Digital image of a heart

The introduction of a performance-related financial incentive scheme for GPs led to a dramatic almost five-fold rise in the number of patients whose heart rhythm condition was said to have been ‘cured’, say University of Birmingham researchers.

Academics at the University of Birmingham’s Institute of Applied Health Research, supported by NIHR ARC West Midlands, conducted a study into patients with the most common heart rhythm condition, called atrial fibrillation. It mainly affects older people, with around 1.4 million sufferers in the UK, and it greatly increases the risk of stroke. To avoid strokes, it is important patients take anticoagulant drugs to prevent blood clotting. A previous study by the University of Birmingham showed that even after atrial fibrillation is recorded as ‘cured’, patients remain at high risk of stroke and should continue taking anticoagulants.

In this new study, published in BMJ Open, researchers analysed GP records dating between 2000 and 2016 of 250,788 patients with atrial fibrillation, of which 14,757 patients were recorded to have cured, or ‘resolved’, atrial fibrillation.

The researchers found that prior to 2005, resolved cases of atrial fibrillation were uncommon, but became almost five times more frequent after the introduction of the management of the condition in GP performance targets in 2006 (rising from 5.7 per 1,000 person-years in 2005, to 26.3 per 1,000 person-years in 2006). It has remained high ever since and increased again when further changes were made to the incentive scheme in 2012.

The targets are part of the Quality and Outcomes Framework (QOF), a voluntary scheme within the General Medical Services contract aimed at improving the quality of clinical care. QOF sees GPs keeping a register of patients with chronic disease. They are paid an incentive to ensure a specific percentage of atrial fibrillation patients receive drugs for stroke prevention. However, patients with ‘resolved’ atrial fibrillation are excluded from this register.

Research Fellow Dr Nicola Adderley, of the University of Birmingham, said: “It is possible that this increase was, in part, the result of GP practices catching up with recording ‘resolved’ atrial fibrillation following the introduction of QOF.

“However, we know from our previous research that the vast majority of patients with resolved atrial fibrillation do not receive stroke prevention drugs.

“Our latest study gives evidence that, since the introduction of these performance targets, patients with atrial fibrillation are deemed to be cured simply because they aren’t being prescribed anticoagulants.”

Tom Marshall, Professor of Public Health and Primary Care, of the University of Birmingham, said: “In this new study we also found that, since 2006, the increase in resolved cases of atrial fibrillation was most striking in the months of January to March, just before the date in April when the performance targets are measured.

“Prior to 2006, resolved cases of atrial fibrillation were recorded throughout the year with little monthly variation in incidence.

“The effect of this is that GPs’ performance appears improved, which can be equated to getting troublesome children to stay at home on the day of a school inspection.”

Senior Clinical Lecturer Dr Krish Nirantharakumar, of the University of Birmingham, said: “The problem is that if a patient is reported as cured they are removed from the register and therefore fall out of the system, which stops GPs keeping an eye on people with ongoing atrial fibrillation.

“Our previous research has shown that atrial fibrillation cannot ever safely be considered as resolved – it is a condition that can be present one day and absent the next and giving someone the all-clear can be a mistake.

“It can come back without a patient or their doctor realising, which means they continue to be at high risk of stroke and should still be prescribed clot-preventing drugs.

“Across the UK there are around 100,000 people with atrial fibrillation which is reported as resolved, of which around 2,000 will suffer strokes each year. They are largely untreated, yet treatment of these patients would prevent about 1,000 strokes per year.”

Professor Marshall concluded: “We hope this research will lead to changes to the QOF rules so these patients don’t come off the register if they are labelled ‘resolved’.”

Those with atrial fibrillation may be aware of noticeable heart palpitations, where their heart feels like it's pounding, fluttering or beating irregularly. Sometimes atrial fibrillation does not cause any symptoms and a person who has it is completely unaware that their heart rate is irregular.

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  • Adderley et al (2019). ‘Temporal variation in the diagnosis of resolved atrial fibrillation and the influence of performance targets on clinical coding: cohort study.’ BMJ Open. DOI: 10.1136/bmjopen-2019-030454
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