Table 4

Implementation requirements for AF screening

Topic	Current status	Indicative quotes	Opportunities/Challenges for implementation	Indicative quotes
Location of screening	Primary care is the most appropriate location for AF screening	‘Primary care is the most applicable option’. (Participant 1, HCP)	Short appointments in primary care mean that HCP may not prioritise AF screening without clear evidence of benefit.	‘GPs do not have time to do screening as only 7 minutes allocated for each patient’. (Participant 21, HCP)
	There were mixed views about the suitability of pharmacies as a screening location because: pharmacists could easily be trained in the necessary screening skills pharmacies operate on a profit basis with a customer rather than a patient relationship, which may influence screening patterns	‘It would be easy for them [pharmacists] to learn to check pulses … how to use a hand held ECG’. (Participant 16, HCP) “I do not think that involvement of pharmacies is appropriate they have a ‘for profit’ perspective”. (Participant 12, regulator)	If pharmacies are used for AF screening, protocols must be developed for screening processes, data storage and data transfer.	“I am not quite sure what the data protection issues would be for pharmacist screening … the storing of the ECG and appropriate communication with the patient’s GP about the results and so on”. (Participant 16, HCP)
	In exception, dentists and podiatrists were suggested as other suitable locations for AF screening	‘One possible is encouraging dental practices, while the patient is sitting in the chair for 10 minutes is to have those patients sitting with a device that records a single ECG’. (Participant 16, HCP)	Dentists have registered patients; therefore data storage and transfer issues are less complex than community or commercial locations.	‘Patients tend to be registered in the same way that they are registered with a GP, and there could be communication between the dentist and patient’s GP about the results’. (Participant 16, HCP)
Personnel requirements	Primary care professionals (and allied HCP in other locations) require further training in: ECG interpretation patient education for AF	‘Sufficient education is also needed for the personnel who will perform this screening and inform the patients’. (Participant 1, HCP)	Training should include: how, who and when to screen; advice for patients about the pros and cons of screening and treatment.	‘Screening could be implemented in [country] if nurses and GPs were educated how to screen for AF and how to explain the screening to patients’. (Participant 20, HCP)
	Introducing AF screening in primary care would result in increased burden for already time-pressured GPs	‘The main barrier is that doctors do not have enough time per patient’. (Participant 20, HCP)	Practice nurses or non-medically trained primary care employees could inform and guide the patient through AF screening using a single-lead device.	“We should use everybody—every contact counts. Particularly in view of modern technology there doesn’t need to be a lot of skill involved in the detection part”. (Participant 17, regulator)
Regulatory requirements	For the implementation of national screening programmes, sufficient evidence of effect must be evaluated by national review committees	‘The implementation of screening depends on a positive vote of the [review committee] by the evaluation of the committee evidence based efficiency of the screening for the targeted population’. (Participant 10, regulator)	Advocates for AF screening must present: clear guidance and protocols for screening; present evidence of effectiveness of screening and for ‘quality standards, affordability and accessibility’ to national review committees.	‘Various considerations are taken into account: scientific evidence, European guidelines … health economic data, budget, budget, social acceptability, ensure high quality and organisational feasibility’. (Participant 3, regulator)
Regulatory requirements	Where screening or interpretation is performed outside primary or secondary care environments, there are data protection issues that are not adequately addressed	‘Where would the data be stored? How safe the data will be protected in case of abroad storage?’ (Participant 10, regulator)	Where telehealth centres or community testing are implemented clear protocols for safe data transfer and storage are required.	“If we act according to GPDR, then we are basically safe with regard to data protection”. (Participant 5, regulator)
Payment mechanisms	Reimbursement pathways vary across Europe: national, local and private payment mechanisms exist a pan-European approach to payment is impossible	‘Specificity in the [country] health care system… here it is based on national health funding’. (Participant 15, regulator) ‘The majority of a patient’s health insurance is centrally GP-based. GPs are paid on a combined capitation and fee-for-service’. (Participant 5, regulator)	Even within countries, locally focused payment mechanisms may prevent a coordinated approach to the implementation of AF screening without a nationally regulated screening approach.	‘The new improvement framework for primary care is called “improving together”… it is less specific as to what is tackled—it is very much ground up—which makes it difficult to be prescriptive about anything’. (Participant 18, regulator)
Payment mechanisms	Costs for telehealth provision is not covered by current reimbursement systems, creating a potential conflict between primary care and the creation of new service provision	‘Evaluation of AF by a tele-health provider is a structure that is not available … Costs could not be claimed within the current reimbursement structure’. (Participant 8, regulator)	Upcoming screening trials should include a clear overview of the associated costs and cost-effectiveness.	“Studies would be needed to prove that its use is cost-effective in order to convince the physicians and the authorities”. (Participant 22, regulator)

AF, atrial fibrillation; GP, general practitioner; HCP, healthcare professional.