부산대학교 도서관

Introduction: Atrial fibrillation (AF) is an irregular rhythm of the heart that is associated with 30% of strokes. Substantial undiagnosed AF might be detectable by hand-held ECG devices, and treatment with anticoagulation might reduce the risk of stroke. For an AF screening programme to be endorsed by a national policy-making body, it needs to be proven that the programme causes more benefit (namely in stroke reduction) than harm. The SAFER trial is a trial of an AF screening programme designed to provide this evidence. Whether an AF screening programme provides more benefit than risk will depend on how it is delivered, and therefore many policy-making bodies require a plan for delivery. There is currently no such understanding of or plans for the delivery of an AF screening programme. The research question of this PhD is: how is the screening programme for atrial fibrillation within the SAFER trial delivered, and what recommendations can be made from this for the delivery of a screening programme for atrial fibrillation at a national scale? Methods: I undertook a scoping review of the literature to synthesise detailed schematics for generic screening programmes to identify activities and components that an AF screening programme could require. I also conducted a scoping review to locate the most relevant implementation theory(ies) to aid in the methods and analysis of a process evaluation of SAFER. I then undertook a process evaluation of SAFER. This included studies of which group of staff (general practice staff or central administrators) should undertake the majority of tasks, how participants should be supported, how staff can best manage and be managed in their roles, and how staff training can be optimised. I undertook consultations with 26 stakeholders to create a logic model, observed 43 hours of training and 16 patientpractitioner consultations, conducted 49 semi-structured interviews with practice and trial staff, collected 24 documents and emails for analysis, assessed 230 training evaluation forms, collected 270 practice staff survey responses, and collected online data on characteristics of 36 practices. I created a theory of intervention for a national scale AF screening programme from the literature reviews and the process evaluation, and from this theory I provided a list of recommendations for the delivery of such a programme. Results: I created detailed schematics for generic screening programmes and selected the Consolidated Framework for Implementation Research (CFIR) as the key implementation theory to aid the conduct and analysis of the process evaluation. I found that both general practice and the trial team were successful in eliciting high quality traces from participants in a remotely run AF screening programme, but that general practice staff might have been better at reaching underserved participants while the trial team were more consistent in performance. I found that training for staff was successful and well received. From practice surveys, over 30% of practices were already providing opportunistic screening for AF but nearly 20% of practices were not monitoring patients with AF annually. Combining primary and secondary data, I created theories of change for the programme that highlighted how practices needed to improve guideline compliant care of AF but were able to interpret and act on screening results, that trial staff required achievable targets and a nurturing environment to become competent and confident, that public information needed to be balanced by detailing both benefits and harms of screening, that results needed to be reported with as few indeterminate results as possible, that specific strategies for online and flexible training should be provided for staff, and that a positive public and staff experience were key to a functioning programme. I made some key recommendations for policymakers based on these findings. Conclusion: I have provided theory and recommendations for the delivery of a national scale AF screening programme. I have shown that an evidence-based plan for delivery is of value and should be considered as a criterion before endorsing any screening programme. In the process, I have reported novel methods and approaches for future researchers.