Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study


Autoři: Vilius Savickas aff001;  Adrian J. Stewart aff002;  Melanie Rees-Roberts aff003;  Vanessa Short aff003;  Sukvinder K. Bhamra aff001;  Sarah A. Corlett aff001;  Alistair Mathie aff001;  Emma L. Veale aff001
Působiště autorů: Medway School of Pharmacy, University of Kent and University of Greenwich, Chatham Maritime, Kent, United Kingdom aff001;  Medway Maritime Hospital, Cardiology, Gillingham, Kent, United Kingdom aff002;  Centre for Health Services Studies, University of Kent, Canterbury, United Kingdom aff003;  Newton Place Surgery, Faversham, United Kingdom aff004
Vyšlo v časopise: Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study. PLoS Med 17(7): e32767. doi:10.1371/journal.pmed.1003197
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003197

Souhrn

Background

Growing prevalence of atrial fibrillation (AF) in the ageing population and its associated life-changing health and resource implications have led to a need to improve its early detection. Primary care is an ideal place to screen for AF; however, this is limited by shortages in general practitioner (GP) resources. Recent increases in the number of clinical pharmacists within primary care makes them ideally placed to conduct AF screening. This study aimed to determine the feasibility of GP practice–based clinical pharmacists to screen the over-65s for AF, using digital technology and pulse palpation during the influenza vaccination season.

Methods and findings

Screening was conducted over two influenza vaccination seasons, 2017–2018 and 2018–2019, in four GP practices in Kent, United Kingdom. Pharmacists were trained by a cardiologist to pulse palpate, record, and interpret a single-lead ECG (SLECG). Eligible persons aged ≥65 years (y) attending an influenza vaccination clinic were offered a free heart rhythm check. Six hundred four participants were screened (median age 73 y, 42.7% male). Total prevalence of AF was 4.3%. All participants with AF qualified for anticoagulation and were more likely to be male (57.7%); be older; have an increased body mass index (BMI); and have a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, previous Stroke, Vascular disease, Age 65–74 years, Sex category) score ≥ 3. The sensitivity and specificity of clinical pharmacists diagnosing AF using pulse palpation was 76.9% (95% confidence interval [CI] 56.4–91.0) and 92.2% (95% CI 89.7–94.3), respectively. This rose to 88.5% (95% CI 69.9–97.6) and 97.2% (95% CI 95.5–98.4) with an SLECG. At follow-up, four participants (0.7%) were diagnosed with new AF and three (0.5%) were initiated on anticoagulation. Screening with SLECG also helped identify new non-AF cardiovascular diagnoses, such as left ventricular hypertrophy, in 28 participants (4.6%). The screening strategy was cost-effective in 71.8% and 64.3% of the estimates for SLECG or pulse palpation, respectively. Feedback from participants (422/604) was generally positive. Key limitations of the study were that the intervention did not reach individuals who did not attend the practice for an influenza vaccination and there was a limited representation of UK ethnic minority groups in the study cohort.

Conclusions

This study demonstrates that AF screening performed by GP practice–based pharmacists was feasible, economically viable, and positively endorsed by participants. Furthermore, diagnosis of AF by the clinical pharmacist using an SLECG was more sensitive and more specific than the use of pulse palpation alone. Future research should explore the key barriers preventing the adoption of national screening programmes.

Klíčová slova:

Allied health care professionals – Atrial fibrillation – Electrocardiography – Heart failure – Influenza – Pharmacists – Questionnaires – Vaccination and immunization


Zdroje

1. King S, Fitzgerald A, Bartlett C, Mahon J, Arber M, Carr E, et al. The UK NSC recommendation on Atrial Fibrillation screening in adults [Internet]. 2019 [cited 2020 Jan 14]. Available from: https://legacyscreening.phe.org.uk/atrialfibrillation.

