“The AF landscaping tool, which we have very recently starting using, has brought some much needed clarity for the CCGs that we are working with. It also makes it much easier to spot areas within the pathway that are not optimal and therefore would benefit from additional resources.”
Anthony Anandan, Imperial College Health Partners

The Atrial Fibrillation Data Landscape Tool, developed by Greater Manchester AHSN, aims to reduce atrial fibrillation (AF) related strokes by 365 per year – the equivalent of one stroke a day. It is a unique tool bringing together all publicly available data about AF prevalence, stroke incidence and anticoagulant treatment, from the datasets for every CCG in England, in an easy-to-use dashboard format.

Each CCG has timely and accurate access to their own data through a pull down menu, and can easily compare their local information with national, regional and RightCare matched averages. The tool provides insights into each CCG’s local AF patient pathway, to enable commissioners to better direct resources to where they are most needed, in line with NICE clinical guidelines (CG180, 2014) for best practice to improve standards of care in AF, including anticoagulation for patients at high risk of stroke.

By December 2016 the tool had been adopted by six out of the 15 AHSNs across England, and it has wide applicability across the UK. The tool is part of a Manchester-wide AF improvement programme, in collaboration with Public Health England’s (PHE) initiative to improve AF management and reduce the number of avoidable AF-related strokes.

Challenges / problems identified
  • The incidence of atrial fibrillation (AF), a common and treatable risk factor for ischaemic stroke, is predicted to increase in the coming decades, securing its status as a public health priority. Age is a strong predictor of AF, with prevalence increasing from 0.5% in people aged 50–59 years, up to 10% in people aged 80 years or older.
  • AF-related incident strokes have trebled in people aged 80 years or older in the past 25 years, and will continue to increase as more people live longer with the condition.
  • The societal costs of stroke in the UK are estimated at £8.9 billion per year, with each stroke costing more than £24,000. Strokes related to AF are often more severe and cost more than non-AF strokes, with higher morbidity and mortality.
  • Oral anti-coagulation therapy is a well-evidenced way to prevent AF-related strokes in high-risk patients, and is supported by guidelines.
    NICE (2014) identified that more than half of all patients with known AF were not on effective medication. NHS Improvement suggests around 8,000 AF related strokes per year could be prevented if the condition was better managed, saving the NHS £95 million annually.
Actions taken

The interactive, online AF and AF-related Stroke Data Landscape Tool provides timely, localised reporting of key national data sets, including Hospital Episode Statistics (HES), Quality Outcomes Framework (QOF), Sentinel Stroke National Audit Programme (SSNAP), GRASP-AF and Time in Therapeutic Range (TTR) data, providing the broadest evidential picture of care across the AF patient pathway. This provides CCGs with rich insights into their own local AF patient pathway to help pinpoint areas to direct resources; guiding them in using best practice commissioning tools and developing business cases for practice-based initiatives to improve AF detection rates and medicines management.

Impacts / outcomes

365strokes GMThrough optimal implementation of AF guidelines, the GM AHSN team aims to prevent 365 avoidable strokes next year – a stroke a day – across Greater Manchester. This ambition is aligned with the Public Health England (PHE) goal to reduce 5,000 strokes in England over five years, and a recent call from NICE for CCGs to focus on preventing 8,000 strokes per year through better AF diagnosis and optimal anticoagulation.

To date, the AF- and AF-stroke Landscape Tool has been adopted by Greater Manchester, The Innovation Agency (North West Coast), Imperial College Partners, Kent, Surrey and Sussex, Wessex, Yorkshire & Humber and West Midlands AHSNs for use with their CCGs.

The AF Landscape Tool has already been used by CCGs in Greater Manchester to provide evidence to support specific practice-level projects and business cases. For example:

  • A potential gap in AF diagnosis at two localities was identified and used to support a business case to purchase digital (mobile) AF diagnostic devices.
  • Lower-than-expected anti-coagulation rates in one CCG led to the development of community pharmacy-led medication review programme.

Insights from the Landscape Tool have been used by the AHSN in partnership with the University of Manchester to develop a unique algorithm that extracts key safety indicators from TTR data, allowing for appropriate use of medicines reviews and identification of Warfarin-resistant patients who may benefit from an alternative medicine.

PHE is now incorporating the AF Landscape Tool and its data management approach into their dataset production to target improvements in the management of AF across England.

The success of the AF Landscape Tool will continue to be measured through adoption of NICE CG180 guidance at all levels, as well as the stroke-reduction projects it has helped to identify across the GM area.

The tool is currently being used to identify the first 50 practices with the greatest opportunity for improvement to allow for effective deployment of review services and support. Commenced Oct 2016.

The tool’s main benefits are around maximising the outcomes of deployed resources. GM AHSN is targeting the practices with the biggest opportunity to improve, which means avoiding more strokes than if interventions were more adhoc.

Significantly, we believe we have a highly transferable tool that tracks the adoption of CG180 which we will copy on other programmes.

Tips for implementation

The AF Landscape Tool contains the datasets for every CCG in England. Each CCG has timely and accurate access to their own data through a pull down menu, and can easily compare their local information with national, regional and RightCare matched averages.

The datasets span primary and secondary care, including emergency admissions, and help bring together operational, clinical and management roles to make the decisions needed to drive change throughout each organisation.

The Landscape Tool concept is easily scalable and has already been adopted by six other AHSNs across England.

Next steps and spread

Version 1.0 of the tool is updated on a quarterly basis, in line with SSNAP reports, and will be updated with new QOF CHA2DS2-VASc reporting, when it becomes available.

A patient-facing version of the tool is in development in collaboration with the Stroke Association.

Version 2.0 of the AF-Landscape Tool is now under development to make the data even more widely accessible and to better guide healthcare decision-making and implementation of NICE guidelines.

Going forward we hope to be able to develop data landscape tools to provide insight into other longterm health conditions such as diabetes and kidney disease.

“[The Greater Manchester (GM) AHSN Team’s] work enhances the overall programme to improve outcomes for people with AF, whether it be the development of the dashboard, promoting self-management or taking an holistic approach to stroke prevention.”
Dr Peter Elton, GM & Eastern Cheshire Strategic Clinical Network

Plans for the future

Version 2.0 of the AF Landscape Tool is planned for release in 2017, and will focus on more easily sharable and customisable interfaces to enable broader access and uptake, as well as looking at ways to integrate other relevant datasets. Updates to the Tool will also rapidly capture any changes in key datasets, including new QOF indicators, to track progress against PHE’s goal of preventing 5,000 AF-related strokes per year.

Start and end dates


Contact for help and advice

Jane Macdonald, Director of Improvement and Nursing
T: 0161 206 7962
E: jane.macdonald@gmahsn.org

Isabelle Masters, Communications
T: 0161 206 7993
E: isabelle.masters@gmahsn.org