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

Background. There is strong research evidence that anticoagulation of patie nts with nonrheumatic atrial fibrillation reduces the morbidity and mortali ty of stroke. This evidence is incompletely applied. Objectives. We aimed to report consequences associated with the intention t o apply evidence about anticoagulation for non-rheumatic atrial fibrillatio n (NRAF), to individuals in general medical practice. Methods. The study involved prospective structured reporting of the process es of applying evidence about NRAF to individual patients in six general pr actices 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 follow ed by a review of individual patients' records according to protocol criter ia. The main outcomes were indentification of the characteristics of the pa tients, quantitation of GPs' intention to change treatment, explicit report ing of the reasons for not anticoagulating individuals and time to achieve the practice protocol. Results. The data collected confirmed that patients excluded from the autho ritative 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 a mount of change required in patient management. In reviewing their patients ' records with the intention of following evidence-based practice, practiti oners explicitly described and regarded as appropriate their reasons for no t prescribing anticoagulation to certain individuals. The review process wa s time-consuming and will need to be repeated as further evidence emerges. Conclusion. Evidence of the complexity of applying trial results to general practice patients with NRAF is confirmed and extended.