2. Ball J, Carrington MJ, McMurray JJ, Stewart S. Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century. Int J Cardiol. 2013;167(5):1807–24. doi: 10.1016/j.ijcard.2012.12.093 23380698

3. Williams BA, Honushefsky AM, Berger PB. Temporal Trends in the Incidence, Prevalence, and Survival of Patients With Atrial Fibrillation From 2004 to 2016. Am J Cardiol. 2017;120(11):1961–5. doi: 10.1016/j.amjcard.2017.08.014 29033050

4. Marini C, De Santis F, Sacco S, Russo T, Olivieri L, Totaro R, et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke. 2005;36(6):1115–9. doi: 10.1161/01.STR.0000166053.83476.4a 15879330

5. Santhanakrishnan R, Wang N, Larson MG, Magnani JW, McManus DD, Lubitz SA, et al. Atrial Fibrillation Begets Heart Failure and Vice Versa: Temporal Associations and Differences in Preserved Versus Reduced Ejection Fraction. Circulation. 2016;133(5):484–92. doi: 10.1161/CIRCULATIONAHA.115.018614 26746177

6. Stewart S, Murphy NF, Walker A, McGuire A, McMurray JJ. Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK. Heart. 2004;90(3):286–92. doi: 10.1136/hrt.2002.008748 14966048

7. England NHS. The NHS Long Term Plan [Internet]. 2019 [cited 2020 Jany 14]. Available from: https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/.

8. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893–962. doi: 10.1093/eurheartj/ehw210 27567408

9. Freedman B, Camm J, Calkins H, Healey JS, Rosenqvist M, Wang J, et al. Screening for Atrial Fibrillation: A Report of the AF-SCREEN International Collaboration. Circulation. 2017;135(19):1851–67. doi: 10.1161/CIRCULATIONAHA.116.026693 28483832

10. Zoni-Berisso M, Lercari F, Carazza T, Domenicucci S. Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol. 2014;6:213–20. doi: 10.2147/CLEP.S47385 24966695

11. Staerk L, Wang B, Preis SR, Larson MG, Lubitz SA, Ellinor PT, et al. Lifetime risk of atrial fibrillation according to optimal, borderline, or elevated levels of risk factors: cohort study based on longitudinal data from the Framingham Heart Study. Bmj. 2018;361:k1453. doi: 10.1136/bmj.k1453 29699974

12. Staerk L, Sherer JA, Ko D, Benjamin EJ, Helm RH. Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes. Circulation research. 2017;120(9):1501–17. doi: 10.1161/CIRCRESAHA.117.309732 28450367

13. Watanabe H, Watanabe T, Sasaki S, Nagai K, Roden DM, Aizawa Y. Close bidirectional relationship between chronic kidney disease and atrial fibrillation: the Niigata preventive medicine study. Am Heart J. 2009;158(4):629–36. doi: 10.1016/j.ahj.2009.06.031 19781424

14. Benjamin EJ, Levy D, Vaziri SM, D'Agostino RB, Belanger AJ, Wolf PA. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. JAMA. 1994;271(11):840–4. 8114238

15. Kingston A, Robinson L, Booth H, Knapp M, Jagger C. Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Age Ageing. 2018;47(3):374–80. doi: 10.1093/ageing/afx201 29370339

16. NHS Digital. Trends in Consultation Rates in General Practice—1995–2009 [Internet]. 2019 [cited 2020 Jan 14]. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/trends-in-consultation-rates-in-general-practice/trends-in-consultation-rates-in-general-practice-1995-2009.

17. Orchard J, Freedman SB, Lowres N, Peiris D, Neubeck L. iPhone ECG screening by practice nurses and receptionists for atrial fibrillation in general practice: the GP-SEARCH qualitative pilot study. Aust Fam Physician. 2014;43(5):315–9. 24791776

18. Orchard J, Lowres N, Freedman SB, Ladak L, Lee W, Zwar N, et al. Screening for atrial fibrillation during influenza vaccinations by primary care nurses using a smartphone electrocardiograph (iECG): A feasibility study. European journal of preventive cardiology. 2016;23(2 suppl):13–20. doi: 10.1177/2047487316670255 27892421

19. Kaasenbrood F, Hollander M, Rutten FH, Gerhards LJ, Hoes AW, Tieleman RG. Yield of screening for atrial fibrillation in primary care with a hand-held, single-lead electrocardiogram device during influenza vaccination. Europace. 2016;18(10):1514–20. doi: 10.1093/europace/euv426 26851813

20. Hobbs FD, Fitzmaurice DA, Mant J, Murray E, Jowett S, Bryan S, et al. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess. 2005;9(40):iii–iv, ix-x, 1–74. doi: 10.3310/hta9400 16202350

21. Morgan S, Mant D. Randomised trial of two approaches to screening for atrial fibrillation in UK general practice. Br J Gen Pract. 2002;52(478):373–80. 12014534

22. The Kings Fund. Closing the gap: key areas for action on the health and care workforce [Internet]. 2019 [cited 2020 Jan 14]. Available from: https://www.kingsfund.org.uk/sites/default/files/2019-03/closing-the-gap-health-care-workforce-overview_0.pdf.

