AF screening appears to have become a hot topic again. Some would cynically say this is being driven by the pharma companies selling NOACs who always like to promote a disease that they have a drug for. However, Public Health England appear to agree it’s a priority and there is a lot of evidence that there is a lot of undiagnosed AF out there in the community. Of course, Atrial Fibrillation is a major risk factor for Stroke. Stroke is a costly disabling life changing problem and in many ways, it meets all the criteria for a condition that should be screened for, yet no real screening programme exists other than the cardiovascular health check programme.
Years ago, when I was in the PCT Primary Care Directorate, I added to a pre QOF scheme we ran the need to record a pulse rate and rhythm on any patient who was having a BP done. It was surprising how many people had BPs done (and it’s also surprising how many didn’t) and hadn’t got their pulse recorded. In theory you should be measuring it while doing the blood pressure and you should at least get a feel for if it is regular. Newer electronic machines should have AF detection on them though a lot don’t. Whilst I no longer have the exact data, in a year we significantly increased the number of pulses recorded and identified quite a lot of AF.
Others have tried similar. From standing outside supermarkets to more locally, the fire brigade offering AF checks when doing a home check with an AF detection stick. It’s a great idea of cross organisational working and really adds value, targeting people who otherwise might not be screened.
Almost at the start of our GP Federation we recognised that AF screening, as well as other cardiovascular markers are important, particularly for our populations. We spent some money on buying every GP who wanted one an Alivecor hand held ECG device, we bought in an ECG service and we pushed the CCG to put in a bid for an AF screening device from Cardiocity.
How they work – The Alivecors (there are rumours these are available for free through the NHS – but we bought in bulk at a discount from Technomed) are small 10cm long devices upon which a patient places their fingers to get a single lead ECG trace. They work through sound and utilise the clinician’s smartphone which needs to have the Kardia app installed on it. This app is free – and although aimed at the public works well for clinicians. You can record 30 second traces of multiple patients and store them – it gives you an electronic interpretation which errs on the side of caution i.e. if it says its normal it probably is but if not, it needs looking into. You can, if needs be, email or print the trace out so you can get it into the GP record or send it in with a patient if admitting them. It’s very portable battery powered, and I have one in my jacket pocket at all times and use it a lot. I tend to use it when examining a patient and to be fair, although I could use it for screening I don’t – largely as I don’t have time.
It’s time to standardise care – The ECG service from Technomed is worth mentioning. They are an ECG interpretation service. They do 12 lead ECGs and others, including event and holter monitors. One of the great beliefs of our model of GP Federations is that in order to push general practice towards being a leading light in an ACS, general practice needs not only to up its game but to standardise and harmonise its care delivery; retaining individual flare and creativity but ensuring basic minimum standards. We recognised early on that different clinicians and different practices dealt with ECGs in different ways, partly based on funding, partly based on historic reasons, including training and interest and space.
Some practices would do their own ECGs the same day, some would refer to hospital and the patient could wait weeks. Of course, not only were practices different, different clinicians were different, some are confident about reporting ECGs, some aren’t. This could lead to things being missed or the other way around, things being referred for advice that didn’t need to be. Often GPs will ask colleagues for informal advice but often due to time a referral can happen.
Our idea was to purchase our practices one device that came with standardised reporting. We won some funding and purchased a service from Technomed where all practices received an ECG machine. It’s the same device and is co-installed and co-supported by the Alliance IT Team with Technomed. It’s centrally reported through the cloud and now all GPs in practices that took it up have access to a rapid standardised reported ECG. We did think that practices might want to receive payment to do this, but most were happy to have a high quality supported service that helped them clinically and administratively and showed they were doing a good job.
Lastly, but not least we persuaded the CCG to put in an ETTF bid for Cardiocity AF Screening Machines – one per practice.
These are boxes that connect via USB to a computer. They have 2 hand shaped panels on them and a patient puts their hand on and after 30 seconds it either says they are ok or not. The main arrhythmia detected is AF, but it is possible to pull off other rhythms. The box can be run on a standalone kiosk, but we think it works better either connected to a reception machine, a HCA machine or a nurse doing treatment room. Our data shows that in most practices 80% or more of a registered list will present at least once a year, and so with a little bit of targeting it should be possible to reach large numbers of people. We have practices who have had it running during flu clinics or at other times; we have largely left it up to practices. Take up has been variable but any cases found is better than none and we are looking, now we have the kit, into how we might build screening into local LES schemes or other ways of incentivising.