Healthcare provider and patient perspectives on access to and management of atrial fibrillation in the Northern Province, Sri Lanka: a rapid evaluation of barriers and facilitators to care

Sheron, Vethanayagam Antony; Shanmugathas, Shivany; Gooden, Tiffany E; Guruparan, Mahesan; Kumarendran, Balachandran; Lip, Gregory Y.H.; Manaseki‐Holland, Semira; Nirantharakumar, Krishnarajah; Shribavan, Kaneshamoorthy; Subaschandren, Kumaran; Surenthirakumaran, Rajendra; Thomas, G. Neil; Greenfield, Sheila; Lane, Deirdre A.; Beane, Abi; Arasalingam, A.; Brocklehurst, Peter; Cheng, Kar Keung; El-Bouri, Wahbi K.; Feng, Mei; Goulart, Alessandra Carvalho; Guo, Yutao; Gusso, Gustavo Diniz Ferreira; Humphreys, Lindsey; Jolly, Kate; Jowett, Sue; Kodippily, Chamira; Lancashire, Emma; Li, Xuewen; Li, Yanguang; Lobban, Trudie; Lotufo, Paulo A; Moore, David; Olmos, Rodrigo Díaz; Paschoal, Elisabete; Pirasanth, Paskaran; Uruthirakumar, Powsiga; Romagnolli, Carla; Santos, Itamar S; Shantsila, Alena; Szmigin, Isabelle; Tai, Meihui; Toippa, Timo; Varella, Ana C.; Wang, Hao; Wang, Jingya; Zhang, Hui; Zhong, Jiaoyue

doi:10.1186/s12913-022-08440-1

Cited by 5 publications

(5 citation statements)

References 32 publications

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“…However, we know from previous research [15] that AF training is lacking in primary care units in São Paulo which can result in AF symptoms being ignored or misdiagnosed, thus depriving patients of life-saving medication. This was found in our other two project sites in Sri Lanka and China [24], confirming that poor primary care training in recognition, diagnosis and management of AF is likely a common problem in many LMICs. Avoiding stroke with anticoagulation is a key pillar of evidence-based optimal management of AF (ABC pathway) [6], but improved clinician awareness, use of clinical risk stratification [13], skills to conduct initial investigation and knowledge of treatment options by primary care staff is vital for enabling this to occur.…”

Section: Plos Onesupporting

confidence: 79%

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: Plos Onesupporting

confidence: 79%

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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“…Another plausible reason may be due to the limited access to INR tests. Our previous research found that patients with AF must travel far distances to receive care at the Jaffna Teaching Hospital and is a barrier to optimal care (in pre-pandemic times), particularly for rural inhabitants 36 . Similar findings have been highlighted in our research in Brazil, indicating that access to INR tests is an issue in other LMICs 37 .…”

Section: Discussionmentioning

confidence: 99%

“…This study was conducted at the only tertiary hospital in the Northern Province that has cardiologists and can conduct 12-lead echocardiogram tests. Thus, most patients with AF in the province that retain AF care from government facilities, must visit Jaffna Teaching Hospital for care 36 . Our sample is therefore largely representative of all patients with AF receiving government-funded care in the region.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

“…In conclusion, our findings highlight that AF diagnoses mostly occur in the A&E or inpatient department in the Northern Provence of Sri Lanka. Whilst most patients retained in care at the Jaffna Teaching Hospital (the only facility with specialist AF care) 36 are on anticoagulants and rate and rhythm control medication and receive routine INR tests, early diagnosis in primary care facilities must be prioritized to provide life-saving preventative medications for reducing AF-related strokes and achieve the first step within the ABC pathway. The frequency of follow-up care visits was fewer than guideline recommendations, which in part was due to the COVID-19 pandemic but could also be due to the limited access to INR tests, a barrier 38 likely shared by other LMICs.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

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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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“…Additionally, given this is the first study to investigate the AF care pathway in a South Asian country and one of the few to be conducted in any LMIC, the results of our study are nonetheless a critical start to understanding how and where patients with AF go for care, what areas of the pathway need improvements and what needs to be prioritized in future AF research in LMICs.In conclusion, our findings highlight that AF diagnoses mostly occur in the A&E or inpatient department in the Northern Provence of Sri Lanka. Whilst most patients retained in care at the Jaffna Teaching Hospital (the only facility with specialist AF care)36 are on anticoagulants and rate and rhythm control medication and receive routine INR tests, early diagnosis in primary care facilities must be prioritized in Sri Lanka to provide life-saving preventative medications for reducing AF-related strokes and achieve the first step within the ABC pathway. The frequency of follow-up care visits was fewer than guideline recommendations, which in part was due to the COVID-19 pandemic but could also be due to the limited access to INR tests, a barrier 38 likely shared by other LMICs.…”

mentioning

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. 2023

NIHR Open Res

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Background Early diagnosis and continuity of care is vital for atrial fibrillation (AF), a major risk factor for stroke that requires regular monitoring when treated with warfarin; however, evidence on AF care in LMICs is lacking. We aimed to identify the AF patient pathway in Northern Province, Sri Lanka and to determine how the COVID-19 pandemic impacted AF care. Methods This descriptive longitudinal study utilised two questionnaires, which were previously used in India and Mongolia to quantitatively evaluate the AF pathway: one at baseline and one ≥3 months following baseline. Adults (≥18 years) with AF were recruited from the A&E department and outpatient clinics located at the Jaffna Teaching Hospital, the only tertiary hospital with cardiologists and 12-lead echocardiogram facilities in the Province. Data were collected between October 2020 and June 2021 and analysed using descriptive statistics. Results This study included 151 participants (median age 57 years, IQR 49-67; 70% female). Most participants were diagnosed in the A&E (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; most visited an outpatient department (88%). The COVID-19 pandemic negatively impacted 39% of participants’ care: fewer healthcare visits, delayed or unattainable medications, and longer intervals between blood tests; however, 24% of participants received their medication by ambulance, public health staff or post. Conclusions Primary care was not involved in the diagnosis of AF, leading to most diagnoses occurring after a medical emergency. The frequency of blood tests was lower than guideline recommendations and 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/emergencies.

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Healthcare provider and patient perspectives on access to and management of atrial fibrillation in the Northern Province, Sri Lanka: a rapid evaluation of barriers and facilitators to care

Cited by 5 publications

References 32 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

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

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