Anticoagulation for atrial fibrillation in general practice: a critical evaluation of the implementation of changes to practice

Abstract

This thesis critically evaluated, and updated existing knowledge, improving scholarship about the nature of oral-anticoagulation (OAC) use and changes to OAC management in general-practice in patients with atrial fibrillation (AF).
This thesis represents an original contribution to knowledge by presenting a new integrated-care model for AF/OAC care in general-practice; Developed uniquely via an Insider-Researcher lens and assessment of AF/OAC care; Which used context-specific data to combine existing methods within related methodologies in a novel way; To provide an original exploration of the embedding processes involved in AF/OAC care in general-practice.
This thesis also provides a significant contribution to knowledge in several ways. Firstly, this thesis challenges the previously accepted assumptions about OAC use and underuse in general-practice, establishes and answers a knowledge-gap about the extent of GP involvement in the OAC rates reported. Secondly, this thesis proposes a new, initial theory, of how a general-practice affected the OAC rates reported; whilst, also identifying a further literary gap about the essential roles for General-Practice Nurses (GPNs) required to deliver improved AF/OAC care, via a general-practice integrative-care model. Thirdly, the insider-researcher approach that was taken using a form of realist evaluation incorporating the Normalization Process Theory (NPT), positively impacts on existing nurse-led research within general-practice settings.
The context of this study is the high stroke burden attributable to the increasingly prevalent cardiac arrythmia AF, for which an effective risk-reducing treatment, OAC, is historically underused and for which general-practice holds responsibility. This study involves a mixed-methods approach, which includes a quantitative examination of the clinical pathways and management of an AF cohort, and a qualitative investigation about clinicians’ experiences of transformation of OAC practice in a large general-practice in Northern England.
Using realism as a methodological perspective, an insider-researcher approach incorporating the Normalization Process Theory (NPT) produced a new program theory about the roles of general practitioners and other practice staff in stroke prevention work in AF patients.
Between June and October 2013, the electronic records of 297 AF patients included in a general-practice caseload were analyzed, following their initial presentation to eventual diagnosis and treatment with OAC. Then, between October and December 2013, clinical staff within the same setting were also questioned about their roles before, during and after changes to OAC and AF care in the general practice.
Findings showed that historic underuse did exist as suggested by the literature with only 51.9% of patients initially taking OAC in 2013. Furthermore, the findings also indicated the presence of a limited GP role, who were involved in only 24.9% of all previous AF diagnoses. However, several contextual factors, which resulted in a series of mechanisms for OAC service change, also existed. These led to increased general-practice diagnoses of AF, totaling 78.6% of new AF patients and a 91.1% uptake of OAC in all patients diagnosed with AF after 2013 up to 2017.
Historical OAC use in treating AF patients in general practice has been previously shaped by the GPs’ willingness to refer to specialists and by the outcomes of decision-making by specialists. Furthermore, there has been no previous recognized role for nurses in AF/OAC care, both within the literature, and within this practice. This was exemplified by a lack of awareness about stroke, AF and OAC; which also resulted in significant clinical anxiety.
AF and OAC care are complex interventions that require multiple Context-Mechanism-Outcome (CMO) factors, occurring in various configurations, to achieve changes in clinical general-practice. Nursing activity in general practice was integral to achieving improvements in OAC treatment change and improved outcomes. The nature of roles, knowledge and agency are critically integrated to processes of OAC and AF treatment change and are, themselves, constructs of power that reflect embedded historical general-practice funding models. Outcomes of significantly increased OAC use, routine AF case-finding and internal OAC initiation occurred because of role-specific CMO-configurations.
Increases in OAC use to prevent stroke is possible in general-practice using an integrated-care approach. But further research is required to explore the possible variations of integrated care that are used more widely in general-practice, and explore patients’ roles within decisions about OAC use, within these integrated-care models.