The patient pathway in cardiovascular care: a position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT)

"Background: This position paper highlights the opportunistic integral role of the pharmacist across the patient pathway utilizing cardiovascular care as an example. The paper aims to highlight the potential roles that pharmacists worldwide can have (or already have) to provide efficient patient care in the context of interprofessional collaboration. Methods: It results from a literature review and experts seeking advice to identify existing interventions and potential innovative interventions. We developed a conceptual framework highlighting seven critical phases in the patient pathway and for each of those listed some of the initiatives identified by our experts worldwide. Results: Existing pharmacists' interventions in each of these phases have been identified globally. Various examples in the area of prevention and self‐management were found to exist for long; the contribution for early detection and subsequently to timely diagnosis were also quite clear; integration of care was perhaps one of the areas needing greater development, although interventions in secondary care were also quite common. Tertiary care and end of life interventions were found to often be left for other healthcare professionals. Conclusion: On the basis of the findings, we can argue that much has been done but globally consider that pharmacists are still an untapped resource potentially useful for improved patient care."info:eu-repo/semantics/publishedVersio

Implementation and evaluation of a computerised anticoagulation decision support tool for managing atrial fibrillation

Background: Anticoagulation therapy for patients with atrial fibrillation (AF) remains a national challenge. A decision support tool (DST) was developed to assist healthcare professionals (HCPs) in the appropriate prescribing of anticoagulants in patients with AF. This thesis aimed to evaluate the utility of the DST and associated patient decision aid (PDA) for anticoagulant decision making in clinical practice. Methods: This study involved a series of sequential stages in the evaluation of the DST. Semi-structured interviews were conducted with forty-seven HCPs to explore their perceptions of anticoagulation prescribing decision. Using a vignette, the perspective of HCPs on the potential utility of the DST and associated PDA were explored using both semi-structured interviews and questionnaires. Second interviews were conducted approximately eight weeks from the initial contact to explore HCPs’ perspectives on the actual utility from implementing the DST and associated PDA in routine clinical practice. The perspectives of a group of AF patients’ who had experienced the DA during consultation were explored using semi-structured interviews and questionnaires. Results: Qualitative themes elicited during initial contact revealed that anticoagulants prescribing decision can be suboptimal. Findings from the pre-intervention evaluation showed that the DST has potential to improve the quality of anticoagulants decision process. Findings from post-intervention evaluation demonstrated improvements in anticoagulants decision-making in clinical practice. Findings from fourteen patients revealed that the DA was effective in facilitating a quality decision that was informed and consistent with personal values and expectations. Conclusions: This study demonstrated the positive impact the DST can have on the quality of anticoagulants decision-making in clinical practice and provides a unique contribution to the existing CDSS research. The ever-increasing demand for a quality decision-making process in clinical practice is a fertile environment for clinicians and policymakers to consider the potential impact that the DST and associated PDA can offer

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

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

Investigating prescribers' experiences of direct-acting oral anticoagulants for the management of nonvalvular atrial fibrillation.

Direct-acting oral anticoagulants (DOACs) have relatively recently been licensed for stroke and systemic embolism prevention in patients with non-valvular atrial fibrillation (AF) and have replaced warfarin as the first line agent of choice. The aim of this research was to determine prescribers' views and experiences of the use of DOACs for the management of non-valvular AF. The first phase was a PROSPERO-registered systematic review of clinicians' views and experiences of DOACs for the management of non-valvular atrial fibrillation. Ten studies were identified. In those studies reporting clinician preference, DOACs were first choice over warfarin in naïve patients, based on perceptions of evidence that DOACs had effectiveness equivalent or superior to warfarin and were also superior in safety. Other advantageous factors were in those with an unstable International Normalized Ratio and who were likely to miss appointments. There were, however, concerns relating to management of over-anticoagulation and experiences of observed bleeding rates. In addition to the lack of studies, none of the studies had used theory in the development of the data collection tools or analysis, indicating a gap in the literature. The second phase was a cross-sectional survey of prescriber's views, behaviours and experiences related to prescribing DOACs for the management of non-valvular AF. The survey was conducted in NHS Highland, inviting all medical and non-medical prescribers to participate. Items on potential influences on DOAC prescribing were based on the Theoretical Domains Framework (TDF). Principal component analysis (PCA) of the TDF items gave four components. Component scores were positive for (i) role of professionals, their knowledge and skills and (ii) influences on prescribing. There did, however, appear to be issues in switching from warfarin to DOACs or from one DOAC to another. Scores were more neutral for (iii) consequences of prescribing and (iv) monitoring for safety and effectiveness. There were low levels of agreement for statements relating to DOACs being more effective, safer and cost-effective than warfarin. There were similar responses around the complexity of bleeding management and detection of over and under-anticoagulation. Less experienced prescribers were statistically significantly more positive than more experienced prescribers in terms of the consequences of prescribing (p < 0.05). Content analysis of the responses to the open questions identified that the overwhelming perceived benefit was the absence of need for INR monitoring, with the main limitations being the lack of a suitable reversal agent and ability to monitor anticoagulation status.Given the updated recommendations of Healthcare Improvement Scotland (HIS) to use edoxaban first line, the final phase was a cross-sectional survey of prescriber's views, behaviours and experiences related to prescribing edoxaban for the management of non-valvular AF. Responses were received from 103 prescribers in NHS Highland. While almost all respondents had been encouraged to implement this recommendation of prescribing edoxaban, less than one third had either switched patients from warfarin or other DOACs to edoxaban. The following three PCA components identified in the previous survey were applied to the TDF determinants: the role of professionals, their knowledge and skills; influences on prescribing; and consequences of prescribing. While component scores for the first two components were positive, the scores for consequences of prescribing were more neutral. Although a number of respondents described edoxaban (and other DOAC) related adverse drug reactions (ADRs), very few had submitted a Yellow Card report to the Medicines and Healthcare products Regulatory Agency (MHRA). Content analysis of the responses to the open questions identified benefits and limitations similar to the previous survey. This doctoral research has generated original findings in terms of DOACs views, experiences and behaviours related to management of non-valvular AF. There is merit in reviewing the local and national guidelines, particularly in relation to switching and awareness of the evidence base. Attention should be paid to the literature on guideline implementation

