Screening of Atrial Fibrillation in Dental Practices: a qualitative feasibility study

doi:10.21203/rs.3.rs-2235895/v1

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Screening of Atrial Fibrillation in Dental Practices: a qualitative feasibility study

https://doi.org/10.21203/rs.3.rs-2235895/v1

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Introduction: To increase the detection of unknown atrial fibrillation (AF), general practitioners have started screening their patients using small devices. It is thought that can also be utilised as they have regular access to patients.

Aims: This qualitative study aimed to explore perceptions and barriers of dental staff for screening of AF using a hand-held electronic device in primary dental care.

Setting: A large mixed NHS and private general dental practice in the Northwest of England

Methods: Views from staff included dentists, dental therapists, dental nurses, and managers. Interviews were semi-structured, face-to-face, audio recorded and transcribed verbatim. The interviews continued until there were no new themes or patterns emerging from the data and thematic saturation had been achieved.

Results: Eleven participants were interviewed, and main themes generated were methodology for screening, acceptability for screening within the practice, attitudes to screening, and implementation of screening. Overall, participants were positive about implementing screening in a dental practice but expressed concerns about time and remuneration. Staff also gave encouraging feedback regarding the simplicity of the portable screening device.

Conclusions: Participants felt that AF screening was a good concept but may be challenging to implement in NHS Dentistry, especially due to the pandemic.

Health sciences/Health care/Dentistry/Dental psychology

Health sciences/Health care/Dentistry/Dental public health

Overall views were mixed, although most felt positive about screening
Staff felt the main barriers for screening were remuneration and workload
Piloting screening in dental settings with dental care professionals is indicated

Atrial fibrillation (AF) is the most common heart rhythm abnormality,¹ affecting about 33·5 million people worldwide.² AF is associated with a five-fold increased stroke risk, but appropriate anticoagulation in eligible patients can reduce this risk by around 65%.³ Stroke is estimated to cost the NHS around £3 billion per year and the National Institute for Health and Care Excellence (NICE) guidance states that around 7,000 strokes and 2,000 premature deaths could be avoided every year through effective diagnosis of AF. ⁴ AF is more common with increasing age; the prevalence is 1 in 10 among those aged 75 year and older.⁵ The population is aging and data suggests that by 2050, a quarter of the population will be aged over 60; in the UK the estimated prevalence of AF by 2060 will be 1.6 million.⁶ This makes older people a priority group for preventive efforts.⁷

Growing attention is being given to the connection between poor oral health and the impact this can have on general health. Dental practices are increasingly seen as an appropriate place in which to undertake health prevention in a wider sense.^{8 9} Thus, since poor oral health has been linked to an increased risk of cardiovascular disease, it is also appropriate to start thinking about dental practices as a place where cardiovascular conditions are a focus of prevention strategies.

The main oral disease linked to poor cardiovascular health is periodontitis,¹⁰ which is an infection of the gingivae (gums) and alveolar bone surrounding the teeth. Periodontitis is extremely common; it affects almost half the population,¹¹ and one in ten people have a severe form of the disease which can result in mobile teeth.¹² There is supporting literature suggesting an increased circulation of inflammatory markers with AF, including c-reactive protein and interleukin-six.^{13, 14} These biomarkers are also associated with periodontitis and have been shown to reduce following professional dental cleaning and oral hygiene advice.^{15, 16}

There are a limited number of studies showing an association with oral diseases and AF using hospital data,^17–20 however, prospective or randomised controlled trials are still lacking. A recent study that monitored patients for 17 years found an increased incidence of AF and stroke with periodontitis,²¹ and another study in Hamburg assessed 5,634 participants with AF for severity of periodontitis had found an increased association before adjusting for confounders.²² Current reviews have suggested the importance of prospective clinical studies to investigate a possible link further.^23,24

Recently, there has been evidence that opportunistic screening for AF may prove beneficial.²⁵ Indeed, a systematic review concluded that although screening for AF is beneficial, targeted screening is more cost-effective than systematic screening.²⁶ Uittenbogaart et al (2022) found that clinicians like general practitioners prefer to use hand-held devices for screening of AF over methods like palpating a patient’s pulse, as the reading can be saved or stored.²⁷ A qualitative study interviewing pharmacists using focus groups concluded that AF screening should be incorporated into general practices and prioritised for high-risk patients;²⁵ another qualitative research article also highlighted the importance of screening high risk patients.²⁸ In one study, general practitioners (GP) were asked to screen all the patients aged 65 years or older over a 3-month period, using the AliveCor device; unknown AF was detected in 471 (6.2%) of the 7585 patients screened.²⁹ However, there is currently no literature in relation to dentists’ views on screening for AF.