23. NHS England. NHS survey says nine out of 10 patients have ‘confidence and trust’ in their GP [Internet]. 2019 [cited 2020 Jan 14]. Available from: https://www.england.nhs.uk/2019/07/nine-out-of-10-patients-have-confidence-and-trust-in-their-gp/.

24. NHS England and British Medical Association. Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan [Internet]. 2019 [cited 2020 Jan 14]. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf.

25. NHS England. Five-year deal to expand GP services and kick start NHS Long Term Plan implementation [Internet]. 2019 [cited 2020 Jan 14]. Available from: https://www.england.nhs.uk/2019/01/five-year-deal-to-expand-gp-services-and-kick-start-nhs-long-term-plan-implementation/.

26. NHS England and Health Education England. Clinical pharmacists in general practice pilot [Internet]. 2015 [cited 2020 Jan 14]. Available from: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/07/clinical-pharmacists-gp-pilot.pdf.

27. Bradley F, Seston E, Mannall C, Cutts C. Evolution of the general practice pharmacist's role in England: a longitudinal study. The British journal of general practice: the journal of the Royal College of General Practitioners. 2018;68(675):e727–e34. doi: 10.3399/bjgp18X698849 30154077

28. Mann C, Anderson C, Avery AJ, Waring J, Boyd MJ. Clinical Pharmacists in General Practice: Pilot scheme Independent Evaluation Report: Full Report [Internet]. 2018 [cited 2020 Jan 14]. Available from: https://www.nottingham.ac.uk/pharmacy/documents/generalpracticeyearfwdrev/clinical-pharmacists-in-general-practice-pilot-scheme-full-report.pdf.

29. Taggar JS, Coleman T, Lewis S, Heneghan C, Jones M. Accuracy of methods for detecting an irregular pulse and suspected atrial fibrillation: A systematic review and meta-analysis. European journal of preventive cardiology. 2016;23(12):1330–8. doi: 10.1177/2047487315611347 26464292

30. Zungsontiporn N, Link MS. Newer technologies for detection of atrial fibrillation. BMJ (Clinical research ed). 2018;363:k3946. doi: 10.1136/bmj.k3946 30333105

31. National Institute for Health and Care Excellence. CG180 Atrial fibrillation: management [Internet]. 2014 [cited 2020 Jan 14]. Available from: https://www.nice.org.uk/guidance/cg180.

32. Savickas V, Stewart AJ, Mathie A, Bhamra SK, Corlett SA, Veale EL. Atrial fibrillation screening in general practice by clinical pharmacists using pulse palpation and single-lead ECG during the influenza vaccination season: a multi-site feasibility study. European Heart Journal. 2018;39(suppl_1). doi: 10.1093/eurheartj/ehy563.P4470

33. Veale EL, Stewart AJ, Mathie A, Lall SK, Rees-Roberts M, Savickas V, et al. Pharmacists detecting atrial fibrillation (PDAF) in primary care during the influenza vaccination season: a multisite, cross-sectional screening protocol. BMJ Open. 2018;8(3):e021121. doi: 10.1136/bmjopen-2017-021121 29540425

34. Loong T-W. Understanding sensitivity and specificity with the right side of the brain. BMJ (Clinical research ed). 2003;327(7417):716–9. doi: 10.1136/bmj.327.7417.716 14512479

35. Baratloo A, Hosseini M, Negida A, El Ashal G. Part 1: Simple Definition and Calculation of Accuracy, Sensitivity and Specificity. Emerg (Tehran). 2015;3(2):48–9. 26495380

36. Colquhoun D. An investigation of the false discovery rate and the misinterpretation of p-values. R Soc Open Sci. 2014;1(3):140216. doi: 10.1098/rsos.140216 26064558

37. Vasconcellos-Silva PR, Carvalho D, Lucena C. Word frequency and content analysis approach to identify demand patterns in a virtual community of carriers of hepatitis C. Interactive journal of medical research. 2013;2(2):e12. doi: 10.2196/ijmr.2384 23827772

38. Lavrakas PJ. Content Analysis. Encyclopedia of Survey Research Methods. Thousand Oaks, California. 2008. p. 141–4.

39. Medical Research Council. Developing and evaluating complex interventions [Internet]. 2008 [cited 2020 Jan 14]. Available from: https://mrc.ukri.org/documents/pdf/complex-interventions-guidance/.

