Department, Agency for Health Quality and Assessment of Catalonia (AQuAS) Barcelona, Spain, (8)Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ healthcare), Nijmegen, Netherlands, (9)Centre for Health Informatics, Institute of Population Health, The University of Manchester, 10School of Sociology and Social Policy, University of Leeds, (11)NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, (12)CIBER Epidemiologia y Salud Publica (CIBERESP), IMIM-Hospital del mar, Barcelona, Spain

Background: Patient-reported outcomes measures (PROM) assess a patient’s subjective appraisal of outcomes from their own perspective. Despite hypothesised benefits PROM feedback supporting decision making in clinical practice and improving outcomes there is uncertainty surrounding their effectiveness in these areas. We assessed the impact of the use of PROM feedback on patient-reported health outcomes and processes of care.

Method: We registered the protocol of this systematic review of randomised controls trials (RCTs) in the Cochrane Library. We searched MEDLINE, EMBASE, CINAHL, clinical trial registries and five other databases from inception to 30/09/2018, as well as grey literature and consulted experts in the field. Two review authors independently screened and selected studies for inclusion. We included RCTs directly comparing the effects on outcomes and processes of care of feedback of PROM to clinicians and/or patients with the impact of not providing such feedback. Two review authors independently extracted data from the included studies and evaluated study quality. We evaluated the impact of PROM feedback on patient-reported outcomes including symptoms, functioning, health perceptions, and quality of life; and a range of processes of health care including communication, clinical management and health service utilization, and patient satisfaction. We conducted a meta-analysis of the results where possible.

Results: We identified 97 randomised trials which assessed the effectiveness of PROM feedback in improving processes and/or outcomes of care in a broad range of disciplines including psychiatry, primary care, and oncology. Studies were conducted across diverse ambulatory primary and secondary care settings in North America and Europe. The certainty of the evidence varied between very low and moderate. Many of the studies included in the review were at risk of bias due to study designs which increased the likelihood of allocation concealment and contamination.

PROM feedback probably slightly improves quality of life (standardised mean difference (SMD) 0.015, 95% confidence interval (CI) 0.03 to 0.27; 11 studies; 1998 participants), and probably leads to an increase in disease control (odds ratio (OR) 1.56, 95% CI 1.23 to 1.97; 14 studies, 2806 participants), patient-physician communication (SMD 0.37, 95% CI 0.2 to 0.54; 3 studies; 571 participants), and diagnosis and notation (OR 2.56, 95% CI 1.86 to 3.53; 22 studies; 7223 participants), for which we graded the evidence as moderate certainty. The intervention probably makes little or no difference for general health perceptions (SMD 0.04, 95% CI - 0.17 to 0.24; 2 studies, 552 participants), social functioning (SMD 0, 95% CI -0.08 to 0.08; 13 studies; 2423 participants), and pain (SMD -0.01, 95% CI -0.09 to 0.08; 6 studies, 2283 participants), which we also graded as moderate certainty. We are uncertain about the effect of PROM feedback on physical (13 studies; 2685 participants) and mental functioning (31 studies; 7048 participants), as well as fatigue (SMD 0, 95% CI -0.45 to 0.45; 6 studies, 638 participants), as the certainty of the evidence was very low. We did not find studies reporting on adverse effects.

Implications: Interventions which assess and feedback patient-reported outcomes using PROMs can improve the detection of healthcare issues, leading to appropriate diagnosis and referral as well as increasing patient perception of their care and disease control. Patient functioning and outcomes were improved slightly in mental health care settings and small improvements to quality of life were associated with the intervention across all studies. There is a need for more high-quality studies in this area, particularly studies which employ cluster designs and utilize techniques to maintain allocation concealment.


The PEONY Study: A qualitative investigation of views and experiences of primary and secondary care clinicians delivering postnatal care to women with hypertensive disorders of pregnancy

Sergio A. Silverio(1), Amanda Bye(2), Yan-Shing Chang(3), Debra Bick(4)
(1)King's College London, (2)Department of Psychological Medicine, King’s College London, (3)Department of Child and Family Health, King’s College London, (4)Warwick Clinical Trials Unit, University of Warwick

Background: Hypertensive disorders of pregnancy [HDP] include gestational hypertension, chronic hypertension, pre-eclampsia, eclampsia, and eclampsia imposed on chronic hypertension.  HDP are severe and concerning health problems which women can experience during, and occasionally, after a pregnancy.  They are also a leading cause of direct maternal deaths globally (Say et al., 2014).  There remains little international consensus on HDP diagnosis (Cairns et al., 2016), but they are thought to affect approximately 5%–10% of women, though this figure is rising (NICE, 2019). To date, literature has focused on management of HDP during pregnancy (Magee & von Dadelszen, 2013), but focus is increasing on postnatal management, reflecting the evidence which suggests risk of HDP recurrence in subsequent pregnancies (Kayem et al., 2011).  This is the first study which aimed to explore in-depth the views and experiences of a group of UK clinicians of postnatal management of women who had HDP, their awareness of relevant NICE guidance and barriers and facilitators to implementation of NICE recommendations.  