This is an exploratory study which involves interviewing staff members about whether screening for AF in dental practices is feasible.

Study Design: This was a prospective qualitative research study at one large mixed NHS and private General Dental Practice in the Northwest of England. The practice has more than 10 surgeries, a workforce of over 50 staff members, and >40,000 patients registered. Purposive sampling was used to ensure different types of staff recruited for data collection. Participants that expressed an interest were given an information leaflet and consent form to sign.

Prior to the interview, participants were given a questionnaire to collect participant demographics, and a briefing which included information about AF and the characteristics associated with high-risk of AF such as age, hypertension, heart failure, previous stoke or vascular disease, and diabetes mellitus.³⁰ They also received information about a hand-held electrocardiogram (ECG) device commonly used to screen for AF, Kardia (Figure 1), which is clinically validated for recording, storing, and transferring single channel lead I ECGs.³¹

The interview schedule was sent to all participants a few days before their scheduled meeting in a flipped interview approach (Supplementary Table 1). This was to try and relax the participants, allow time to prepare answers, and stimulate discussion. Interviews were conducted face-to-face to ensure non-verbal cues were captured by the researcher (AH) in the research diary. Interviews were audio recorded and subsequently transcribed verbatim, assigning identification numbers to preserve anonymity. The meetings continued until there were no new recurring themes or patterns emerging from the data and thematic saturation had been achieved.

Ethical approval: The study was approved by the School Ethics Review Board at the University of Aberdeen (SERB/2022/4/2339), and the University acted as sponsor. NHS ethics and trust approval was sought but were not required as the research was non-invasive and did not include vulnerable people or patients. A research passport was granted by the local Clinical Research Network primary care team to allow research to take place within the practice.

Data analysis: Final data analysis of outcomes took place with NVivo after data reached saturation. Main themes and sub-themes were developed iteratively alongside further data collection with a search for confirming and disconfirming cases. A second researcher reviewed the transcripts, coding, and emerging themes to ensure consistency. Thematic framework analysis was chosen as the research objectives were focused around gathering views or opinions about screening in a dental practice rather than a new phenomenon or theory. The participant journey is summarised in Figure 2.

Patient and public involvement: Representatives from a local hospital assisted with the study design and reviewed all documentation to participants, ensuring that they were easy to interpret.

In total, 52 individuals received information about the study, 14 participants expressed and interest and 13 were invited for interview. Eleven participants were questioned, and this included NHS and private dentists, dental therapists, dental nurses, and managers. Four of the participants had five years or less experience, four participants had greater than five but less than ten years, and the remaining three participants had more than ten years’ experience working as a dental professional. Three were non-clinical staff and a further three participants worked full-time as a private clinician. The participant demographics are summarised in a chart below (Figure 3.); individual participant characteristics are not discussed to preserve anonymity. Four main themes emerged and included: screening methodology, acceptability, attitudes to screening, and implementation.

Acceptability

Overall, non-clinicians were all mainly positive because it gave them an opportunity to develop extra skills and it increased the skill set of the practice, although there were concerns about how the practice could overcome potential barriers.

“I think majority of nurses enjoy having that little bit more responsibility with a patient, being able to help patients a little bit more in that more hands-on treatments, and able to help them rather than just all being the dentist that does everything.” (P7)

Clinicians’ views were mixed about whether the screening would work; all three full-time private clinicians and another clinician (4 out of 7 clinicians) said that the screening was a good idea, but it would not have a priority because of existing barriers within NHS Dentistry and that there would be resistance if it affected the time-constraints and workflow in the practice.

