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Improving management of atrial fibrillation

 

Clinical bottom line

Doing simple things well, and getting services organised, can lead to substantial improvements in the management and treatment of patients with atrial fibrillation.


This paper describes the introduction of a quality-driven hospital clinic for anticoagulation of people with atrial fibrillation. It will be useful to refer to the web essays on management, because many of the points raised in this paper are described in the essays. The paper is an exemplar of how to do it, using good principles.

Reference

GL Gaughan et al. Improving management of atrial fibrillation and anticoagulation in a community hospital. Journal on Quality Improvement 2000 26:18-28.

Study

The study takes place in a 230-bed acute hospital in Boston. In 1996 a quality council was set up, which examined discharges of patients with atrial fibrillation to see that they were appropriately anticoagulated. At that time 45% of patients with chronic atrial fibrillation were discharged on warfarin.

A proposal in May 1996 suggested instituting an anticoagulation clinic as part of a quality improvement initiative. Baseline surveys were done to examine performance at that time. It was adequate without being excellent. The majority of patients were not safely anticoagulated.

Discussions with interested parties, informal at first but formal later led to the agreement of anticoagulation goals, including:

A core, small, mutidisciplinary group led the process, devised a business plan, implemented software and INR measurement changes, including treatment algorithms, enlisted physician support, implemented and monitored the project.

Results

The new service and attendant educational programmes were instituted in the latter half of 1997. Monitoring of performance occurred over the first 18 months, during which time the percentage of patients on warfarin or warfarin or aspirin increased (Figure 1). The proportion of eligible patients on warfarin after 18 months was 90%, and the proportion of all patients on anticoagulant or antiplatelet was 90%. As well as this, there was a small but important increase in the number of INR measurements that were within the appropriate range.

Figure 1: Performance over the first 18 months


Comment

This paper well describes how to implement change, and it is relevant to the process in general, not just to anticoagulation for atrial fibrillation. One intriguing aspect was the production and presentation of a business plan, which gave costs, and revenues. Clearly a "profit" was going to be made. This was obviously key to getting the support of senior management and implementing the programme.