Clinical pharmacists and nurses' perceptions on implementing anticoagulation therapy recommendations for the frail elderly: An exploratory study based on psychological theory

Background: Stroke is a leading cause of mortality and disability in Canada. Persons with atrial fibrillation (AF) have a five-fold increased risk of developing a stroke. AF is a significant contributor to stroke at all ages and the prevalence of AF is rising with age. In Canada, the treatment for persons with chronic non-valvular AF is to provide long-term oral anticoagulation therapy (OAT) with warfarin, which has been shown to reduce the risk of stroke by two-thirds. Routine care administered by physicians is often inconvenient because it requires regular doctor visits, a time lag between laboratory testing and follow ups, and frequent ad-hoc dose adjustments to prevent adverse outcomes. These challenges often contribute to poor OAT management to result in an increased risk of bleeding and clotting. These risks are further complicated for people with AF who are older, frail, have multiple co-morbidities and polypharmacy. The solution is to offset these complications through optimizing delivery of OAT using anticoagulation management services (AMS). Research has shown that pharmacist or nurse-led AMS are comparable or better than physician-led care in terms of cost-effectiveness and patient outcomes. Despite this, AMS clinics need to establish a more integrated approach for the optimal delivery of OAT management. Published and available in the literature are clinical recommendations by Garcia et al. (2008) on how to optimize OAT delivery in outpatient AMS settings; however, the deliberate implementation of the guideline remains an issue. Objectives: To address the problem in the context of a frail, aging population, this study explores the pharmacists and nurses’ perceptions of implementing Garcia et al.’s (2008) clinical guideline for optimal OAT management in existing specialized AMS clinics within the Waterloo-Wellington Local Health Integration Network (WWLHIN) community. Specifically, this study uses Michie et al.’s (2005) psychological theory to explore (1) how existing intrinsic and extrinsic factors hindered or supported; and (2) how behavioural changes facilitate the implementation of Garcia et al.’s (2008) clinical guideline for optimal OAT management. Methods: This study used a qualitative, explorative design with a purposive sample of clinicians (key informants) working in AMS clinics within the WWLHIN community: Waterloo-Kitchener, Cambridge and Guelph. Key informants were recruited from family health teams (FHTs) and community pharmacies, and sampled until the point of saturation. Semi-structured interview questions covered 12 domains under a theoretical lens, Michie et al.’s (2005) psychological theory: (1) Knowledge, (2) Skills, (3) Social/professional role and identity, (4) Beliefs about capabilities, (5) Beliefs about consequences, (6) Motivation and goals, (7) Memory, attention and decision processes, (8) Environmental context and resources, (9) Social influences, (10) Emotion, (11) Behavioural regulation, and (12) Nature of the behaviours. These 12 domains represent the relevant factors that influence the implementation of clinical guidelines. Garcia et al. (2008) published a clinical guideline with 9 key recommendations for optimal delivery of OAT management in outpatient AMS settings: (1) Qualifications of Personnel, (2) Supervision, (3) Care Management and Coordination, (4) Documentation, (5) Patient Education, (6) Patient Selection and Assessment, (7) Laboratory Monitoring, (8) Initiation and Stabilization of Warfarin Therapy, and (9) Maintenance of Therapy. Interviews averaged 40 minutes per key informant and produced a total of 108 pages of transcript. Data were coded and analyzed using NVIVO Pro 11 based on the theoretical framework. Results: There were six clinics that participated in the study: three family health teams and three community pharmacies with AMS clinics. Within these six clinics, there were a total of eight key informants: six pharmacists and two registered nurses. The majority of key informants were from the Kitchener-Waterloo region with more than one-year experience in OAT in the community setting. There were five salient themes in the results: (1) Inadequate reimbursement for logistical operation of AMS clinics; (2) Clinicians’ awareness of how to apply knowledge to support practices; (3) Tailored organizational supports for the frail elderly; (4) Engagement of efforts to improve interprofessional communication and collaboration; and (5) Use of compatible software platforms for documentation. Theme 1 hindered, theme 2 and 3 supported, and theme 4 and 5 facilitate the implementation of Garcia et al.’s (2008) clinical guideline for the optimal delivery of OAT management in participating AMS clinics. Discussion: In determining that inadequate funding was a key barrier to implementation, the finding suggests that if key informants cannot cover their costs, they cannot offer optimal OAT management per the clinical guideline. There is currently no coverage of services and materials for OAT management by pharmacists and nurses in Canada, except for Quebec. Instead, Ontario’s pharmacists in community AMS clinics use other means to recover costs for OAT management services. In light of these findings, there needs to be appropriate funding for community AMS to continue their valuable services, otherwise OAT management may fall back to usual care and block optimal practices. Other factors affecting implementation are awareness of how to apply each recommendation of the clinical guideline to support practice and tailored organizational supports for the frail elderly. Although there was general awareness of the recommendations, one exception was the finding that suggests that key informants relied on an incomplete frailty assessment; this finding reflected other work showing that clinicians tend to diagnose frailty syndrome based on chronological age rather than biological age. Furthermore, other work corroborated the finding that tailored organizational supports for the frail elderly, such as physical tools, face-to-face interactions and home visits, enabled the implementation of the clinical guideline via improving medication adherence and monitoring of other health issues. In addition, other studies supported the finding that clinicians should engage in interprofessional communication and collaboration, especially during care transitions to facilitate optimal practices. One strategy was for nurse navigators to act as the focal point of contact for seamless care transitions, but existing pharmacists and nurses can also expand their scope of practice to methodically provide continuity of care and coordination of services in community-based AMS settings. Other work also supported the finding that social networking with experts in the local and wider regions facilitated optimal practices through maintaining competencies and gaining new knowledge. Another facilitator of optimal OAT management was to use compatible software platforms for standardized OAT documentation to integrate a systematic approach to management. However, the selection of an anticoagulation software program is complicated with many considerations, depending on individual clinic’s needs. There needs to be further investigation on the limited literature on the implications of using compatible software platforms for standardized documentation of OAT management. Conclusion: Linking key themes to the domains of Michie et al.’s (2005) psychological theory that influenced the implementation of the clinical guideline: (1) Inadequate reimbursement for logistical operation of AMS clinics was an environmental constraint (domain #8); (2) Clinicians’ awareness of how to apply knowledge to support practices was having the knowledge and skills (domains #1 and 2); (3) Tailored organizational supports for the frail elderly were environmental resources within their context (domain #8); (4) Engagement of efforts to improve interprofessional communication and collaboration was using social influences to prompt behavioural changes (domains #9 and 12); and (5) Use of compatible software platforms for documentation was a proposed system to change the nature of behaviours related to tracking and recording anticoagulation data (domain #12). Using the underlying theory, these key themes represent important factors for the deliberate implementation of the clinical guideline for optimizing delivery of OAT management. Insights on how various factors affect the implementation the clinical guideline can help key stakeholders scale up efforts for a broader, more uniform approach to optimal OAT management for a frail, elderly population

