Introduction

This quality standard covers the treatment and management of atrial fibrillation (including paroxysmal, persistent and permanent atrial fibrillation, and atrial flutter) in adults (18 years and older). For more information see the topic overview. Both valvular and non‑valvular atrial fibrillation are covered unless specified otherwise in the statement.

Why this quality standard is needed

Atrial fibrillation is a condition that affects the heart, causing it to beat irregularly and too fast. When this happens, blood does not flow properly through the heart and the rest of the body. This means that people with atrial fibrillation may be at increased risk of blood clots. Clots can block blood vessels, and a stroke can occur if a blood vessel in the brain is blocked by a clot. As a result, if left untreated atrial fibrillation is a significant risk factor for stroke and other morbidities.

Atrial fibrillation is the most common sustained cardiac arrhythmia, and estimates suggest that its prevalence is increasing. The Health and Social Care Information Centre's 2011–12 Quality and outcomes framework estimated the prevalence of known atrial fibrillation to be 1.57%. The NHS Improving Quality Guidance on risk assessment and stroke prevention for atrial fibrillation (GRASP-AF) tool estimated the prevalence to be between 1.65% and 1.76%. However, it has been shown that the true prevalence of atrial fibrillation is underestimated and could be around 2.0% (Hobbs et al. [2005] 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 Technology Assessment 40: 1–74).

The management of atrial fibrillation aims to prevent complications, particularly stroke, and alleviate symptoms. Drug treatments include anticoagulants to reduce the risk of stroke, antiarrhythmics to restore or maintain normal heart rhythm and drugs to slow the heart rate in adults who remain in atrial fibrillation. Non‑pharmacological management includes electrical cardioversion, which may be used to 'shock' the heart back to its normal rhythm, and catheter or surgical ablation to create lesions to stop the abnormal electrical impulses that cause atrial fibrillation.

The quality standard is expected to contribute to improvements in the following outcomes:

  • mortality rates in adults with atrial fibrillation

  • stroke and transient ischaemic attack rates in adults with atrial fibrillation

  • admission rates for adults with a primary diagnosis of atrial fibrillation

  • quality of life of adults with atrial fibrillation.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i Adults

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease (PHOF 4.4*)

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions (ASCOF 1A**)

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Reducing time spent in hospital by people with long‑term conditions

2.3i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)

4 Ensuring that people have a positive experience of care

Overarching indicator

4a Patient experience of primary care

i GP services

4b Patient experience of hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving access to primary care services

4.4 Access to (i) GP services

Aligning across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF)

** Indicator complementary with Adult Social Care Outcomes Framework (ASCOF)

Table 2 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.3 Mortality rate from causes considered preventable ** (NHSOF 1a)

4.4 Under 75 mortality rate from all cardiovascular disease (including heart disease and stroke)* (NHSOF 1.1)

Aligning across the health and social care system

* Indicator shared with the NHS Outcomes Framework (NHSOF)

** Complementary to indicators in the NHS Outcomes Framework (NHSOF)

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to atrial fibrillation.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE Pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and are supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that impact on patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for atrial fibrillation: treatment and management specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole atrial fibrillation care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults with atrial fibrillation.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality atrial fibrillation service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating adults with atrial fibrillation should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with atrial fibrillation. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.