Review of screening studies for atrial fibrillation in rural populations of 11 countries

Impact of a Comprehensive Guideline Dissemination Strategy on Diabetes Diagnostic Test Rates: an Interrupted Time Series

BACKGROUND

Diabetes Canada launched a comprehensive Dissemination and Implementation (D&I) strategy to optimize uptake of their 2013 Clinical Practice Guidelines; the strategy involved continuing professional development courses, webinars, an interactive website, applications for mobile devices, point-of-care decision support tools, and media awareness campaigns. It included a focus on promoting HbA1c as the recommended diagnostic test for diabetes.

OBJECTIVE

To determine the impact of Diabetes Canada's 2013 D&I strategy on physician test-ordering behavior, specifically HbA1c testing, for the diagnosis of diabetes, using provincial healthcare administrative data.

DESIGN

Population-based interrupted time series.

SETTING

Ontario, Canada.

PARTICIPANTS

Ontario residents aged 40-79 not previously diagnosed with diabetes.

MEASUREMENTS

For each quarter between January 2005 and December 2014, we conducted an interrupted time series analysis on the first-order difference of the proportion of patients receiving HbA1c tests per quarter with an autoregressive integrated moving average model with the intervention step occurring in quarter 2 of 2013. Subgroup analyses by rurality, physician graduation year, and practice size were also conducted.

RESULTS

There were 32 quarters pre-intervention and 6 post-intervention; average sample size per quarter was 5,298,686 individuals. Pre-intervention, the quarter-to-quarter growth was 1.51 HbA1c tests per quarter per 1000 people. Post-intervention, the quarter-to-quarter growth increased by 8.45 tests per 1000 people (p < 0.005). Growth of HbA1c ordering differed significantly by region, years since physician graduation, and practice size.

LIMITATIONS

Incomplete data collection, inadequate stratification, and other unidentified confounders.

CONCLUSION

The D&I strategy resulted in a significant increase in the growth of HbA1c tests. The successful uptake of this recommendation may be due to its simplicity; guideline developers should consider this when drafting recommendations. Furthermore, differential uptake by user groups suggests that future strategies should include targeted barrier analysis and interventions to these groups.

Incremental yield of ECG screening repeated annually over 4 years in an adult Japanese population without prior atrial fibrillation: a retrospective cohort study

OBJECTIVES

International guidelines recommend opportunistic screening for atrial fibrillation (AF); however, there is no current data to inform how often to repeat screening. We aimed to investigate the incremental annual yield and stroke risk of new AF cases in individuals screened annually over 4 years.

DESIGN

A retrospective cohort study.

SETTING

Hokuriku Health Service Association, Toyama prefecture, Japan.

PARTICIPANTS

Employees and their families receiving annual health examinations from Hokuriku Health Service Association.

INTERVENTION

Each subject received an annual health examination (including 12-lead ECG) from 2014 to 2017. Only subjects with baseline ECGs in 2012 and/or 2013 were included.

MAIN OUTCOME MEASURES

Rates (cases/100 person-years) of new AF identified each year for 4 consecutive years of screening (stratified according to gender and age groups). Calculated stroke risk of new AF cases using modified CHA₂DS₂-VASc scores (without heart failure data) (CHA₂DS₂VASc = C: congestive heart failure [1 point]; H: hypertension [1 point]; A2: age 65-74 years [1 point] or age ≥75 years [2 points]; D: diabetes mellitus [1 point]; S: prior stroke or transient ischemic attack [2 points]; VA: vascular disease [1 point]; and Sc: sex category [female] [1 point]) RESULTS: In 2014, 88 218 subjects had an ECG (46.8±12.5 years; 64% men): identifying 346 (0.39%) known AF and 69 (0.08%) new AF. The incidence rate of new AF increased with age from 0.01% (<50 years) to 0.98% (≥75 years) and was higher in men (0.1%) than women (0.05%). Repeated annual screening over 4 years identified a consistent new AF yield 0.06%-0.10% per year (0.33%-0.55% ≥65 years). Forty-two per cent of all new AF cases, and 76% of cases aged ≥65 years, had a class-1 oral anticoagulation (OAC) recommendation (modified CHA₂DS₂-VASc score ≥2 men, ≥3 women).

CONCLUSIONS

Repeated annual ECG screening of the same population provides a consistent yield of new AF each year. The majority of new AF (≥65 years) are eligible for anticoagulation for stroke prevention. Although AF prevalence and incidence are lower in Japan than Western countries, 2318 new cases would be identified in Toyama prefecture each year with annual screening, of whom ~927 would have a high stroke risk with a recommendation for OAC therapy.

Atrial Fibrillation Screen, Management And Guideline Recommended Therapy (AF SMART II) in the rural primary care setting: an implementation study protocol

INTRODUCTION

Screening for atrial fibrillation (AF) in people ≥65 years is now recommended by guidelines and expert consensus. While AF is often asymptomatic, it is the most common heart arrhythmia and is associated with increased risk of stroke. Early identification and treatment with oral anticoagulants can substantially reduce stroke risk. The general practice setting is ideal for opportunistic screening and provides a natural pathway for treatment for those identified.This study aims to investigate the feasibility of implementing screening for AF in rural general practice using novel electronic tools. It will assess whether screening will fit within an existing workflow to quickly and accurately identify AF, and will potentially inform a generalisable, scalable approach.

METHODS AND ANALYSIS

Screening with a smartphone ECG will be conducted by general practitioners and practice nurses in rural general practices in New South Wales, Australia for 3-4 months during 2018-2019. Up to 10 practices will be recruited, and we aim to screen 2000 patients aged ≥65 years. Practices will be given an electronic screening prompt and electronic decision support to guide evidence-based treatment for those with AF. De-identified data will be collected using a clinical audit tool and qualitative interviews will be conducted with selected practice staff. A process evaluation and cost-effectiveness analysis will also be undertaken. Outcomes include implementation success (proportion of eligible patients screened, fidelity to protocol), proportion of people screened identified with new AF and rates of treatment with anticoagulants and antiplatelets at baseline and completion. Results will be compared against an earlier metropolitan study and a 'control' dataset of practices.

ETHICS AND DISSEMINATION

Ethics approval was received from the University of Sydney Human Research Ethics Committee on 27 February 2018 (Project no.: 2017/1017). Results will be disseminated through various forums, including peer-reviewed publication and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12618000004268; Pre-results.