Doctor of Philosophy

dissertationMedical knowledge learned in medical school can become quickly outdated given the tremendous growth of the biomedical literature. It is the responsibility of medical practitioners to continuously update their knowledge with recent, best available clinical evidence to make informed decisions about patient care. However, clinicians often have little time to spend on reading the primary literature even within their narrow specialty. As a result, they often rely on systematic evidence reviews developed by medical experts to fulfill their information needs. At the present, systematic reviews of clinical research are manually created and updated, which is expensive, slow, and unable to keep up with the rapidly growing pace of medical literature. This dissertation research aims to enhance the traditional systematic review development process using computer-aided solutions. The first study investigates query expansion and scientific quality ranking approaches to enhance literature search on clinical guideline topics. The study showed that unsupervised methods can improve retrieval performance of a popular biomedical search engine (PubMed). The proposed methods improve the comprehensiveness of literature search and increase the ratio of finding relevant studies with reduced screening effort. The second and third studies aim to enhance the traditional manual data extraction process. The second study developed a framework to extract and classify texts from PDF reports. This study demonstrated that a rule-based multipass sieve approach is more effective than a machine-learning approach in categorizing document-level structures and iv that classifying and filtering publication metadata and semistructured texts enhances the performance of an information extraction system. The proposed method could serve as a document processing step in any text mining research on PDF documents. The third study proposed a solution for the computer-aided data extraction by recommending relevant sentences and key phrases extracted from publication reports. This study demonstrated that using a machine-learning classifier to prioritize sentences for specific data elements performs equally or better than an abstract screening approach, and might save time and reduce errors in the full-text screening process. In summary, this dissertation showed that there are promising opportunities for technology enhancement to assist in the development of systematic reviews. In this modern age when computing resources are getting cheaper and more powerful, the failure to apply computer technologies to assist and optimize the manual processes is a lost opportunity to improve the timeliness of systematic reviews. This research provides methodologies and tests hypotheses, which can serve as the basis for further large-scale software engineering projects aimed at fully realizing the prospect of computer-aided systematic reviews