title: Primary Care Atrial Fibrillation Service: outcomes from consultant-led anticoagulation assessment clinics in the primary care setting in the UK.
abstract: OBJECTIVE
  Stroke-risk in atrial fibrillation (AF) can be significantly reduced by appropriate thromboembolic prophylaxis. However, National Institute for Health and Care Excellence estimates suggest that up to half of eligible patients with AF are not anticoagulated, with severe consequences for stroke prevention. We aimed to determine the outcome of an innovative Primary Care AF (PCAF) service on anticoagulation uptake in a cohort of high-risk patients with AF in the UK.
  
  
  METHODS
  The PCAF service is a novel cooperative pathway providing specialist resources within general practitioner (GP) practices. It utilises a four-phase protocol to identify high-risk patients with AF (CHA2DS2-VASc ≥ 1) who are suboptimally anticoagulated, and delivers Consultant-led anticoagulation assessment within the local GP practice. We assessed rates of anticoagulation in high-risk patients before and after PCAF service intervention, and determined compliance with newly-initiated anticoagulation at follow-up.
  
  
  RESULTS
  The PCAF service was delivered in 56 GP practices (population 386,624; AF prevalence 2.1%) between June 2012 and June 2014. 1579 high-risk patients with AF with suboptimal anticoagulation (either not taking any anticoagulation or taking warfarin but with a low time-in-therapeutic-range) were invited for review, with 86% attending. Of 1063 eligible patients on no anticoagulation, 1020 (96%) agreed to start warfarin (459 (43%)) or a non-vitamin K antagonist oral anticoagulant (NOAC, 561 (53%)). The overall proportion of eligible patients receiving anticoagulation improved from 77% to 95% (p<0.0001). Additionally, 111/121 (92%) patients suboptimally treated with warfarin agreed to switch to a NOAC. Audit of eight practices after 195 (185-606) days showed that 90% of patients started on a new anticoagulant therapy had continued treatment. Based on data extrapolated from previous studies, around 30-35 strokes per year may have been prevented in these previously under-treated high-risk patients.
  
  
  CONCLUSIONS
  Systematic identification of patients with AF with high stroke-risk and consultation in PCAF consultant-led clinics effectively delivers oral anticoagulation to high-risk patients with AF in the community.
authors.affiliation: Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK Imperial College London, London, UK.
authors.forename: Moloy
authors.initials: M
authors.lastname: Das
authors.affiliation: Inspira Health Solutions Ltd., Bury, UK.
authors.forename: Lee
authors.initials: L
authors.lastname: Panter
authors.affiliation: Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK Imperial College London, London, UK.
authors.forename: Gareth J
authors.initials: GJ
authors.lastname: Wynn
authors.affiliation: Inspira Health Solutions Ltd., Bury, UK.
authors.forename: Rob M
authors.initials: RM
authors.lastname: Taylor
authors.affiliation: Inspira Health Solutions Ltd., Bury, UK.
authors.forename: Neil
authors.initials: N
authors.lastname: Connor
authors.affiliation: Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK.
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Mills
authors.affiliation: University of Birmingham Centre for Cardiovascular Sciences, University of Birmingham, Birmingham, UK Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany.
authors.forename: Paulus
authors.initials: P
authors.lastname: Kirchhof
authors.affiliation: Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK Imperial College London, London, UK.
authors.forename: Dhiraj
authors.initials: D
authors.lastname: Gupta
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D003253:Consultants; D058006:General Practice; D006268:Health Facilities; D006296:Health Services; D006801:Humans; D010349:Patient Compliance; D011320:Primary Health Care; D018570:Risk Assessment; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D014812:Vitamin K; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014812:Vitamin K; D014859:Warfarin