Introduction

Atrial fibrillation (AF) is the most common heart arrhythmia and a leading cause of stroke. While medications can prevent stroke in people with AF, barriers persist including lack of diagnosis, treatment nonadherence, and racial and ethnic disparities. This toolkit assists primary care teams in understanding their patients’ risk and promoting evidence-based, patient-centered, equitable treatment with anticoagulants using quality improvement strategies.

About AF

Atrial fibrillation is the most common heart arrhythmia. It is the primary diagnosis for nearly half-a-million hospitalizations in the U.S., and more than 150,000 deaths each year, a number that is rising as the population ages.

AF increases the risk of stroke fivefold, with more recurrence, more severe disability, and increased mortality. Stroke, the 5th leading cause of death, is linked to AF 1 out of 5 times.

With proper treatment, including anticoagulation medications, the stroke-risk posed by AF can be significantly reduced. Unfortunately, as many as one-third of patients with an AF diagnosis are not adherent to their medications and an estimated 15 percent of individuals with AF are undiagnosed.

AF and Racial and Ethnic Disparities

While AF is more common among white populations, people of color with AF are much less likely to receive optimal, evidence-based treatment, with poorer outcomes, including death. A meta-analysis of nearly sixty studies has shown that people of color were less likely to receive anticoagulation for stroke prevention or rhythm control modalities:

• Multiple studies show lower use of anticoagulant therapies among Black patients compared to White;
• When anticoagulants are used, the newer Direct Oral Anticoagulants (DOAC) were much less often prescribed for patients of color; and
• Rhythm control interventions such as catheter ablation were much less likely among people of color as well.

Studies have shown that these disparities cannot be explained away by less insurance coverage or other social determinants of health.

AF Screening

Multiple factors have led to increasing interest in AF screening, including: the growing prevalence of the disease; high levels of undiagnosed and untreated AF, including among those who suffer a preventable ischemic stroke; and, increasingly, available screening tools (see Table 1). Nonetheless, insufficient evidence on the benefits and optimal implementation strategy has prevented the issuance of screening recommendations by the U.S. Preventive Services Task Force.

Examples of Tools for AF Screening

Photoplethysmography via smartwatch or watch:

AppleWatch, Technology compatible with a wide range of smartphones

Blood pressure monitor:

WatchBP Home A, Omron M6

Handheld devise or smartphone compatible ECG:

Kardia (Alivecor), Zenicor ECG (Zenicor), MyDiagnostic (Applied Biomedical Systems BV)

Patch ECG Monitors:

Zio (iRhythm), Cardiostat (Icentia), Nuvant (Corventis)

Patient Education

Evidence shows that medications, especially DOACs, are safe and effective in preventing stroke although they do present some bleeding risk. Engaging and educating patients with or at high risk of AF is especially important in discussing anticoagulation choices. A number of resources are available for clinical teams and their patients.

• https://www.hrsonline.org/guide-atrial-fibrillation
• https://upbeat.org/heart-rhythm-disorders/atrial-fibrillation
• https://stopafib.org/
• https://www.cardiosmart.org/docs/default-source/assets/decision-aid/afib-stroke-prevention_high-risk.pdf?sfvrsn=b4180609_1
• myafibexperience.org

The Center for Sustainable Health Care
Quality and Equity (SHC)

Has developed a model for assisting primary care teams and their community partners in improving care, especially in diverse and underserved communities. Quality Improvement Education – QIE – relies on the rapid cycle improvement approach and collective impact model, helping primary care practices and community organizations educate patients and the larger community about specific health care needs while improving preventive care, screening, treatment, specialty referral, illness self-management, adherence, connection to services that address social risks, and research recruitment.

SHC’s QIE principles include:

• Patient-centered, engaging patients and community leaders in program and treatment planning as well as educational activities;
• Team-based, with all members of the practice team, included to create efficiencies in care, avoid burn-out, and tap into the strong motivation held by all to take good care of patients;
• Local champion-driven, from the clinic and community promoting sustainable improvement;
• Data-directed guided NMQF’s state-of-the-art health geographic information system (GIS) along with clinical chart and survey data; and
• Collaborative, partnering with patient advocates, health systems, researchers, and innovation company partners.
  

Champion Selection:

SHC’s QI model begins with the identification of the QI project leads – or champions. At the practice level, a physician and one or more additional clinical and practice management staff form the champion team; they identify the issues, review baseline practice gaps, consider strategies for improvement, lead the implementation of the QI project, and communicate throughout the program with health care system leaders, practice staff, and patients.

Practice Assessment:

A number of resources can help the champions review potential gaps in care. The EHR data can be used to identify specific patient populations (e.g., patients at high risk for AF) and treatment patterns (e.g., Black vs. white patients with AF receiving a DOAC). Community-based data can inform the champions about important local needs in their community. Completion of a practice assessment survey can help the champions consider the overall picture for a given condition. Worksheets can be used to probe inefficiencies in practice workflow or identify root causes. Patient surveys can be developed to probe their perspective on care. Links to resources

Baseline Assessment:

A number of resources can help practice champions understand gaps in care, including EHR-data (e.g., DOAC prescription rates among White and Black AF patients); community assessment tools, and other practice tools for understanding workflow in a practice.

See SHC’s DRIVE program resources at:

• See SHC’s DRIVE program resources at: CLICK HERE
• AF Screening Practice Assessment Survey: CLICK HERE
• Community Health Assessment & Health Improvement Planning: CLICK HERE
• Community Health Assessment and Improvement Planning: CLICK HERE
• Cause and Effect Diagram: CLICK HERE
• Using Root Cause Analysis to Improve Quality and Performance: CLICK HERE

PDSA Design and Implementation:

The cornerstone of rapid cycle improvement, which can be applied to a wide range of clinical and practice improvement targets, is developing a PDSA – Plan-Do-Study-Act – project. A PDSA is a very targeted and specific plan for improvement, the implementation of which is tracked using a run chart. This approach embraces small steps that are assessed in an ongoing fashion. After the champions do their baseline assessment to identify a gap and communicate with the practice staff, about their plans, gaining their input, the next step is to flesh out your PDSA and implement it! Be sure to keep your practice colleagues aware of results as you proceed, as this will help broaden the implementation of successful QI activities.

• PDSA and Run Chart Templates can be found at:
  https://42oj7n1mxvww21alh644xsv1-wpengine.netdna-ssl.com/wp-content/uploads/6_PDSA_Worksheet.pdf
• QI Library: The table below outlines some QI projects which have been implemented successfully by practices. (Download Spreadsheet PDF)
  

Acknowledgement of Support

This activity is funded by an Independent Medical Education grant from the Bristol-Myers Squibb-Pfizer Alliance.

Collaborative Partners

AXDEV Global and SHC thank their collaborative partners in the design and development of this program, especially Dr. Andrea Russo and her team at Cooper University Health Care, the Heart Rhythm Society, and the American Heart Association. Special acknowledgement to Dr. Gregory Hood.