Atrial fibrillation: Developing anticoagulation management and therapy for atrial fibrillation through primary care

As risk of stroke increases with age, stroke prevention in elderly people with atrial fibrillation is a key aspect of management for this group. Anticoagulation therapy with warfarin is highly effective in reducing stroke risk but is associated with monitoring costs and higher risk of haemorrhage compared with other treatments.

Work by Professor David Fitzmaurice, Professor of Primary Care at University of Birmingham on this area has focused on service re-design, screening and treatment for AF and has included generation of robust primary evidence through RCTs, economic evaluation and systematic review.

Shifting service delivery into primary care

Until a decade ago, patients in the UK who received oral anticoagulation management were managed in secondary care because of the need for monitoring via a laboratory blood test, the international normalised ratio (INR). Funded by a NHS national R&D Primary Care Career Scientist Award Professor David Fitzmaurice and colleagues (Dr Kate Fletcher; Professor Richard Hobbs; Mr Roger Holder; Dr Susan Jowett; Professor Gregory Lip; Professor Jonathan Mant; Dr Ellen Murray; Mrs Andrea Roalfe) has undertaken an extensive primary care research programme within the area of service delivery for oral anticoagulation management to investigate the integration and evaluation of new technologies & the Birmingham model, comprising computerised decision support dosing software, and point of care INR testing within primary care, to facilitate oral anticoagulation management.

Self-monitoring of oral anticoagulation

The SMART (Self-Management of Anticoagulation: a Randomised Trial) study (PI: Fitzmaurice, £285K, MRC, 1999-2002) demonstrated the effectiveness of self-management for approximately 25% of patients receiving warfarin, compared with routine care whether provided through primary or secondary care. These data were the first UK RCT data and the first in the world from primary care and have underpinned subsequent meta-analyses demonstrating the clinical and cost-effectiveness of this model of care (Garcia-Alamino et al Cochrane review 2010).

More recently, the Patient Self-Management registry (PI: Fitzmaurice £50k, NIHR National School for Primary Care Research 2011-2014) has been developed. This electronic central register provides a valuable tool for studying the safety and effectiveness of this method of service delivery. This study is evaluating the feasibility of patients with AF who self-monitor or self-manage their conditions entering their data onto a website to produce a register.

Screening for AF

The Screening for Atrial Fibrillation in the Elderly (SAFE) study (Fitzmaurice (PI), Hobbs,Mant, £485k HTA funded 1999-2003) was a trial of systematic screening versus routine practice for the detection of AF in 15,000 patients aged over 65. SAFE determined the optimal method of AF diagnosis & ECG interpretation and established the incremental cost-effectiveness (Jowett) of different screening options compared with routine clinical practice, determining that opportunistic screening was most cost-effective.

Management of AF

Funded by the MRC, Fitzmaurice and Hobbs undertook the BAFTA (Birmingham Atrial Fibrillation Treatment of the Aged) study comparing the efficacy of warfarin with that of aspirin for the prevention of stroke in a primary care population of 973 patients with AF aged 75 years or over. The BAFTA study provided accurate data on the risk of haemorrhage, which appears to be an important factor in physicians’ decisions whether to prescribe warfarin. In addition, the study demonstrated the actual benefits of warfarin compared to aspirin and reported data showing improved efficacy and equivalent safety of warfarin versus aspirin in stroke prevention in the very elderly. The study provided evidence to support the use of anticoagulation therapy (warfarin) for people aged over 75 with AF unless there are contraindications or the patient chooses otherwise.

The University of Birmingham is an internationally-respected centre of excellence for research in AF, and has made crucial impacts in international clinical practice guidelines and improvements in patient care.

Primary care research at the University of Birmingham has led to the transfer of oral anticoagulation services from secondary to primary care, and latterly patient self-management, resulting in improved clinical outcomes. In addition, the BAFTA trial has provided evidence to support the use of anticoagulation therapy (warfarin) for people aged over 75 who have atrial fibrillation, resulting in changes in clinical management of these patients.

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