Yes / Objective: To better understand the factors influencing the uptake of direct oral anticoagulants (DOACs) across different health economies in National Health Service England from the perspective of health professionals and other health economy stakeholders. Design: Qualitative interview study using a critical realism perspective and informed by the Diffusion of Innovations in Service Organisations model. Setting: Three health economies in the North of England, United Kingdom. Participants: Healthcare professionals involved in the management of patients requiring oral anticoagulants, stakeholders involved in the implementation of DOACs and representatives of pharmaceutical industry companies and patient support groups. Intervention: Semistructured interviews (face-to-face or telephone) were conducted with 46 participants. Interviews were analysed using the Framework method. Results: Identified factors having an impact on the uptake of DOACs were grouped into four themes: perceived value of the innovation, clinician practice environment, local health economy readiness for change, and the external health service context. Together, these factors influenced what therapy options were offered and prescribed to patients with atrial fibrillation. The interviews also highlighted strategies used to improve or restrict the uptake of DOACs and tensions between providing patient-centred care and managing financial implications for commissioners. Conclusions: The findings contribute to the wider literature by providing a new and in-depth understanding on the uptake of DOACs. The findings may be applicable to other new medicines used in chronic health conditions. / This work presents research funded by the Pharmacy Research UK (grant number: PRUK-2018-GA-1-KM) and Leeds Teaching Hospitals NHS Trust (grant number: N/A).

Transient Ischemic Attack (TIA) is a prominent risk factor for subsequent stroke, and its associated morbidity, mortality, and health care costs. Studies have demonstrated up to 80% reductions in subsequent stroke rate with prompt, optimized protocols for rapid TIA evaluation and treatment. National Stroke Association (NSA) and American Heart Association (AHA) guidelines have recommended institution of protocols assuring timely completion of the recommended testing, and evaluation by a stroke expert within 48 hours. However, limited literature exists on the implementation of guideline-based care in rural regions, and the few studies related to TIA suggest that barriers including difficulty accessing services and poorly updated TIA knowledge amongst rural, non-neurologist providers exist despite national guidelines. Behavior change theories have suggested that evaluating factors hindering or motivating behavior change may aid in tailoring implementation of guideline-based practices. This descriptive study sought to understand ED health care providers' perceived barriers to implementation of NSA/AHA TIA guidelines in a rural state. All healthcare providers in each of the state's emergency departments were invited by email to complete an online anonymous survey assessing knowledge of present TIA guidelines and perceived barriers to implementation of these guidelines in their practice setting using a modified Barriers and Facilitators Assessment Instrument (BFAI). After completing the knowledge based questions, respondents were presented a brief educational overview of the guidelines to ensure adequate familiarity with the TIA guidelines to complete the BFAI. Thirty-nine respondents completed the survey. Twenty-seven worked at regional or academic medical centers, and 12 worked at critical access hospitals representing the more rural regions of the state. Consistent with prior work, the most notable finding of this study was a low awareness of the present TIA guidelines amongst ED providers, with none of the survey respondents correctly identifying all items consistent with the evaluation guidelines for TIA. In addition to a low awareness of the guidelines, a number of perceived barriers to implementation were identified, which may inform efforts at implementation, and/or offer a model for similar barrier assessment elsewhere.

Background: Single-cohort studies suggest that second-generation stents (SGS; “mesh stents”) may improve carotid artery stenting (CAS) outcomes by limiting peri- and postprocedural cerebral embolism. SGS differ in the stent frame construction, mesh material, and design, as well as in mesh-to-frame position (inside/outside). Objectives: To compare clinical outcomes of SGS in relation to first-generation stents (FGSs; single-layer) in CAS. Methods: We performed a systematic review and meta-analysis of clinical studies with FGSs and SGS (PRISMA methodology, 3302 records). Endpoints were 30-day death, stroke, myocardial infarction (DSM), and 12-month ipsilateral stroke (IS) and restenosis (ISR). A random-effect model was applied. Results: Data of 68,422 patients from 112 eligible studies (68.2% men, 44.9% symptomatic) were meta-analyzed. Thirty-day DSM was 1.30% vs. 4.11% (p < 0.01, data for SGS vs. FGS). Among SGS, both Casper/Roadsaver and CGuard reduced 30-day DSM (by 2.78 and 3.03 absolute percent, p = 0.02 and p < 0.001), whereas the Gore stent was neutral. SGSs significantly improved outcomes compared with closed-cell FGS (30-day stroke 0.6% vs. 2.32%, p = 0.014; DSM 1.3% vs. 3.15%, p < 0.01). At 12 months, in relation to FGS, Casper/Roadsaver reduced IS (−3.25%, p < 0.05) but increased ISR (+3.19%, p = 0.04), CGuard showed a reduction in both IS and ISR (−3.13%, −3.63%; p = 0.01, p < 0.01), whereas the Gore stent was neutral. Conclusions: Pooled SGS use was associated with improved short- and long-term clinical results of CAS. Individual SGS types, however, differed significantly in their outcomes, indicating a lack of a “mesh stent” class effect. Findings from this meta-analysis may provide clinically relevant information in anticipation of large-scale randomized trials.