This case study features in the NHS Innovation Accelerator’s year three research report, Understanding how and why the NHS adopts innovation.
AliveCor’s Kardia Mobile Electrocardiogram (ECG) device is a mobile heart monitor that can detect, monitor, and manage heart arrhythmias with automatic analysis. The Kardia captures ECG recordings of the heart within 30 seconds and can be used anytime, anywhere, providing instant feedback. It can also detect atrial fibrillation (AF) – a major cause of stroke.
425,000 people aged 64 and over are estimated to have undiagnosed AF . Early detection and monitoring can pave the way for better treatment for people with AF and avoidance of AF-related strokes. Conservatively, an AF-related stroke costs the NHS £12,228 in the first year alone.
The Atrial Fibrillation Association (AFA) recognised the opportunity to offer ECGs in local settings. Through work with a Local Pharmacy Committee (LPC), the AFA undertook a six-week trial of Kardia in community pharmacies in 2013. The trial demonstrated that Kardia could be used in pharmacies to detect AF.
For Care City – an NHS Test Bed – reducing the high incidence of stroke was a priority area and therefore there was an ambition to increase prevention of strokes.
Care City was familiar with AliveCor’s Kardia because it was on the NHS Innovation Accelerator (NIA). Additionally, the lead pharmacist at Care City was also secretary to the LPC and therefore had prior knowledge of the AFA Kardia trial. To select the innovations to be part of the bid to be a test bed, Care City had robust selection criteria involving a stakeholder panel presentation. Alivecor was successful in meeting the criteria, and the Kardia device became one of several innovations tested within the test bed.
Kardia was tested within community pharmacies and GP practices. Through the trial, Care City wanted to assess whether Kardia could reduce the incidence of stroke through earlier detection and treatment of AF.
Trial – phase one
Phase one tested whether AF could be detected by the following staff groups using Kardia in two care settings:
1. Health Care Assistants in GP practices
2. Pharmacists and pharmacist assistants in community pharmacies
Care City trained both staff groups in how to use Kardia, and – in consultation with Alivecor – developed a standard operating procedure and flowchart for staff to follow. Patients over the age of 65 were invited to be screened, and any patients with abnormal ECGs detected in pharmacies were referred to their GPs.
The need for iteration and adaption to the training and pathway were soon identified:
1. The noise and bustle of some pharmacies led to misleading results from the test. The training was therefore adapted to include where and more clearly explain how the ECG should be undertaken.
2. GPs felt the pathway created unnecessary steps as patients were referred by the pharmacist to them, when all they could do was to refer patients to the hospital-based cardiology team.
An iteration on the pathway was therefore made. A ‘one-stop’ clinic was set up in the local hospital and a triage process was established in which the traces captured in the pharmacies were sent via a new IT platform to the clinic. Those with clear indications of AF were invited to the clinic.
Trial – phase two
The aim of phase two was to identify the optimal care pathway post-diagnosis of AF using the Kardia device. This included reducing access to treatment from 12 weeks to two weeks to protect people from the possibility of AF-related strokes.
The Test Bed convened a working party with representatives of all relevant stakeholders: pharmacists, GPs, community nurses, cardiologists and cardiology nurses, and commissioners to design the new pathway. The local CCG also joined the working party; partly because early detection may increase workload flowing through the pathway, and partly to ensure the safety and quality of the pathway.
21 pharmacies took part in phase two, although most of the pathway developments were associated with the pharmacies. In the trial, 672 traces were captured in the pharmacies of which 110 were referred to the clinic. The clinic triaged out 74 which meant that 36 patients were invited for further tests.
Key champions: In the Test Bed trial a lead pharmacist championed the use of Kardia in community pharmacies.
Trialling within different contexts: Two major barriers to the adoption of Kardia were identified in the examples. First, it had to be shown that the device could be used by GP practice and pharmacy staff to capture ECGs. Second, once AF had been detected, a pathway was needed to confirm diagnosis and provide timely, effective treatment.
With the lead pharmacist’s role in the AFA trial, Care City was able to support trialling of Kardia in different settings, and also trial a new care pathway within which the device could be embedded.
Funding and infrastructure: As an NHS Test Bed, Care City was able to provide the resources to systematically test the use of Kardia in GP practices and in community pharmacies, and facilitate the development of the optimal pathway for the early detection and subsequent treatment of AF.
In North East London, the Barking, Havering and Redbridge Provider Alliance have obtained funds to distribute more Kardia devices, and have committed to developing the AF pathway across their region.
AliveCor’s Kardia is a digital application with convincing evidence of its ability to yield valuable diagnostic information when used in a primary care setting. However, there are many ways it can be used within existing care settings. The examples here demonstrate the adaptions required for it to be successfully embedded within GP practice and pharmacy settings. Furthermore, when an intervention is found to accelerate detection, redesign of the care pathway may also be needed to ensure newly diagnosed patients can rapidly access appropriate treatment.
1. Lily Barnett, Programme Manager, Care City Test Bed [at time of writing]
2. Mark Hashemi, AliveCor Distributor, Technomed
3. Jenny Shand, Executive Lead for Care City Test Bed, Programme Director, UCLPartners
4. Francis White, NIA Fellow, AliveCor’s Kardia [at time of writing]
5. Name withheld, Local Pharmaceutical Committee
6. Name withheld, Consultant Pharmacist