背景:参加澳大利亚初级保健的房颤(AF)人群中有很大一部分没有接受遵循指南的口服抗凝药(OAC)治疗。本研究旨在从全科医生(GP)的角度探讨房颤患者不遵守血栓预防指南的原因,并将这些原因映射到能力。机会,动机-行为(COM-B)模型,用于识别支持实践变化的潜在机会。
方法:使用半结构化访谈对在西澳大利亚州执业的全科医生进行了探索性定性描述性研究,从2020年11月到2021年2月。框架方法被用来促进专题分析,使用NVivo软件。面试回复也被映射到COM-B模型。
结果:最初同意的10名GP中有9名参加了半结构化访谈(男性=56%,中位年龄=52岁,6名参与者达到数据饱和)。对访谈笔录的分析产生了两个主题:(1)全科医生的决策过程和(2)患者拒绝接受OAC。COM-B模型映射确定了可能影响依从性的行为因素:能力(GP对AF指南建议的知识和理解),机会(接触心脏病专家,和患者拒绝服用OAC),和动机(使用正式的出血风险评估工具)。
结论:全科医生确定了房颤患者不遵守血栓预防指南的各种原因。多方面的干预措施应考虑提高依从性的行为机会,包括教育和培训,电子决策支持,由专职医疗专业人员进行临床审核,一般做法和当地医院之间的伙伴关系,和心脏病专家主导的支持全科医生的干预措施。需要进一步的研究来捕获患者拒绝OAC的原因。
BACKGROUND: A significant proportion of the atrial fibrillation (AF) population attending Australian primary care is not receiving
guideline-adherent oral anticoagulant (OAC) treatment. This study aimed to explore reasons for non-adherence to thromboprophylaxis
guidelines in AF from the perspectives of general practitioners (GPs) and to map these reasons to the Capability, Opportunity, Motivation-Behaviour (COM-B) model to identify potential opportunities to support practice change.
METHODS: An exploratory qualitative descriptive study among GPs practising in Western Australia was conducted using semi-structured interviews, from November 2020 to February 2021. The Framework Method was employed to facilitate thematic analysis, using NVivo software. Interview responses were also mapped to the COM-B model.
RESULTS: Nine of the 10 GPs initially consented participated in the semi-structured interview (Male = 56%, median age = 52 years, data saturation reached with 6 participants). Two themes emerged from analysis of the interview transcripts: (1) GPs\' decision-making process and (2) Patient refusal to take OACs. The COM-B model mapping identified behavioural factors that could impact adherence: capability (GPs\' knowledge and understanding of AF
guideline recommendations), opportunity (access to a cardiologist, and patients\' refusal to take OACs), and motivation (using formal bleeding risk assessment tools).
CONCLUSIONS: GPs identified various reasons contributing to non-adherence to thromboprophylaxis
guidelines in patients with AF. Multifaceted interventions should consider behavioural opportunities to improve adherence, including education and training, electronic decision support, clinical audits by allied health professionals, partnership between general practices and local hospitals, and cardiologist-led interventions to support GPs. Further studies are needed to capture patients\' reasons for refusing OACs.