{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T21:55:10Z","timestamp":1789682110544,"version":"4.0.1"},"update-to":[{"DOI":"10.3310\/nihropenres.13497.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,2,23]],"date-time":"2026-02-23T00:00:00Z","timestamp":1771804800000}},{"DOI":"10.3310\/nihropenres.13497.2","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,2,23]],"date-time":"2026-02-23T00:00:00Z","timestamp":1771804800000}}],"reference-count":31,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2026,2,23]],"date-time":"2026-02-23T00:00:00Z","timestamp":1771804800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000272","name":"National Institute for Health and Care Research","doi-asserted-by":"publisher","award":["17\/63\/121"],"award-info":[{"award-number":["17\/63\/121"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["openresearch.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["NIHR Open Res"],"abstract":"<ns3:p>Background Early diagnosis and continuity of care is vital for atrial fibrillation (AF), to reduce stroke ; There is a lack of understanding of when and how AF is being diagnosed and managed the care pathway) in in low- and middle-income countries (LMICs). We aimed to identify the AF care pathway in Northern Province, Sri Lanka and determine how the COVID-19 pandemic impacted the care pathway. Methods This descriptive longitudinal study utilised two quantitative questionnaires to evaluate the AF pathway: The first questionnaire (baseline) was used to identify where AF was being diagnosed and the second questionnaire (3 months following baseline) was used to identify where and how often AF follow-up care was being received. How the COVID-19 pandemic impacted the care pathway was asked in the second questionnaire. We aimed to recruit 236 adults (\u226518 years) with AF from Jaffna Teaching Hospital. Data were collected between October 2020 and June 2021 and analysed using descriptive statistics. Results 151 participants were recruited (median age 57 years; 70% female). Most participants were diagnosed in the accident &amp; emergency (38%) or inpatient department (26%), followed by an outpatient department (19%) or private facility (16%). Nearly all (97%) participants received follow-up care during the study period, with an average of 1.3 AF-related healthcare visits per person for a month; most visited an outpatient department (88%). The COVID-19 pandemic negatively impacted 39% of participants\u2019 care: healthcare visits were reduced or, delayed or medications were unattainable, and longer intervals between blood tests were experienced; however, 24% of participants were able to receive their medication by ambulance, public health staff or post during lockdowns. Conclusions Primary care was not involved in the diagnosis of AF, indicating that most diagnoses occurr after a medical emergency. The frequency of blood tests was lower than the guideline recommendations of one per month which could in-part be due to the adverse impacts of the pandemic. Strengthening primary and community-based care may enable early diagnosis and improve continuity of care during and beyond future healthcare crises.<\/ns3:p>","DOI":"10.3310\/nihropenres.13497.3","type":"journal-article","created":{"date-parts":[[2026,2,23]],"date-time":"2026-02-23T07:09:05Z","timestamp":1771830545000},"page":"63","update-policy":"https:\/\/doi.org\/10.3310\/nihropenres.crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["The pathway to diagnosis and follow-up care for atrial fibrillation in Sri Lanka: a descriptive longitudinal study"],"prefix":"10.3310","volume":"3","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4848-3238","authenticated-orcid":false,"given":"Vethanayagam","family":"Antony Sheron","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tiffany E.","family":"Gooden","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Powsiga","family":"Uruthirakumar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kanesamoorthy","family":"Shribavan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahesan","family":"Guruparan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kumaran","family":"Subaschandren","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7566-1626","authenticated-orcid":false,"given":"Gregory Y. H.","family":"Lip","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krishnarajah","family":"Nirantharakumar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G. Neil","family":"Thomas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rajendra","family":"Surenthirakumaran","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Balachandran","family":"Kumarendran","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5827-8855","authenticated-orcid":false,"given":"Semira","family":"Manaseki-Holland","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"NIHR Global Health Research Group on Atrial Fibrillation Management","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"6221","published-online":{"date-parts":[[2026,2,23]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"821-6","DOI":"10.1016\/j.lpm.2007.09.019","article-title":"Atrial Fibrillation: the most common arrhythmia.","volume":"37","author":"J Le Heuzey","year":"2008","journal-title":"Presse Med."},{"key":"ref2","doi-asserted-by":"publisher","first-page":"217-21","DOI":"10.1177\/1747493019897870","article-title":"Global epidemiology of Atrial Fibrillation: an increasing epidemic and public health challenge.","volume":"16","author":"G Lippi","year":"2021","journal-title":"Int J Stroke."