“I think it's a good idea, but at the same time, I feel like we can be, especially now, really busy, overwhelmed. I feel like it's quite underfunded in general, the shortage of dentists, a long waiting list for dental treatment. A lot of demand, like, you know, terms of work and the workload, I feel like it's, it's not quite a priority in dental practice.” (P12)

Most participants (7 out of 11 participants) were positive and felt it will be rewarding to potentially prevent a stroke and save lives. Participants were keen however, to stress that their preference was not diagnose AF, but to refer patients to their GP for confirmation, A few participants expressed more concerns than others, and some also highlighted there will always be individuals within a practice that are more likely to accept the screening than others.

“I think it's a brilliant idea. I think it's extremely straightforward and I don't think it's going to take a huge amount to implement it. I think especially knowing the information that I've been given in the briefing about the percentages and the number of people that potentially have atrial fibrillation that don't know that makes it much more important for me.” (P10)

Participants felt that patients and the public would see the screening as positive, but they might feel sceptical about dentists screening for a non-dental related problem, and it may heighten anxiety.

Attitudes to screening

Participants discussed more about the barriers than the benefits for screening (76 references to barriers, compared to 56 benefits). The most common advantage was dental practices had more regular access to patients than a GP, as patients only attended when there was a problem. Other benefits for screening in a dental practice included being comfortable with screening (for oral cancer), breaking bad news, psychological reward for saving lives and utilising prevention in a healthcare setting, with some participants also quoting “making every contact count” (MECC). Most references to barriers were regarding the increased workload, which has worsened since COVID-19. Remuneration (lack of) was also discussed by all participants as a barrier. There were concerns from clinicians about how the screening could be incorporated into the dental appointment and the amount of administrative time it would take to refer patients to their GP, whilst non-clinicians felt the responsibility of a referral was with the clinician.

“If the check-up takes longer, that means fewer patients will be seen long-term. If fewer patients are seen, obviously there’s a negative health care consequence of that, but also the remuneration to the individual will be negative, it will be a reduced rate. With the current feeling towards NHS dentistry, as that clinicians (we) are expected to constantly be doing more and receive less pay, that could be quite a barrier.” (P2)

Screening Methodology

Participants received information from the briefing about the screening device and how to target high-risk patients, all responded positively about using the device to screen for AF. They felt the screening was simple, quick and the device was portable and easy to clean. All participants thought that patients should have the screening incorporated into a dental appointment (opportunistic), rather than coming into the practice just for the screening, as the latter approach would attract patients that are healthier and more conscious about their health. When participants were asked about a possible method to target patients that were high-risk from their dental records, most felt that this was unnecessary, and that software should be able to create a “flag” in the software to notify staff of patients that are high-risk. Some staff thought that targeting patients could be simplified to age only, and everyone should be allowed to have screening if they wished.

“I think the medical histories when we check on the patient's health, if it flags up, there's an indicator, isn't it, on the medical history that says if there's a heart problem, or you can set indicators for certain types of problems.” (P11)

Implementation

This was the most discussed theme with 235 out of 540 references on how to implement screening within a dental practice. Participants felt training was essential, it should be led by experts, hands-on, and during working hours. Some suggested doing the screening during lunch hours because of financial loss.

“I think it'd have to be hands on. You'd need to run different simulations of what kinds of patients are coming in and then, maybe even acting sessions on how you're managing each situation.” (P8)

When discussing possible models, many felt advertisement could be made online, with leaflets in the practice, with invitations sent via a text message before they attend an appointment or via a letter for those who do not have a mobile phone. If a patient agrees to screening, then time is incorporated into their dental appointment (participants varied between 5-30 minutes for additional screening time). Clinicians felt dental nurses or treatment co-ordinators (in private practices) could screen to save clinical time but felt having a spare surgery was unlikely, and screening by reception staff breached confidentiality. If the clinician was screening patients, then a cost would need to be calculated to cover the time lost as an associate.

