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GPs set for incentives to screen for atrial fibrillation

GP practices could soon be offered incentives through QOF to screen elderly people for atrial fibrillation, under new NICE plans unveiled this week.

The proposals will see 30 GP practices piloting yearly pulse checks in elderly people at particularly high risk of stroke, as part of a drive to boost earlier detection of the heart arrhythmia.

The move comes despite opposition from GP leaders, who argue that screening for atrial fibrillation goes against National Screening Committee advice and that it is another example of the tick-box culture.

The plan for a QOF screening indicator has been introduced after concerns that up to 470,000 adults with atrial fibrillation have not been diagnosed and are therefore not receiving appropriate advice to reduce their risk of stroke, NICE said.

The 30 GP practices will test out an indicator that rewards yearly pulse palpation checks in patients over the age of 65 who have conditions such as COPD and diabetes.

The practices will also try out an indicator on yearly reviews of the ‘quality’ of anticoagulation in those patients already diagnosed and receiving treatment for atrial fibrillation, as previously proposed.

This comes after NHS Improvement said that round 8,000 extra strokes could be prevented each year if the condition was better managed – saving the NHS £95 million a year.

NICE said it was not yet known what the exact wording of the indicators would be, but that they could be rolled out in 2017/18, if they ‘are found to improve the identification and management of atrial fibrillation’. 

Dr Andrew Black, a GP in Herefordshire and deputy chair of the indicator advisory committee, said: 'Improving the identification of atrial fibrillation and ensuring we perform timely reviews of treatment are two very easy steps we can take, which could have a huge benefit to our patients.

'I am glad these indicators are being piloted and I look forward to reviewing the impact they have had.'

However, both indicators have been met with scepticism amongst GP leaders.

Dr Peter Swinyard, chair of the Family Doctor Association, said it is increasing bureaucracy both should be vetoed even if they are validated through the pilots.

He said: 'It’s another box to tick , when you get these extra boxes to tick in certain groups – but does that really save lives?

'We do pick people up – we do already check the pulse – and I’m not sure giving us yet another hurdle to jump is going to help anything at a time when we are so short on appointments and manpower.'

The RCGP’s expert group on overdiagnosis warned the approach ‘is a proposal to screen for atrial fibrillation’ and that ‘NICE should not be promoting a screening activity that has been considered by the National Screening Committee and rejected’.

It also rejected the idea of the anticoagulation review indicator, arguing this ‘will be time consuming’, ‘likely to become a tick-box exercise’ and could cause ‘confusion and irritation’ among patients.

However, the NICE indicators advisory committee dismissed these concerns during a recent meeting, minutes reveal.

The committee said that yearly pulse checks should not have ‘major implications on resources as this process should be done when carrying out other processes such as blood pressure checks’, and that, as the approach only targets an ‘at-risk’ group, ‘it does not constitute screening’.

And it ruled the yearly anticoagulation review ‘would not be captured in a generic indicator on medication review’.

However, it comes as the GPC and NHS England are in talks over the future of QOF.

 

Readers' comments (13)

  • It is good to pick up more diseases and treat it but we are already struggling with the current ones. NHS England---can you provide more CLINICAL staff and less pen pushing/less new directives/new guidelines/new targets? Scrap the QoF.

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  • "as the approach only targets an ‘at-risk’ group, ‘it does not constitute screening’."

    I wonder what the National Screening Committee would make of this claim? Yes, glad you asked, that is indeed the same NSC who advised against screening for AF...

    http://legacy.screening.nhs.uk/atrialfibrillation

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  • We've done it previously as an add on LES to the flu jabs, and it was pretty effective. Dead easy to do and money for old rope.

    The NOACs should make management easy enough, but the cost of using them will probably blow a big hole in CCG drug budgets.

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  • Is it really so much hassle to take a person's pulse when they have come into the surgery anyway? And, if that person is elderly, overweight, has heart problems etc, isn't this doubly so?

    In fact, I'd go so far as to suggest checking the pulse should be done as a matter of course. The pulse will tell you so much about about someone's general health.
    Why is it so many doctors seem to think they shouldn't touch the patient at all these days? Get a grip. It only takes seconds!

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  • Sure, this screening programme will cause a flutter if not proper fibrillation in inundated ECG departments. We already have waiting lists of up to 8 weeks for ECGs here - don't know what the situation is in other parts of he country.

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  • I think it Ian excellent idea and should be done at ALL visits to identify and treat patients with AF and hence minimise risks of CVA.

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  • To Sanjeev Junela - Or you could spend a little money on an ECG machine for the practice. My practice has had one since the 1980's. I am gobsmacked that GP practices still do not have this most basic diagnostic tool on site. Our waiting time for ECGs is until there is a spare 5 minutes on the couch in one of the treatment rooms. Usually no more than 30 minutes.
    On a broader note- when did pulse taking become a complicated technical intervention worthy of additional payment- I would argue a clinician not taking the pulse of an appropriate person is in my opinion potentially negligent. What a low level we are stooping to as a profession- shame on us!

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  • I diagnosed the onset of my own AF years ago and our ecg was confirmatory. In my view the ECG was useful and timely.
    I am more concerned about the quality of anti-coagulation.
    I urge that the calibration of INR test gear and the standardisation of anticoag medication should be available on line for all to check.

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  • Funny how no-one was promoting this when there was only a cheap generic anticoagulant, not a new expensive on-patent NOAC.......
    Am I getting too cynical?

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  • Vinci Ho

    (1) We all can agree that checking the pulse alongside BP is natural in an physical examination in any age group . Question is how often should we check on patients , especially those asymptomatic with no registered chronic illnesses. That refers to the principle of screening . Every 5 years , every 3 years? Perhaps , that really needs some statistics to support some arguments. But we also know there is something called interval incidents , just like in breast , cervical , bowel and AAA screening . A selected age group e.g. 65 makes sense.
    (2) The ball does not stop at the point of picking up the irregularly irregular pulse . It leads to verification of the diagnosis,subsequent oral anticoagulant and the actual counselling of which one to use(as well as options of treating AF). It should be quite a proactive , dynamic sequence of actions.One can argue a community one stop shop for GPs to refer after picking up AF is one way but it depends on waiting time . I would argue patients prefer to be followed up by the same clinician(or the colleagues in same practice, hence not for locums working short period of time here and there). Clearly , it demonstrates the essential role of general practitioners from palpating the pulse to commencing oral anticoagulants in a fashion of continuity .(Yes , yes , not the cup of tea for those arguing fast and easy GP access!)
    (3) Overall , we are dealing with both secondary prevention of AF and more importantly primary prevention of systemic embolisation and hence , stroke . If the health stakeholders genuinely understand this health philosophy and science , fund (including funding to train) General Practice 'properly' in a package as I am not sure several QOF points are really up to it.

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