Applying research evidence to individuals in primary care: a study using non-rheumatic atrial fibrillation

BACKGROUND: There is strong research evidence that anticoagulation of patients with nonrheumatic atrial fibrillation reduces the morbidity and mortality of stroke. This evidence is incompletely applied. OBJECTIVES: We aimed to report consequences associated with the intention to apply evidence about anticoagulation for non-rheumatic atrial fibrillation (NRAF) to individuals in general medical practice. METHODS: The study involved prospective structured reporting of the processes of applying evidence about NRAF to individual patients in six general practices in Cambridge. The subjects were patients identified to have NRAF in these practices. The intervention consisted of a practice-based review of evidence and the construction of a practice-owned protocol. This was followed by a review of individual patients' records according to protocol criteria. The main outcomes were indentification of the characteristics of the patients, quantitation of GPs' intention to change treatment, explicit reporting of the reasons for not anticoagulating individuals and time to achieve the practice protocol. RESULTS: The data collected confirmed that patients excluded from the authoritative randomized controlled trials predominate among patients cared for in general medical practice. Practitioners overestimated the prevalence of NRAF in their patients and underestimated the extent to which their current practice offered intervention. Practitioners initially overestimated the amount of change required in patient management. In reviewing their patients' records with the intention of following evidence-based practice, practitioners explicitly described and regarded as appropriate their reasons for not prescribing anticoagulation to certain individuals. The review process was time-consuming and will need to be repeated as further evidence emerges.