Method: This was a qualitative study using semi-structured interviews with twenty clinicians who had experience of providing postnatal care to women who had hypertensive disorders of pregnancy.  A maximum variation, purposive sample (Coyne, 1997; Higginbottom, 2004) was used to recruit participants from across four National Health Service maternity units and three general practice clinics in South-East and South-West London.  Data were managed using NVivo software and thematic analysis was used for coding and theme generation (see Braun & Clarke, 2006; 2013).  The analysis was inductive and consultative (Terry et al., 2017), with discrepancies resolved amongst the team (Silverio et al., 2019), which culminated in theme saturation being achieved (Vasileiou et al., 2018).

Results: Four main themes were generated: Variation in Knowledge and Clinical Practice; Communication and Education; Provision of Care; Locus of Responsibility for Care.  Each theme had a number of sub-themes. Perceived barriers to implementation of NICE guidance included lack of postnatal care plans and pathways, poor continuity of care, poor anti-hypertensive medication management, uncertainty around responsibility for postnatal care, and women’s lack of awareness of the importance of postnatal follow-up for their future health.  Some clinicians considered that women were discharged from inpatient care too soon, and primary care clinicians did not have specialist knowledge of HDP management.  Most clinicians acknowledged the need for better planning, communication and coordination of care across health settings.

Implications: Evidence of longer-term maternal health consequences following HDP is accumulating. Clinicians should ensure that relevant NICE guidance is implemented, that they are familiar with guidance and that women are involved in decisions about ongoing care and why this is important. The continued low priority accorded to postnatal care means that missed opportunities to improve outcomes for women, their infants and families will continue.


Preventing Cerebral Palsy in Preterm Delivery (PreCePT) – Applied research in Scaling Up Quality Improvement

Brent Opmeer(1), Karen Luyt(2), Theresa Redaniel(1), Ruta Margelyte(1), Carlos Sillero-Rejon(1), Christalla Pithara(1), Pippa Craggs(1), Noshin Menzies(3), Vardeep Deogan(3), Emma Treolar(3), Sabi Redwood(1)
(1)NIHR ARC West, (2)University Hospitals Bristol NHS Foundation Trust, (3)West of England Academic Health Science Network

Background: NICE Preterm labour and birth guideline (NG25, 2015) recommends use of MgSO4 in deliveries below 30 weeks gestation, to prevent cerebral palsy and other neurological problems associated with preterm delivert. Despite national guidance, the uptake of MgSO4 supplementation in eligible births was slow in the UK. This presentation aims to provide an overview of the PreCePT QI approaches, including rationale and methods used, and to present and reflect on lessons learned on its development and implementation. 

Method: In PreCePT, a quality improvement toolkit and approach was developed, and the feasibility of this approach has been piloted in 5 maternity units in the South West of England. Building upon the success of the PreCePT Project, NHS England have rolled out a PReCePT toolkit nationwide, delivered by the Academic Health Science Networks (AHSN) via the PReCePT National Programme (NPP).  The PreCePT QI intervention is implemented all participating units, through a QI toolkit and network support for a midwife and/or obstetric champion to improve the delivery of preterm care and collaboration between midwives, obstetricians and neonatologists (in the network support arm); and clinical backfill as well as microcoaching on top of this basic level of support (in the enhanced support group). To accommodate differences across the country in readiness of units to get all study arrangements in place, the PreCePT QI intervention has been implemented in two waves. The PReCePT Study is now embedded within the NPP, and investigates whether an enhanced micro-level QI support, improves and sustains MgSO4 uptake for fetal neuroprotection over and above the NPP network-delivered QI intervention. 

Results: Forty-eight maternity units in England have been randomised to either receive the enhanced support model (16 units) or be observed while implementing the standard support model (32 units). The PreCePT QI toolkit has been succesfully implemented in all participating units; primary outcome data on magnesium use are routinely collected through the national neontal audit and made available at the end of follow-up; relevant data on organisational aspects as well as resource use throughout the QI implementation were successfully collected from almost all units. Qualitative interviews are currently carried out with selected staff from participating units from both trial arms.

For scaling up QI-interventions, network support of local teams, lead by a clinical champions, with network support and/or additional micro-coaching, appears to be a feasible and successful approach; analyses of primary and secondary outcomes will show whether a more enhanced model for support has added value and may be cost-effective. 

