Organisation of care for patients using direct oral anticoagulants

Positive approaches to safety: Learning from what we do well

Historical and current methodologies in patient safety are based on a deficit-based model, defining safety as the absence of harm. This model is aligned with the human innate negativity bias and the general philosophy of health care: to diagnose and cure illness and to relieve suffering. While this approach has underpinned measurable progress in healthcare outcomes, a common narrative in the healthcare literature indicates that this progress is stalling or slowing. It is important to learn from and improve poor outcomes, but the deficit-based approach has some theoretical limitations. In this article, we discuss some of the theoretical limitations of the prevailing approach to patient safety and introduce emerging, complementary approaches in this field of practice. Safety-II and resilience engineering represent a new paradigm of safety, characterized by focusing on the entirety of work, with a system-wide lens, rather than single incidents of failure. More overtly positive approaches are available, specifically focusing on success-both outstanding success and everyday success-including exnovation, appreciative inquiry, learning from excellence and positive deviance. These approaches are not mutually exclusive. The new methods described in this article are not intended as replacements of the current methods, rather they are presented as complementary tools, designed to allow the reader to take a balanced and holistic view of patient safety.

Long-term adherence to direct oral anticoagulants in patients with atrial fibrillation; a comparative cross-sectional study

BACKGROUND

Long-term treatment with direct oral anticoagulants (DOAC) is required for the majority of patients with non-valvular atrial fibrillation (AF) to prevent ischemic stroke and systemic embolism. Adherence to therapy may impact clinical outcomes. Therefore, the purpose of this study was to assess the potential impact of structured follow-up on long-term adherence to DOAC therapy compared to standard care.

METHODS

This is a cross sectional study on the implementation phase of medication adherence to DOACs, comparing patients with AF following completion of structured follow-up of minimally 1 year with those who received standard care. All patients used DOACs for more than two years and completed a questionnaire on adherence. Adherence was measured with the MMAS-8 score and assessed via an online webportal.

RESULTS

A total of 212 patients were included. The mean MMAS-8 score was 7.55(SD 0.93) after structured follow-up and 7.25(SD 1.01) for standard care; p=0.045. Following structured follow-up 64.1% of patients had a high adherence (MMAS score of 8) compared to 50% receiving standard care; p=0.05. Patients following structured follow-up on a once daily DOAC regime had higher MMAS-8 scores compared to those on a twice daily regime; 7.74(SD 0.74) vs. 7.00(SD 1.22); p<0.001. The rates of minor bleedings were 10.6% versus 21.4% respectively, p=0.038.

CONCLUSION

In patients on long-term DOAC treatment, adherence to therapy was significantly increased after receiving an initial period of structured follow-up compared to standard care. Additionally, adherence to DOAC therapy was higher with once-daily treatment regimen. Significant more minor bleedings were reported in the standard care group. . These results indicate that implementation of structured follow-up of patients with AF using DOACs merits further evaluation.

Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation

Atrial fibrillation (AF) is associated with an increased risk of stroke, which can be prevented by the use of oral anticoagulation. Although non-vitamin K antagonist oral anticoagulants (NOACs) have become the first choice for stroke prevention in the majority of patients with non-valvular AF, adherence and persistence to these medications remain suboptimal, which may translate into poor health outcomes and increased healthcare costs. Factors influencing adherence and persistence have been suggested to be patient-related, physician-related, and healthcare system-related. In this review, we discuss factors influencing patient adherence and persistence to NOACs and possible problem solving strategies, especially involving an integrated care management, aiming for the improvement in patient outcomes and treatment satisfaction.

The Functional Resonance Analysis Method as a health care research methodology: a scoping review

OBJECTIVE

The objective of this review was to examine and map the literature on the use of the Functional Resonance Analysis Method (FRAM) in health care research.

INTRODUCTION

The FRAM is a resilient health care tool that offers an approach to deconstruct complex systems by mapping health care processes to identify essential activities, how they are interrelated, and the variability that emerges, which can strengthen or compromise outcomes. Insight into how the FRAM has been operationalized in health care can help researchers and policy-makers understand how this method can be used to strengthen health care systems.

INCLUSION CRITERIA

This scoping review included research and narrative reports on the application of the FRAM in any health care setting. The focus was to identify the key concepts and definitions used to describe the FRAM, the research questions, aims, and objectives used to study the FRAM, the methods used to operationalize the FRAM, the health care processes examined, and the key findings.

METHODS

A three-step search strategy was used to find published and unpublished research and narrative reports conducted in any country. Only papers published in English were considered. No limits were placed on the year of publication. CINAHL, MEDLINE, Embase, PsycINFO, Inspec Engineering Village, ProQuest Nursing & Allied Health were searched originally in June 2020 and again in March 2021. A search of the gray literature was also completed in March 2021. Data were extracted from papers by two independent reviewers using a data extraction tool developed by the reviewers. Search results are summarized in a flow diagram, and the extracted data are presented in tabular format.

RESULTS

Thirty-one papers were included in the final review, and most (n = 25; 80.6%) provided a description or definition of the FRAM. Only two (n = 2; 6.5%) identified a specific research question. The remaining papers each identified an overall aim or objective in applying the FRAM, the most common being to understand a health care process (n = 20; 64.5%). Eleven different methods of data collection were identified, with interviews being the most common (n = 21; 67.7%). Ten different health care processes were explored, with safety and risk identification (n = 8; 25.8%) being the most examined process. Key findings identified the FRAM as a mapping tool that can identify essential activities or functions of a process (n = 20; 64.5%), how functions are interdependent or coupled (n = 18 58.1%), the variability that can emerge within a process (n = 20; 64.5%), discrepancies between work as done and work as imagined (n = 20; 64.5%), the resiliency that exists within a process (n = 12; 38.7%), and the points of risk within a process (n = 10, 32.3%). Most papers (n = 27; 87.1%) developed models representing the complexity of a process.

CONCLUSIONS

The FRAM aims to use a systems approach to examine complex processes and as evidenced by this review, is suited for use within the health care domain. Interest in the FRAM is growing, with most of the included literature being published since 2017 (n = 24; 77.4%). The FRAM has the potential to provide comprehensive insight into how health care work is done and how that work can become more efficient, safer, and better supported.