Title: The Patient Path to a diagnosis of Atrial Fibrillation: a qualitative study in primary care (P-PAF)
Funder: Department of Health and Social Care

Abstract: Background Atrial fibrillation (AF), the most common clinically significant arrhythmia in the adult population, increases the risk of stroke five-fold and doubles the risk of death. AF-related strokes are more severe with increased disability and mortality than strokes in people without AF. Anticoagulation therapy can prevent up to two-thirds of stroke and reduce mortality by 25%. However AF is largely undiagnosed and a third of people with AF in the UK, an estimated 500,000 people, remain undiagnosed with thousands of additional new cases going undetected each year. Consequently, stroke remains the first manifestation of AF in up to 50% of AF-related strokes. Early diagnosis is important because the risks of AF-related stroke and mortality are highest in the four months of AF. In the absence of a national screening programme for AF it is important that AF is recognised and detected as soon as possible after onset, for timely initiation of therapies to reduce the risk of stroke and death. Aim To improve understanding of the presentations of AF and identify barriers to earlier diagnosis in order to improve detection of AF and reduce the incidence of AF-related stroke and death in the general population. Objectives 1. To explore the experiences and perceptions of patients of the trajectory to a diagnosis of AF, focusing on identifying factors that might enable earlier diagnosis and management 2. To explore the knowledge and experiences of primary care health professionals on detection of AF, including challenges that may lead to delays in diagnosis 3. To hold a workshop with stakeholders to identify key messages to improve awareness and recognition of AF from study findings and ways to improve detection of AF 4. To develop, in collaboration with PPI educational resources aimed at the public and health professionals from findings Methods This is a qualitative study based in primary care. We will recruit a diverse sample of 20 General Practices to the study. We will conduct semi-structured interviews with up to 30 patients diagnosed with AF within the last 6 months identified from the participating practices. We will also interview up to 20 GPs and nurses identified from the participating practices and from within the CCG. The data will be analysed using framework analysis. Educational resources for the public and health professionals will be developed from the findings following a stakeholder workshop to interpret findings. Timelines for delivery The study will be delivered in 15 months. Month 1-3 study set up and recruitment of practices, month 4-12 data collection and data analysis, month 13 stakeholder workshop, and month 13-15 dissemination and development of educational resources. Anticipated impact and dissemination Study findings and educational resources will be disseminated widely to the public and healthcare professionals through publications, conferences and stakeholder and public engagement. The resultant iincreased knowledge and recognition of AF in the public and healthcare professionals will improve the detection of AF; treatment of patients diagnosed with AF will contribute to a reduction of AF-related strokes and mortality.

Lay abstract: Atrial fibrillation (AF) is a heart condition that causes an irregular heartbeat. It affects up to 10 in 100 people over the age of 65. AF greatly increases the risk of stroke and people with AF are five times more likely to have a stroke compared to people without AF. AF-related strokes are more severe, disabling and fatal than strokes not related to AF. Many people with AF are prescribed medicines known as anticoagulants, which help to reduce blood clots forming and causing an AF-related stroke. AF can be difficult to detect because the irregular heartbeat is not present at all times and not all patients have symptoms. New research has shown more patients have symptoms than previously thought, and that patients with symptoms experience delay in getting a diagnosis. This is because patients think some of the symptoms are trivial and doctors do not always associate them with AF. Currently, about 500,000 people with AF in England have not been diagnosed. As a result, half of all AF-related strokes occur in people unaware they have AF. Early diagnosis and treatment is vital because patients are at highest risk of stroke in the first four months of having AF. This study aims to explore patient journeys to AF diagnosis in order to better understand how AF presents. The knowledge from the study will help people to recognise symptoms earlier and seek medical help, and help healthcare professionals to better recognise AF in their day-to-day practice. The study will be conducted in 20 GP practices in the West Midlands. We will carry out interviews with patients who have received a recent diagnosis of AF to understand the range of symptoms they experienced prior to diagnosis and how AF was detected. We will also carry out interviews with GPs and practice nurses to understand the challenges of identifying AF in practice. We will then hold a meeting with a small group including patients, AF experts, GPs, practice nurses and individuals from relevant charities to understand the learning from the findings. Following that we plan to create educational materials from this learning for the public and healthcare professionals. The findings will be shared with the public, healthcare professionals and the NHS in a number of ways including publications, presentations at conferences for GPs, social media, and posters for display in GP practices. The educational materials will be made widely available on the internet and to all relevant charities and organisations. The founder of the AF Association who is a member of the research team will lead on sharing findings with the public. Improved public awareness and clinician understanding of AF will result in earlier detection of AF and treatment to reduce AF-related stroke.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;7.1 INDIVIDUAL CARE NEEDS
Health categories: STROKE;CARDIOVASCULAR