Generalisability of and lessons learned from a mixed-methods study conducted in three low- and middle-income countries to identify care pathways for atrial fibrillation

Gooden, Tiffany E; Wang, Jingya; Carvalho Goulart, Alessandra; Varella, Ana C; Tai, Meihui; Sheron, Vethanayagan Antony; Wang, Hao; Zhang, Hui; Zhong, Jiaoyue; Kumarendran, Balachandran; Nirantharakumar, Krishnarajah; Surenthirakumaran, Rajendra; Bensenor, Isabela M; Guo, Yutao; Lip, Gregory Y H; Thomas, G Neil; Manaseki-Holland, Semira

doi:10.1080/16549716.2023.2231763

Cited by 4 publications

(10 citation statements)

References 52 publications

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“…This study recruited patients with a confirmed diagnosis of AF currently receiving follow-up care; therefore, AF patients not receiving care and patients receiving mostly private care were likely missed from recruitment. As mentioned elsewhere [ 10 ], the large proportion of eligible patients that were not contactable and did not want to take part could have introduced selection bias and our results should be interpreted with caution. It is possible that the unreachable patients represent a more hard-to-reach population who experience additional or different barriers to accessing healthcare.…”

Section: Discussionmentioning

confidence: 80%

“…This study was part of a multi-country mixed-methods study design [ 9 , 10 ]. A mixed-methods design was chosen to allow for contextual drivers to be identified (qualitative component) for a more in-depth understanding of the identified AF care pathways (quantitative component).…”

Section: Methodsmentioning

confidence: 99%

“…The development of baseline and follow-up questionnaires are described elsewhere [ 10 ]. Two trained nurses administered the questionnaires in person or by phone.…”

Section: Methodsmentioning

confidence: 99%

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Identifying and understanding the care pathway of patients with atrial fibrillation in Brazil and the impact of the COVID-19 pandemic: A mixed-methods study

Goulart,

Varella,

Gooden

et al. 2023

PLoS ONE

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Background Atrial fibrillation (AF) is a major risk factor for stroke. To enable improvements to AF diagnosis and follow-up care, understanding current patient pathways and barriers to optimal care are essential. We investigated the patient care pathways and their drivers, and the impact of the COVID-19 pandemic on patient pathways in a middle-income country setting, Brazil. Methods This mixed-methods study in São Paulo, included adults (≥18y) with AF from 13 primary/secondary healthcare facilities. Surveys using baseline, follow-up (administered ≥two months after baseline) and COVID-19 questionnaires (quantitative), and three focus group discussions (FGDs) were conducted. Minimum sample size for the quantitative component was 236 and we aimed to reach saturation with at least three FGDs for the qualitative component. Descriptive statistics were used for quantitative data and a content analysis was used for qualitative data to identify themes related to AF diagnosis and follow-up care. Results 267 participants completed the baseline questionnaire: 25% were diagnosed in primary care, 65% in an emergency or inpatient department. At follow-up (n = 259), 31% visited more than one facility for AF care, and 7% had no follow-up. Intervals between international normalised ratio (INR) tests were increased during the pandemic, and the number of healthcare visits and availability of medication were reduced. Seventeen patients participated in three FGDs and revealed that AF diagnosis often occurred following a medical emergency and patients often delay care-seeking due to misconceptions about AF symptoms. Long waiting times, doctor/patient interactions and health system factors, such as doctor availability and the referral system, influence where participants visited for follow-up care. Conclusions Lack of public awareness and underdeveloped primary healthcare lead to delayed diagnosis, which impacts clinical outcomes and excess patient and healthcare system costs. Health system, care-provider, and pandemic factors disrupt timely and effective continuity of care.

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Section: Discussionmentioning

confidence: 80%

Section: Methodsmentioning

confidence: 99%

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Identifying and understanding the care pathway of patients with atrial fibrillation in Brazil and the impact of the COVID-19 pandemic: A mixed-methods study

Goulart,

Varella,

Gooden

et al. 2023

PLoS ONE

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“…This study was part of a multi-country study aimed to identify the AF care pathway in Brazil, China and Sri Lanka using a prospective study design 23 . Adults (≥18 years) with a…”

Section: Methodsmentioning

confidence: 99%

“…The questionnaires were translated into Tamil, then back translated into English to check for accuracy. Before the study commenced, the questionnaires were piloted with four patients in Sri Lanka; no major changes resulted from piloting the tools 23 . KoBoCollect, (version v2021.2.4.)…”

Section: Data Collectionmentioning

confidence: 99%

The pathway to diagnosis and follow-up care for atrial fibrillation in Sri Lanka: a descriptive longitudinal study

Antony Sheron,

Gooden,

Uruthirakumar

et al. 2024

NIHR Open Res

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Background Early diagnosis and continuity of care is vital for atrial fibrillation (AF), to reduce stroke ; There is a lack of understanding of when and how AF is being diagnosed and managed the care pathway) in in low- and middle-income countries (LMICs). We aimed to identify the AF care pathway in Northern Province, Sri Lanka and determine how the COVID-19 pandemic impacted the care pathway. Methods This descriptive longitudinal study utilised two quantitative questionnaires to evaluate the AF pathway: The first questionnaire (baseline) was used to identify where AF was being diagnosed and the second questionnaire (3 months following baseline) was used to identify where and how often AF follow-up care was being received. How the COVID-19 pandemic impacted the care pathway was asked in the second questionnaire. We aimed to recruit 236 adults (≥18 years) with AF from Jaffna Teaching Hospital. Data were collected between October 2020 and June 2021 and analysed using descriptive statistics. Results 151 participants were recruited (median age 57 years; 70% female). Most participants were diagnosed in the accident & emergency (38%) or inpatient department (26%), followed by an outpatient department (19%) or private facility (16%). Nearly all (97%) participants received follow-up care during the study period, with an average of 1.3 AF-related healthcare visits per person for a month; most visited an outpatient department (88%). The COVID-19 pandemic negatively impacted 39% of participants’ care: healthcare visits were reduced or, delayed or medications were unattainable, and longer intervals between blood tests were experienced; however, 24% of participants were able to receive their medication by ambulance, public health staff or post during lockdowns. Conclusions Primary care was not involved in the diagnosis of AF, indicating that most diagnoses occurr after a medical emergency. The frequency of blood tests was lower than the guideline recommendations of one per month which could in-part be due to the adverse impacts of the pandemic. Strengthening primary and community-based care may enable early diagnosis and improve continuity of care during and beyond future healthcare crises.

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Global voices on atrial fibrillation: South/Southeast Asia

Krittayaphong,

Phrommintikul,

Bahuleyan

et al. 2024

Heart Rhythm O2

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Generalisability of and lessons learned from a mixed-methods study conducted in three low- and middle-income countries to identify care pathways for atrial fibrillation

Cited by 4 publications

References 52 publications

Identifying and understanding the care pathway of patients with atrial fibrillation in Brazil and the impact of the COVID-19 pandemic: A mixed-methods study

Identifying and understanding the care pathway of patients with atrial fibrillation in Brazil and the impact of the COVID-19 pandemic: A mixed-methods study

The pathway to diagnosis and follow-up care for atrial fibrillation in Sri Lanka: a descriptive longitudinal study

Global voices on atrial fibrillation: South/Southeast Asia

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