“So, they need to essentially calculate how long does this take per patient, and then remunerate the dentist based on, for example, how much on average they would make in 10 minutes of doing general dentistry. And if the screening takes 10 minutes, then they need to be paid that amount.” (P6)

Patients that are screened positive would then be referred using an automated GP referral. Most participants felt that screening should be free to NHS patients and that private patients could be asked to pay a small fee to be screened as part of their consultation. It was felt that practices and clinicians should be paid but participants felt there needed to be a cost-benefit analysis to calculate this. An alternative model proposed by one participant involved screening patients in a private booth, like when purchasing passport photos in stores. Patients submit their details, including GP contact and then screen. If the patient is positive, the booth sends an automated electronic referral to their GP or local area team to contact the patient. The advantage for this model is only the practice is remunerated for having the booth and it is less likely to disrupt the workflow of dentistry within the practice. The possible models for screening are summarised in Figure 4.

To the best of our knowledge, this is the first study that has investigated whether screening for atrial fibrillation in dental practices using a portable ECG device is feasible. Clinicians’ views were mixed; although they expressed that the concept was a good idea, there were concerns that it would disrupt workflow of NHS Dentistry which they claimed has worsened since COVID-19. Dental nurses were positive about the prospect of screening within the practice as they had an opportunity to become more hands-on and develop extra skills.

Participants were interviewed by a single researcher to ensure consistency to the types of questions being asked. A second senior researcher reviewed transcripts and emerging themes were discussed and refined. A representative sample of all the different staff roles within the practice was recruited which ensured that everyone’s views were included. Interviewing all staff working in the practice, rather than specific roles (e.g., dentists only) was important as the research objectives were to evaluate whether the screening could work within a practice and who could potentially perform the screening, therefore it was important to include a variety of staff with different roles. A potential limitation of this study is that only 11 participants were recruited; previous studies have interviewed 15 participants for screening of AF in other healthcare settings.^{34, 27} Although this study had availability to recruit more participants, but it was felt that data saturation had been met. Data saturation for thematic analysis is often described as the point in data collection and analysis when new incoming data produces little or no new information to address the research question.³⁵ Previous research has identified the number of qualitative interviews needed for research, and reports that the first six interviews produce most of the relevant data and that little new information was obtained following 20 interviews.³⁶ Another study has demonstrated across four datasets, that up to 92% of all concepts identified within the data analysis were mentioned in the first ten meetings.³⁵

More than two thirds of participants recruited had less than ten years’ experience in a dental setting, however, most staff were young, and this was representative of the sample within the practice. Participants were only recruited from one dental practice and therefore the data potentially lacks generalisability.

Participants in this study suggested piloting the screening on patients in the dental practice and gathering feedback from patients to provide further insight into the potential uptake and acceptability of screening. Dental professionals have previously piloted screening for diabetes in dental practices because of the relationship of diabetes with oral diseases.³³ Further, other authors also suggest that screening for newly diagnosed cardiovascular diseases and AF in dental settings has potential.⁸ General dental practices have an advantage to other healthcare environments for screening, as they have regular access to patients that attend for appointments and can target higher risk patients for stroke related AF using their dental records, as co-morbidities are recorded. Future research to evaluate the feasibility of screening for AF in community settings, dental hospitals or private practices are indicated; dental nurses in the community often have extended skills in these settings, and there is also the possibility for increased capacity and time for screening in community or private practices.

This study suggests that screening for AF in dental practices with the current NHS requirements in England is a good concept and is acceptable in-principle to practice staff, but there are significant barriers including, time, capacity, remuneration, and referrals, which need to be overcome. These barriers have heightened since COVID-19. Further research and piloting of screening for AF in different dental settings that limit the impact of these barriers are indicated, whilst also exploring the patient acceptability and experience of screening.

Conflicts of interest

AOH: this study was partly funded by the Oral and Dental Research Trust OHI Previser Award 2020. In this study, the funding was used to partly cover costs of University approved external transcription service, the funders had not provided any input the study and no salary was provided to any of the authors.

RM: none disclosed

DAL: has received investigator-initiated educational grants from Bristol-Myers Squibb (BMS) and Pfizer, has been a speaker for Bayer, Boehringer Ingelheim, and BMS/Pfizer and has consulted for BMS and Boehringer Ingelheim. No fees are received personally.

GYHL: GYHL: Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, Anthem. No fees are received personally.

RVH: none disclosed

AM: none disclosed

CW: none disclosed

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Screening of Atrial Fibrillation in Dental Practices: a qualitative feasibility study

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