Implications: Our findings will provide evidence on the effect of these different approaches to inform any future perinatal improvement projects. This is important in the current NHS climate with increasing demand for improved patient care that is delivered in a safe and cost-effective manner.  These scaling up efforts will be a significant step increasing the uptake of this intervention in maternity units in England. Nationally around 11,000 infants per year could benefit from this intervention


A Whole Systems Approach to Optimising Detection and Response to Deterioration in Hospitalised Children: Prospective, mixed methods, before and after evaluation of the PUMA Programme

Amy Lloyd
Cardiff University

Background: A range of interventions have been developed and evaluated in order to bring about improvements in processes for detecting and acting on deterioration in hospitalised children.  While evidence to support single interventions is limited, there is a growing consensus of the need for a whole systems approach to optimising performance.  

Methods: We developed an evidence-based theoretically informed whole systems approach to optimising in-patient processes for detecting and acting on deterioration: The PUMA Programme.  The PUMA Programme was implemented in two district general and two tertiary children’s hospitals in the UK and its impacts on patient outcomes and clinical practice was evaluated.  Each case was assessed independently.

The primary quantitative outcome was a composite metric, representing children in a month that experienced one of these events:

  • Mortality

  • Cardiac arrest

  • Respiratory arrest

  • Unplanned admission to Paediatric Intensive Care Unit

  • Unplanned admission to Higher Dependency Unit

Paediatric early warning system changes were assessed through qualitative ward case studies combining observations and interviews with staff and parents, the implementation of the intervention was assessed in a parallel process evaluation.

Results: All sites made system improvements as a result of the PUMA Programme and some of the clearer quantitative findings appeared to relate to qualitative observations.  All systems changed in response to wider contextual factors. Quantitative outcome measures use was challenging because of low event rates. 

Implementation was not a one-shot event, creating challenges for the interrupted time series in conceptualising ‘implementation’ and ‘post-intervention’ periods. 

Interpretation: Organisational level system change can impact positively on clinical outcomes, but alternative outcome measures are required to support research and quality improvement. The PUMA programme supports system optimisation and the approach could be used more widely.

Funding: This project was funded by the National Institute for Health Services and Delivery Research programme (project number 12/178/17).

Building a sustainable improvement programme to improve the detection and management of Atrial Fibrillation (AF) in the North West Coast (NWC)

Michelle Coleiro(1), Julia Reynolds(2)
(1)Innovation Agency, (2)

Introduction: Bold ambitions set by Public Health England to improve the detection and management of AF by 2029, will require regions to work innovatively to improve how they detect, protect and perfect the management of AF.

In 2015, North West Coast’s (NWC) baseline data (QOF 15/16) showed that 24,210 people were estimated to have undetected AF and only 76% of people with high risk AF were treated with an anticoagulation therapy. We aimed to test and embed a large-scale improvement programme across the NWC that worked collaboratively across local communities, primary and secondary care to detect people with possible AF and supported primary care with diagnosis and management.

Method: Core to our programme of AF work has been our ambition to maximise every partnership opportunity for the benefit of local patients; we have

  • Improved our local clinical network and healthcare system partnerships

  • Actively collaborated with partners from Industry to deliver two Joint Working Projects:

  • Leveraged our community assets

  • Adopted national best practice and initiatives to accelerate progress.

Key to the programme has been the adoption of the Detect, Protect, Perfect Campaign developed by the AHSN Network.

Results: Through our partnership approach, we have increased the detection of AF by:

  • Training a team of 65 volunteer AF Ambassadors and the Fire and Rescue Services across Cheshire to perform pulse checks in the community; this has led to the delivery of over 10,000 opportunistic pulse tests and over 1,000 people being signposted for further investigation

  • Distributing over 900 mobile ECG devices to healthcare teams across primary care, Fire and Rescue Services and community services

  • Implementing two joint working projects, across 136 GP practices, to deliver a quality improvement (QI) programme to primary care. This resulted in over 2,300 people being diagnosed with AF

  • Collaborating with ten community pharmacies to pilot a pathway to test for possible AF

  • Delivering 15 AF disease awareness campaigns at community venues across four CCGs from September 2018 to January 2019

We continue to improve the protection (treatment) of people identified with AF by:

  • Working with primary care to focus on the management of people with AF in our QI Collaboratives, in line with NICE guidance. This has led to over 2,000 high risk patients with AF being placed on anticoagulation therapy

  • Collaborating with ten community pharmacies to test and define a pathway to improve the management of AF patients placed on anticoagulation therapy by GP practices

  • Engaging with anticoagulation services to test improvements in communication/ correspondence with GP practices.

Latest QOF data (18/19) from the NWC shows that we now have only 2,100 people with undiagnosed AF in our region, meaning that we have now achieved 98% of our detection rate. Our protection rate has increased to 84% (high-risk AF patients on anticoagulation therapy), an increase of 8% since 2015/16.

Implications: We can achieve large-scale improvement by working innovatively and collaboratively across community, primary and secondary care. Detecting and protecting the missing thousands requires us to work across boundaries as an integrated healthcare system. Our collaborative approach, underpinned by the commitment of the region’s CCGs and GP practices, has demonstrated significant, sustainable improvement in the detection and management of AF for the region.