Patient pathways to diagnosis of atrial fibrillation: findings from a qualitative interview study
Problem
Atrial Fibrillation (AF) is a common heart rhythm disorder. AF increases the risk of stroke five-fold and doubles the risk of death. These risks can be reduced by anticoagulation therapy. However, AF can be difficult to detect because it is often intermittent and not always symptomatic, and where symptoms are present, they can be non-specific. Currently at least one-third of people with AF in the UK remain undiagnosed; this equates to an estimated 500,000 people. We aimed to explore the patient path to diagnosis of AF and identify ways to improve the detection of AF.
Approach
We recruited a diverse sample of 12 GP practices in the West Midlands, and invited patients with a recent diagnosis of AF (≤ 6 months) to participate in an in-depth interview. Participants were asked to narrate their journey from first awareness of symptoms that led to the diagnosis of AF. The interviews were conducted face-to-face, audio-recorded and transcribed. The data were analysed using framework analysis, with two researchers developing a coding framework from a sample of the interviews. Two patient contributors were involved in the development of themes and interpretation of the data.
Findings
Thirty patients were interviewed; the median age was 77 years (range 60 – 90 years) and 57% were male (n=17). Most patients (24/30) were diagnosed on the basis of symptoms experienced rather than by incidental detection. Patients with acute symptoms (n = 3) had a linear pathway characterised by ambulance transfer and subsequent diagnosis in A&E. Patients with non-specific symptoms (n=21) such as breathlessness, reduced fitness, or palpitations rationalised symptoms due to their medical history and therefore delayed seeing a doctor. These patients consulted their GP when symptoms became bothersome, following notification from a smartwatch, or randomly mentioned them when attending the surgery for something else. There was variation in time to diagnosis following first presentation to primary care, ranging from the GP immediately suspecting AF to instances where GPs initially attributed symptoms to co-morbid conditions. The pathway for patients with paroxysmal AF was particularly complex; patient narratives describe a churning in the search for a diagnosis with several experiencing additional delays due to inequalities in access to diagnostic tests such as the 24-hour ECG.
Consequences
These findings indicate two approaches that can directly improve detection of AF. (1) Improving public awareness of AF and its symptoms will aid earlier presentation of patients to primary care. (2) Quality improvement in the health system to ensure equitable access to diagnostic tests will improve time to diagnosis.