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Uptake of a primary care atrial fibrillation screening program (AF-SMART): a realist evaluation of implementation in metropolitan and rural general practice.

ABSTRACT: BACKGROUND:Screening for atrial fibrillation (AF) in people aged ?65?years is recommended by international guidelines. The Atrial Fibrillation Screen, Management And guideline-Recommended Therapy (AF-SMART) studies of opportunistic AF screening in 16 metropolitan and rural general practices were conducted from November 2016-June 2019. These studies trialled custom-designed eHealth tools to support all stages of AF screening in general practice. METHODS:A realist evaluation of the AF-SMART studies, which aimed to explain the circumstances in which the program worked (or not) to increase the proportion of people screened for AF. The initial program theory was based on our previous research, policy documents and screening studies. To test this, we conducted 45 semi-structured interviews with general practitioners (GPs), nurses and practice managers across all participating practices, and collected observational and quantitative screening data. These data were analysed and interpreted to refine the program theory. RESULTS:GPs/nurses liked the eHealth tools, although technical problems sometimes disrupted screening. Time was the main barrier to screening for GPs/nurses, so systems need to be very efficient. Practices with leadership from a senior GP 'screening champion' had broader uptake, especially from the nursing team. Providing regular feedback on screening data was beneficial for quality improvement and motivation. Clear protocols for follow-up of abnormal results were required for successful nurse-led screening in a hierarchical system. Participation in the program had broader benefits of improving AF knowledge and raising the profile of cardiovascular health in the practice. Screening for a shorter, more intense period (eg during influenza vaccination) worked well for practices where sufficient staff time was allocated. CONCLUSIONS:Introducing an AF screening program is likely to be successful in contexts where there is a senior GP 'screening champion', a clear protocol exists for abnormal results, and there is regular data reporting to staff. These contexts link to mechanisms around motivation, leadership, empowerment of nurses, and efficient screening systems. The contexts and mechanisms contribute to the longer-term outcomes of increasing the proportion of people screened and treated for AF, which is recommended by guidelines as a key strategy for the prevention of AF-related stroke. TRIAL REGISTRATIONS:AF SMART (metropolitan): ACTRN12616000850471 (Australia New Zealand Clinical Trials Registry). AF SMART II (rural): ACTRN12618000004268 (Australia New Zealand Clinical Trials Registry).

SUBMITTER: Orchard J

PROVIDER: S-EPMC6896363 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Uptake of a primary care atrial fibrillation screening program (AF-SMART): a realist evaluation of implementation in metropolitan and rural general practice.

Orchard Jessica J Li Jialin J Gallagher Robyn R Freedman Ben B Lowres Nicole N Neubeck Lis L

BMC family practice 20191206 1

<h4>Background</h4>Screening for atrial fibrillation (AF) in people aged ≥65 years is recommended by international guidelines. The Atrial Fibrillation Screen, Management And guideline-Recommended Therapy (AF-SMART) studies of opportunistic AF screening in 16 metropolitan and rural general practices were conducted from November 2016-June 2019. These studies trialled custom-designed eHealth tools to support all stages of AF screening in general practice.<h4>Methods</h4>A realist evaluation of the ...[more]

PMID: 31810441

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Project description:IntroductionScreening for atrial fibrillation (AF) in people ≥65 years is now recommended by guidelines and expert consensus. While AF is often asymptomatic, it is the most common heart arrhythmia and is associated with increased risk of stroke. Early identification and treatment with oral anticoagulants can substantially reduce stroke risk. The general practice setting is ideal for opportunistic screening and provides a natural pathway for treatment for those identified.This study aims to investigate the feasibility of implementing screening for AF in rural general practice using novel electronic tools. It will assess whether screening will fit within an existing workflow to quickly and accurately identify AF, and will potentially inform a generalisable, scalable approach.Methods and analysisScreening with a smartphone ECG will be conducted by general practitioners and practice nurses in rural general practices in New South Wales, Australia for 3-4 months during 2018-2019. Up to 10 practices will be recruited, and we aim to screen 2000 patients aged ≥65 years. Practices will be given an electronic screening prompt and electronic decision support to guide evidence-based treatment for those with AF. De-identified data will be collected using a clinical audit tool and qualitative interviews will be conducted with selected practice staff. A process evaluation and cost-effectiveness analysis will also be undertaken. Outcomes include implementation success (proportion of eligible patients screened, fidelity to protocol), proportion of people screened identified with new AF and rates of treatment with anticoagulants and antiplatelets at baseline and completion. Results will be compared against an earlier metropolitan study and a 'control' dataset of practices.Ethics and disseminationEthics approval was received from the University of Sydney Human Research Ethics Committee on 27 February 2018 (Project no.: 2017/1017). Results will be disseminated through various forums, including peer-reviewed publication and conference presentations.Trial registration numberACTRN12618000004268; Pre-results.

Project description:ObjectiveTo assess whether atrial fibrillation (AF) self-screening stations in general practice waiting rooms improve AF screening, diagnosis, and stroke risk management.Design, settingIntervention study (planned duration: twelve weeks) in six New South Wales general practices (two in rural locations, four in greater metropolitan Sydney), undertaken during 28 August 2020 - 5 August 2021.ParticipantsPeople aged 65 years or more who had not previously been diagnosed with AF, and had appointments for face-to-face GP consultations. People with valvular AF were excluded.InterventionAF self-screening station and software, integrated with practice electronic medical record programs, that identified and invited participation by eligible patients, and exported single-lead electrocardiograms and automated evaluations to patients' medical records.Main outcome measuresScreening rate; incidence of newly diagnosed AF during intervention and pre-intervention periods; prescribing of guideline-recommended anticoagulant medications.ResultsAcross the six participating practices, 2835 of 7849 eligible patients (36.1%) had face-to-face GP appointments during the intervention period, of whom 1127 completed AF self-screening (39.8%; range by practice: 12-74%). AF was diagnosed in 49 screened patients (4.3%), 44 of whom (90%) had CHA2 DS2 -VA scores of 2 or more (high stroke risk). The incidence of newly diagnosed AF during the pre-intervention period was 11 cases per 1000 eligible patients; during the intervention period, it was 22 per 1000 eligible patients (screen-detected: 17 per 1000 eligible patients; otherwise detected: 4.6 per 1000 eligible patients). Prescribing of oral anticoagulation therapy for people newly diagnosed with AF and high stroke risk was similar during the pre-intervention (20 of 24, 83%) and intervention periods (46 of 54, 85%).ConclusionsAF self-screening in general practice waiting rooms is a feasible approach to increasing AF screening and diagnosis rates by reducing time barriers to screening by GPs. AF self-screening could reduce the number of AF-related strokes.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12620000233921 (prospective).

Dataset Information

Uptake of a primary care atrial fibrillation screening program (AF-SMART): a realist evaluation of implementation in metropolitan and rural general practice.

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Uptake of a primary care atrial fibrillation screening program (AF-SMART): a realist evaluation of implementation in metropolitan and rural general practice.

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