40. Edlin R, McCabe C, Hulme C, Hall P, Wright J. Cost Effectiveness Modelling for Health Technology Assessment: A Practical Course. London: Adis; 2015.

41. National Institute for Health and Care Excellence. Costing Report: atrial fibrillation implementing the NICE guideline on atrial fibrillation (CG180) [Internet]. 2014 [cited 2020 Jan 14]. Available from: https://www.nice.org.uk/guidance/cg180/resources/costing-report-pdf-243730909.

42. Lowres N, Neubeck L, Salkeld G, Krass I, McLachlan AJ, Redfern J, et al. Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study. Thromb Haemost. 2014;111(6):1167–76. doi: 10.1160/TH14-03-0231 24687081

43. Jacobs MS, Kaasenbrood F, Postma MJ, van Hulst M, Tieleman RG. Cost-effectiveness of screening for atrial fibrillation in primary care with a handheld, single-lead electrocardiogram device in the Netherlands. Europace. 2018;20(1):12–8. doi: 10.1093/europace/euw285 27733465

44. NICE. The guidelines manual [Internet]. 2012. Available from: https://www.nice.org.uk/process/pmg6/resources/the-guidelines-manual-pdf-2007970804933.

45. Public Health England. The national flu immunisation programme 2019/20 [Internet]. 2019 [cited 2020 Jan 14]. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/03/annual-national-flu-programme-2019-to-2020-1.pdf.

46. Musich S, Wang SS, Hawkins K, Yeh CS. Homebound older adults: Prevalence, characteristics, health care utilization and quality of care. Geriatric nursing (New York, NY). 2015;36(6):445–50. doi: 10.1016/j.gerinurse.2015.06.013 26254815

47. Shah SM, Carey IM, Harris T, DeWilde S, Cook DG. Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study. BMJ (Clinical research ed). 2011;342:d912. doi: 10.1136/bmj.d912 21385803

48. Public Health England. Seasonal influenza vaccine uptake in GP patients: winter season 2018 to 2019 [Internet]. 2019 [cited 2020 Jan 14]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/804889/Seasonal_influenza_vaccine_uptake_in_GP_patients_1819.pdf.

49. Wiesel J, Salomone TJ. Screening for Atrial Fibrillation in Patients >/ = 65 Years Using an Automatic Blood Pressure Monitor in a Skilled Nursing Facility. The American journal of cardiology. 2017;120(8):1322–4. doi: 10.1016/j.amjcard.2017.07.016 28821351

50. Kruger K, Sandli M, Geitung J, Eide GE, Grimsmo A. Atrial fibrillation and heart failure in seven nursing homes. J Nurs Educ Pract. 2012;2(4):22–32. doi: 10.5430/jnep.v2n4p22

51. Lowres N, Neubeck L, Redfern J, Freedman SB. Screening to identify unknown atrial fibrillation. A systematic review. Thromb Haemost. 2013;110(2):213–22. doi: 10.1160/TH13-02-0165 23595785

52. GOV.UK. Population of England and Wales [Internet]. 2018 [cited 2020 Jan 14]. Available from: https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/national-and-regional-populations/population-of-england-and-wales/latest#by-ethnicity.

53. Kent.GOV.UK. 2011 Census: Cultural diversity in Kent [Internet]. 2013 [cited 2020 Jan 14]. Available from: https://www.kent.gov.uk/__data/assets/pdf_file/0009/8559/Cultural-diversity-in-Kent.pdf.pdf.

54. Chan NY, Choy CC. Screening for atrial fibrillation in 13 122 Hong Kong citizens with smartphone electrocardiogram. Heart (British Cardiac Society). 2017;103(1):24–31. doi: 10.1136/heartjnl-2016-309993 27733533

55. Lowres N, Olivier J, Chao T-F, Chen S-A, Chen Y, Diederichsen A, et al. Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals. PLoS Med. 2019;16(9):e1002903–e. doi: 10.1371/journal.pmed.1002903 31553733

56. Svennberg E, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Mass Screening for Untreated Atrial Fibrillation: The STROKESTOP Study. Circulation. 2015. doi: 10.1161/circulationaha.114.014343 25910800

57. Weijs B, Pisters R, Nieuwlaat R, Breithardt G, Le Heuzey JY, Vardas PE, et al. Idiopathic atrial fibrillation revisited in a large longitudinal clinical cohort. Europace: European pacing, arrhythmias, and cardiac electrophysiology: journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2012;14(2):184–90. doi: 10.1093/europace/eur379 22135317

