Hospital admissions for stroke and bleeding in Hounslow following a quality improvement initiative

Q: What are the key findings of this study?

The Hounslow AF quality improvement initiative reduced the rate of hospital admission with stroke as primary diagnosis by 17% (IRR 0.83) compared to pre-intervention trends.

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Atrial fibrillation (AF) (n=294712). Intervention: AF quality improvement (QI) initiative vs. Pre-intervention trend (January 2011 to September 2014). Primary outcome: Rate of admission with stroke as primary diagnosis (IRR 0.83, 95% CI 0.712-0.963, p=<0.014).

Q: What question did this study set out to answer?

To evaluate whether hospital admission rates for stroke and bleeding changed in the Hounslow population following an atrial fibrillation quality improvement initiative.

Kam Ying Wong; Bethan Davies; Yewande Adeleke; Thomas Woodcock; Dionne Matthew; Sara Sekelj; Andi Orlowski; Bradley Porter; Sophia Hashmy; Ammu Mathew; Ron Grant; Agnes Kaba; Brigitte Unger-Graeber; Bruno Petrungaro; Jordan Wallace; Derek Bell; Martín Cowie; Sadia Khan

doi:10.1136/openhrt-2020-001558

Key result

Hounslow AF quality improvement initiative linked to ~17% lower stroke admission rate.

IRR 0.83
95% CI 0.712-0.963
P<0.014
n=294,712

Figures

Why the study?

Undiagnosed and poorly managed AF increases stroke risk; this study evaluated whether stroke and bleeding rates changed in the Hounslow population following an AF quality improvement initiative.

Does a primary care atrial fibrillation quality improvement initiative reduce hospital admissions for stroke and bleeding in a regional population?

Key Points

To evaluate whether hospital admission rates for stroke and bleeding changed in the Hounslow population following an atrial fibrillation quality improvement initiative.
Interrupted time series analysis using hospital admissions data from January 2011 to August 2018 to evaluate age- and sex-standardised admission rates before and after the initiative launched in October 2014.
Primary outcomes included monthly rates of hospital admission for stroke (primary diagnosis, and primary stroke with secondary atrial fibrillation) and bleeding (primary diagnosis with atrial fibrillation or oral anticoagulation use), with adjustment for seasonality.
Admissions with stroke as primary diagnosis decreased by 17% following the intervention (seasonality-adjusted IRR 0.83; 95% CI 0.712 to 0.963; p<0.014).
Admissions with stroke as primary diagnosis and atrial fibrillation as secondary diagnosis decreased postintervention, but the change was not statistically significant after seasonality adjustment (IRR 0.75; 95% CI 0.550 to 1.025; p<0.071).
No statistically significant changes occurred in admissions for bleeding with atrial fibrillation (seasonality-adjusted IRR 0.93; 95% CI 0.597 to 1.449; p<0.749), and slope changes over time were small and non-significant across all models.

Study Design

Type

Observational (n=294,712)

Structured PICO

Does a primary care atrial fibrillation quality improvement initiative reduce hospital admissions for stroke and bleeding in a regional population?

P

Population

Interrupted time series analysis of 294,712 residents in Hounslow, UK, evaluating a primary care atrial fibrillation quality improvement initiative from 2011 to 2018.

I

Intervention

Hounslow AF quality improvement (QI) initiative, comprising GP education, KardiaMobile ECG screening, AF 'at-risk' registers, clinical templates for NICE guideline compliance, nurse reviews, and anticoagulation clinics.

C

Comparator

Pre-intervention observational period (January 2011 to September 2014) representing baseline trends.

O

Outcome

Standardised rate of hospital admission with stroke as primary diagnosis.hard clinical

Main Result

Relative Risk: 0.83 (95% CI 0.712–0.963)

p-value: p=<0.014

A comprehensive primary care quality improvement initiative for atrial fibrillation was associated with a population-level reduction in stroke hospital admissions without increasing bleeding admissions.

Limitations

Use of aggregated HES data without linkage to primary care data
HES data do not include people treated in the community or who died before admission
Lack of a control group prevents causal inference
Expected AF prevalent population was modeled based on a Swedish study
Use of aggregated HES data without individual patient-level linkage to primary care data
Expected AF prevalent population had to be modeled based on a Swedish study
Lack of a control group region
Inability to infer a causal relationship

Implication

Supports primary care AF QI to reduce stroke admissions; extends observational data but leaves open need for randomized confirmation.

Abstract

OBJECTIVE: Atrial fibrillation (AF) is the most common arrhythmia. Undiagnosed and poorly managed AF increases risk of stroke. The Hounslow AF quality improvement (QI) initiative was associated with improved quality of care for patients with AF through increased detection of AF and appropriate anticoagulation. This study aimed to evaluate whether there has been a change in stroke and bleeding rates in the Hounslow population following the QI initiative. METHODS: Using hospital admissions data from January 2011 to August 2018, interrupted time series analysis was performed to investigate the changes in standardised rates of admission with stroke and bleeding, following the start of the QI initiative in October 2014. RESULTS: There was a 17% decrease in the rate of admission with stroke as primary diagnosis (incidence rate ratio (IRR) 0.83; 95% CI 0.712 to 0.963; p<0.014). There was an even larger yet not statistically significant decrease in admission with stroke as primary diagnosis and AF as secondary diagnosis (IRR 0.75; 95% CI 0.550 to 1.025; p<0.071). No significant changes were observed in bleeding admissions. For each outcome, an additional regression model including both the level change and an interaction term for slope change was created. In all cases, the slope change was small and not statistically significant. CONCLUSION: Reduction in stroke admissions may be associated with the AF QI initiative. However, the immediate level change and non-significant slope change suggests a lack of effect of the intervention over time and that the decrease observed may be attributable to other events.

Discussion

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Cite This Study

Wong et al. (2021) conducted an observational in Atrial fibrillation (AF) (n=294,712). AF quality improvement (QI) initiative vs. Pre-intervention trend (January 2011 to September 2014) was evaluated on Rate of admission with stroke as primary diagnosis (IRR 0.83, 95% CI 0.712-0.963, p=<0.014). The Hounslow AF quality improvement initiative reduced the rate of hospital admission with stroke as primary diagnosis by 17% (IRR 0.83) compared to pre-intervention trends.

synapsesocial.com/papers/6a2205d220559d46645801a3 https://doi.org/10.1136/openhrt-2020-001558

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Hospital admissions for stroke and bleeding in Hounslow following a quality improvement initiative

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Hospital admissions for stroke and bleeding in Hounslow following a quality improvement initiative

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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