DECISIONS

The aim of Phase 1 of the study is to collate data about current practice relating to oral anticoagulation (OAC) for stroke prevention. Firstly, we will conduct stakeholder group discussions to collect information about the intended model of service provision at each participating site. These group discussions will include all staff groups (healthcare professional, managerial and administrative), people with AF and those taking OACs for other relevant conditions, and relatives/carers. To develop a picture of intended service provision we will collect information on: the staff involved in OAC management; how, when, and where services are delivered; the roles of multi-professional and multi-specialty team members; resources available (e.g. use of GRASP-AF); training received; provision of support for people taking or considering OAC therapy; transfer of information and care between primary and secondary settings; how and to what extent primary and secondary care provision is integrated; communication with, and support from, local community pharmacies. During this phase of the study we will also collect information on actual management of OAC by extracting anonymised information from the medical records of patients who have known indicators for long-term OAC therapy.

The aim of Phase 2 of the study is conduct in-depth qualitative interviews with healthcare professionals, patients, and their relatives to more fully understand experiences of OAC management, along with their perspectives on the strengths, limitations, barriers and facilitators to effective management of oral anticoagulation. We will interview up to 24 healthcare professionals, 20 people with AF and other conditions, and 10 relatives/carers across the six participating sites. We will endeavour to recruit people with a range of experiences of OAC management including those who have recently commenced taking OACs; who have been taking them for a longer period (>1 year); who have never been prescribed, have declined or discontinued OACs; who have experience of taking VKAs, or DOACs, both, or neither; patients with a range of clinical conditions including if possible non-valvular AF, valvular AF, mechanical heart valve replacement, other structural cardiac disease, and peripheral arterial disease; patients with diverse characteristics with respect to gender, age, ethnicity, previous stroke or arterial thromboembolism diagnosis, and residence (living alone or with a family member).

In Phase 3 of the study, the stakeholder group will use the information from Phases 1 and 2 to co-design an evidence-based care pathway and associated resource guide to support the initiation and ongoing management of oral anticoagulation in stroke and arterial thromboembolism prevention in primary care. We will identify current aspects of good practice, identify areas for improvement, select strategies and measures to change practice, and share between stakeholder groups via an iterative process. The focus of the care pathway will be on supporting, where possible and desired, shared decision-making and patient self-management in relation to anticoagulation. The package is likely to focus on the initiation, optimisation and continuation of treatment in primary care, but will include some elements relating to transfer of care between primary and secondary settings. All elements of the care pathway will be co-designed and are likely to include interventions at organisational level (e.g. overall pathway and procedures), staff level (e.g. training, educational resources, behaviour change interventions), and individual patient/carer level (e.g. behaviour change interventions, support to access and use self-management resources). Next steps in the DECISIONS study will involve funding applications to test the feasibility, acceptability, and effectiveness of the developed care pathway and resource guide.