58. Lobban TCA, Breakwell NE, Antoniou S, Hamedi N. P1200identifying the undiagnosed AF patient using 'know your pulse' campaign during world heart rhythm week 2017. EP Europace. 2018;20(suppl_1):i233–i4. doi: 10.1093/europace/euy015.682

59. Quinn FR, Gladstone DJ, Ivers NM, Sandhu RK, Dolovich L, Ling A, et al. Diagnostic accuracy and yield of screening tests for atrial fibrillation in the family practice setting: a multicentre cohort study. CMAJ open. 2018;6(3):E308–e15. doi: 10.9778/cmajo.20180001 30072410

60. Somerville S, Somerville J, Croft P, Lewis M. Atrial fibrillation: a comparison of methods to identify cases in general practice. The British journal of general practice: the journal of the Royal College of General Practitioners. 2000;50(458):727–9.

61. Ghazal F, Theobald H, Rosenqvist M, Al-Khalili F. Validity of daily self-pulse palpation for atrial fibrillation screening in patients 65 years and older: A cross-sectional study. PLoS Med. 2020;17(3):e1003063. doi: 10.1371/journal.pmed.1003063 32231369

62. Haberman ZC, Jahn RT, Bose R, Tun H, Shinbane JS, Doshi RN, et al. Wireless Smartphone ECG Enables Large-Scale Screening in Diverse Populations. J Cardiovasc Electrophysiol. 2015;26(5):520–6. doi: 10.1111/jce.12634 25651872

63. Lau JK, Lowres N, Neubeck L, Brieger DB, Sy RW, Galloway CD, et al. iPhone ECG application for community screening to detect silent atrial fibrillation: a novel technology to prevent stroke. Int J Cardiol. 2013;165(1):193–4. doi: 10.1016/j.ijcard.2013.01.220 23465249

64. Rajakariar K, Koshy AN, Sajeev JK, Nair S, Roberts L, Teh AW. Accuracy of a smartwatch based single-lead electrocardiogram device in detection of atrial fibrillation. Heart (British Cardiac Society). 2020:heartjnl-2019-316004. doi: 10.1136/heartjnl-2019-316004 31911507

65. Desteghe L, Raymaekers Z, Lutin M, Vijgen J, Dilling-Boer D, Koopman P, et al. Performance of handheld electrocardiogram devices to detect atrial fibrillation in a cardiology and geriatric ward setting. Europace. 2017;19(1):29–39. doi: 10.1093/europace/euw025 26893496

66. Harris K, Edwards D, Mant J. How can we best detect atrial fibrillation? The journal of the Royal College of Physicians of Edinburgh. 2012;42 Suppl 18:5–22. doi: 10.4997/jrcpe.2012.s02 22518390

67. Welton NJ, McAleenan A, Thom HH, Davies P, Hollingworth W, Higgins JP, et al. Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2017;21(29):1–236. doi: 10.3310/hta21290 28629510

68. Lane DA, Ponsford J, Shelley A, Sirpal A, Lip GY. Patient knowledge and perceptions of atrial fibrillation and anticoagulant therapy: effects of an educational intervention programme. The West Birmingham Atrial Fibrillation Project. Int J Cardiol. 2006;110(3):354–8. doi: 10.1016/j.ijcard.2005.07.031 16253356

69. Lowres N, Krass I, Neubeck L, Redfern J, McLachlan AJ, Bennett AA, et al. Atrial fibrillation screening in pharmacies using an iPhone ECG: a qualitative review of implementation. Int J Clin Pharm. 2015;37(6):1111–20. doi: 10.1007/s11096-015-0169-1 26202627

70. Halcox JPJ, Wareham K, Cardew A, Gilmore M, Barry JP, Phillips C, et al. Assessment of Remote Heart Rhythm Sampling Using the AliveCor Heart Monitor to Screen for Atrial Fibrillation: The REHEARSE-AF Study. Circulation. 2017;136(19):1784–94. doi: 10.1161/CIRCULATIONAHA.117.030583 28851729


Článek vyšel v časopise

PLOS Medicine


2020 Číslo 7

Nejčtenější v tomto čísle

Tomuto tématu se dále věnují…


Přihlášení
Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.

Přihlášení

Nemáte účet?  Registrujte se