},{"key":"ref3","doi-asserted-by":"publisher","first-page":"881-887","DOI":"10.1136\/heartjnl-2020-317656","article-title":"Trends of global burden of Atrial Fibrillation\/Flutter from Global Burden of Disease Study 2017.","volume":"107","author":"L Wang","year":"2021","journal-title":"Heart."},{"key":"ref4","doi-asserted-by":"publisher","first-page":"857-67","DOI":"10.7326\/0003-4819-146-12-200706190-00007","article-title":"Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular Atrial Fibrillation.","volume":"146","author":"R Hart","year":"2007","journal-title":"Ann Intern Med."},{"key":"ref5","doi-asserted-by":"publisher","first-page":"627-628","DOI":"10.1038\/nrcardio.2017.153","article-title":"The ABC pathway: an integrated approach to improve AF management.","volume":"14","author":"G Lip","year":"2017","journal-title":"Nat Rev Cardiol."},{"key":"ref6","doi-asserted-by":"publisher","first-page":"1511-1527","DOI":"10.1093\/europace\/euab092","article-title":"The Atrial Fibrillation Better Care pathway for managing Atrial Fibrillation: a review.","volume":"23","author":"D Stevens","year":"2021","journal-title":"Europace."},{"key":"ref7","doi-asserted-by":"publisher","first-page":"735-746D","DOI":"10.2471\/BLT.19.245563","article-title":"Hospital-provision of essential primary care in 56 countries: determinants and quality.","volume":"98","author":"C Arsenault","year":"2020","journal-title":"Bull World Health Organ."},{"key":"ref8","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2020-002640","article-title":"Availability and affordability of medicines and cardiovascular outcomes in 21 high-income, middle-income and low-income countries.","volume":"5","author":"C Chow","year":"2020","journal-title":"BMJ Glob Health."},{"key":"ref9","doi-asserted-by":"publisher","first-page":"883-907","DOI":"10.4070\/kcj.2019.0234","article-title":"Reducing stroke risk in Atrial Fibrillation: adherence to guidelines has improved, but patient persistence with anticoagulant therapy remains suboptimal.","volume":"49","author":"N Lowres","year":"2019","journal-title":"Korean Circ J."},{"key":"ref10","doi-asserted-by":"publisher","first-page":"2965-8","DOI":"10.1161\/STROKEAHA.115.010203","article-title":"Prevalence of stroke and its risk factors in urban Sri Lanka: population-based study.","volume":"46","author":"T Chang","year":"2015","journal-title":"Stroke."},{"key":"ref11","doi-asserted-by":"publisher","DOI":"10.1016\/S2214-109X(22)00234-0","article-title":"Worsening economic crisis in Sri Lanka: impacts on health.","volume":"10","author":"A Matthias","year":"2022","journal-title":"Lancet Glob Health."},{"key":"ref12","doi-asserted-by":"publisher","DOI":"10.1080\/16549716.2023.2231763","article-title":"Generalisability of and lessons learned from a mixed-methods study conducted in three Low- and Middle-Income Countries to identify care pathways for Atrial Fibrillation.","volume":"16","author":"T Gooden","year":"2023","journal-title":"Glob Health Action."},{"key":"ref13","article-title":"Northern Province | Provinces | SoSLC."},{"key":"ref14","doi-asserted-by":"publisher","first-page":"729-740","DOI":"10.1136\/bmjqs-2018-008941","article-title":"Can universal patient-held health booklets promote continuity of care and patient-centred care in low-resource countries? 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We have addressed each comment in a point-by-point format below and have modified the manuscript accordingly. We have uploaded the updated manuscript with tracked changes. Yours sincerely, Mr V A Sheron  \n<b>Reviewer 1 (Akash Batta) comments:<\/b>  The index study by the authors reflects the current status of AF care in a LMIC and highlights a very important aspect: Lack of involvement of primary and secondary care in AF diagnoses and management. Their report although not novel, does make a strong statement in favour of improving the primary care through adequate training of doctors and paramedical staff to pick up the largely under-diagnosed pool of AF patients who only present once there has been a MACCE event which otherwise could have been prevented if picked up earlier. The impact of COVID 19 in their district has also been described in regards to AF care. however, the paper needs a major revamp and editing by an English expert to improve its overall quality and value to current practice.  \n<b>Response: <\/b>Thank you for the positive assessment of the paper. We can confirm that we have read the manuscript thoroughly and have made improvements to the overall quality of the writing. We hope this has elevated the readability of the paper.  \n<b>Comment 1: <\/b>The abstract should be clearly written. It has been written rather poorly and casually compared to the main text. The first line should be rewritten &quot;Early diagnosis and continuity of care is vital for atrial fibrillation (AF), a major risk factor for stroke that requires regular monitoring when treated with warfarin&quot;. Just mention inserted that AF requires treatment with OAC to prevent stroke.  \n<b>Response: <\/b>Thank you for the suggestions, we have amended the abstract throughout to make it clearer; however, we left the first part of the first sentence given the rationale for our research is related to the need for early diagnosis and continuity of care for AF.  \n<b>Comment 2: <\/b>Clarify what you mean by &quot;AF patient pathway&quot;  \n<b>Response: <\/b>We have clarified this in the abstract. For the purpose of our study, we have defined the AF care pathway as comprising the pathway from diagnosis to follow-up\/management.  \n<b>Comment 3: <\/b>Remove these unnecessary details&quot; recruited from the A&amp;E department and outpatient clinics located at the Jaffna Teaching Hospital, the only tertiary hospital with cardiologists and 12-lead echocardiogram facilities in the Province&quot;  \n<b>Response: <\/b>Thank you for the suggestions, we have removed the unnecessary details as suggested.  \n<b>Comment 4: <\/b>Clearly write the objective and major endpoints of the study.  \n<b>Response: <\/b>Thank you, we have amended the abstract to make the aim and outcomes clearer.\n<b> <\/b>  \n<b>Comment 5: <\/b>Add more complications of AF which are clinically relevant like heart failure, myocardial infarction, dementia in addition to stroke alone.  \n<b>Response: <\/b>We have amended the text in the introduction of the manuscript to include additional clinically relevant complications (see below).  \u201cAF increases the risk of hospitalisation and stroke, heart failure and myocardial infarction\u201d \n<b><i>(Introduction \u2013 First paragraph)<\/i><\/b>  \n<b>Comment 6: <\/b>Need to state that warfarin is not synonymous with OAC and recent data even from LMIC shows that NOACS are fast replacing VKAs as the preferred OAC for non-valvular AF  \n<b>Response: <\/b>We agree this is an important point to make. We have amended the text to ensure this is clear (see below). Please note that whilst NOAC usage is increasing in LMIC settings, warfarin is the only available OAC for AF management offered under the Sri Lankan public health system.  \u201cOn the other hand, Novel oral anticoagulants (NOAC) do not require as much monitoring as warfarin and could be hugely advantageous for LMICs given the barriers of accessing healthcare services and INR tests. Whilst recent studies have found an increase in the availability and use of NOACs in LMICs it is still limited in many LMICs, including Sri Lanka where warfarin is the only available OAC within the public health system\u201d \n<b><i>(Introduction \u2013 Paragraph 2)<\/i><\/b>  \n<b>Comment 7: <\/b>The study design should be written as multi-centric rather that multi-country  \n<b>Response: <\/b>Thank you for the suggestions, however, we have respectively left the text as \u2018multi-country\u2019; we felt multi-centric (whilst technically correct) could also mean several centers within the same country whereas our study was conducted in multiple counties and in multiple centers within two of these countries (Brazil and China).  \n<b>Comment 8: <\/b>An important association of AF is coronary artery disease (CAD) which should be described in discussion. This is important as recent evidence indicated a very intricate relationship between AF and CAD which could be utilised at the primary care. Accordingly, one must pay more attention to screening AF in these patents in their primary or secondary care setting. Accordingly, I would strongly suggest addition data on the close link between the two and citing 3-4 recent integrative reviews which highlight this association and guide therapeutic strategies to treat the two diseases.  \n<b>Response: <\/b>Thank you for the suggestions, we have amended the text in the discussion as suggested (see below).  \u201cThis may require a combination of training for healthcare professionals, reliable access to diagnostic equipment, and increased manpower at primary care level, particularly on how to screen and manage the different types of AF and comorbidities such as coronary artery disease due to the complex relationship between the two conditions\u201d \n<b><i>(Discussion \u2013 Paragraph 2)<\/i><\/b>","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/3-63\/v3#referee-comment-3332","order":1,"name":"referee-comment-3332","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.14800.r32003, Luigina Guasti, University of Insubria, Varese, 20 Jun 2024, version 2, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/3-63\/v2#referee-response-32003","order":2,"name":"referee-response-32003","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.14800.r32195, Raif K\u0131l\u0131\u00e7, Memorial Diyarbak\u0131r Hospital, Cermik, Diyarbak\u0131r, 09 Jul 2024, version 2, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/3-63\/v2#referee-response-32195","order":3,"name":"referee-response-32195","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Sheron Antony<\/b>; \n<i>Posted: 02 Dec 2025<\/i>; Reviewer (3): Raif K\u0131l\u0131&ccedil;, Memorial Diyarbak\u0131r Hospital, Cermik, Diyarbak\u0131r, Turkey  In this manuscript, the authors examined \u201cidentifying the AF care pathway in the Northern Province of Sri Lanka and how the COVID-19 pandemic has affected the care pathway.\u201d In this respect, I congratulate the authors and find this manuscript important. However, here I have some revision suggestions for the authors;  Dear Raif K\u0131l\u0131&ccedil;, Thank you for you review for our manuscript titled \u201cThe pathway to diagnosis and follow-up care for atrial fibrillation in Sri Lanka: a descriptive longitudinal study\u201d. We have addressed each comment in a point-by-point format below and have modified the manuscript accordingly. We have uploaded the updated manuscript with tracked changes.  \n<b>Comment 1:<\/b> The introduction is quite long and detailed. Main focus points can be made clear and expressed more succinctly. The introduction can be kept shorter to attract the reader's attention and help them focus more quickly on the main topic of the article. Some paragraphs in the introduction appear to contain repetitive or similar information to each other. These paragraphs can be combined in a more compact and concise manner. \n<b>Response:<\/b> We thank the reviewer for this insightful comment. We have carefully revised the introduction to enhance clarity and conciseness by removing repetitive and non-essential content. Nevertheless, we have intentionally retained key contextual details related to the evidence-based atrial fibrillation (AF) management framework, particularly the ABC pathway, and its implementation disparity between high-income and low- and middle-income countries such as Sri Lanka. We consider this information crucial to justify the study\u2019s rationale and to position our work within the broader global effort to improve AF care pathway.  \n<b>Comment 2:<\/b> It was stated that patient partners were not involved in the design and conduct of the study. Lack of patient participation may limit the impact and validity of the study's results to real-world applications. It is recommended that this be stated in the limitations section. \n<b>Response:<\/b> We agree this is a limitation and we have added this in the manuscript (see below). \u201cFurther, patient and public involvement was not incorporated in the design or conduct of this study. The absence of direct patient engagement may limit the contextual relevance and transferability of the findings to routine clinical practice.  \n<b>Comment 3:<\/b> How the diagnosis of AF is confirmed and the definition and criteria of \u201carrhythmia likely to be AF\u201d can be explained in more detail. \n<b>Response:<\/b> We based our eligibility criteria on self-report by the patient and notes from their clinic book if and when this was available. We have clarified this within the amended manuscript (see below). \u201cAdults (\u226518 years) with a confirmed diagnosis of AF (who were already diagnosed) or an arrhythmia likely to be AF (presented with an irregular heart rhythm on ECG, clinical assessment, or based on symptoms, suggestive of AF) who were visiting any of the included healthcare facilities for AF care and spoke the local language (Tamil) were considered eligible.\u201d  \n<b>Comment 4:<\/b> It was stated that the study was conducted only in the Jaffna region. This may limit the generalizability of the results to other regions across Sri Lanka. It is recommended that this topic be added to the limitations section. \n<b>Response:<\/b> We agree that the regional focus of the study may limit the generalisability of the findings. We have added a statement in the limitations section acknowledging that the findings from this study may not be generalisable to other regions of Sri Lanka. \u201cAlso, the study was limited to participants from the Northern region, which may restrict the generalisability of the results to other areas of Sri Lanka that differ in population characteristics, healthcare access, or AF screening practices.\u201d  \n<b>Comment 5:<\/b> The policy and health system improvements suggested in the discussion section may be more specific. What policy changes are being proposed and how can the feasibility and effectiveness of these recommendations be evaluated? \n<b>Response:<\/b> We appreciate this feedback. We have mentioned various recommendations for future research and potential policy improvements (see below). We are happy to expand on any of these that you feel require further explanation or details. \u201cTo enable early diagnosis of symptomatic and silent AF before a medical crisis and reduce poor prognosis and high healthcare costs, the primary care system must be strengthened. This may require a combination of training for healthcare professionals, reliable access to diagnostic equipment, and increased manpower at primary care level, particularly on how to screen and manage the different types of AF and comorbidities such as coronary artery disease due to the complex relationship between the two conditions. Additionally, patient education on AF (how common it is, how it can be effectively managed and how to conduct self-pulse checking), related symptoms (shortness in breath, excessive tiredness, palpitation) and risk factors (age, obesity, hypertension, diabetes and cardiovascular risks) is important to ensure patients can be aware of how to prevent their risk and seek primary healthcare if any related symptoms occur or if they notice heartbeat irregularities through self-pulse checking.\u201d \u201cNOACs can be an effective alternative to warfarin especially in LMICs where INR facilities are limited, however, the costs of NOACs are hindering their introduction in Sri Lanka and many other LMICs and this must be addressed.\u201d \u201cFurther research should investigate the impacts of offering these delivery options for medications and providing INR tests closer to home on health system and patient cost, clinical outcomes and patient satisfaction in Sri Lanka and other LMICs that likely suffer from the same barriers.\u201d &nbsp; \n<b>Comment 6:<\/b> To increase the evidence and quality of the study, you can cite the reference below; \n<b>Response: <\/b>We agree that it is relevant to our study and it is now cited in the revised manuscript to strengthen the evidence base and enhance the quality of the discussion. K\u0131l\u0131&ccedil; R, G&uuml;zel T, Aktan A, Demir M, et al.: The effect of treatment strategy on long-term follow-up results in patients with nonvalvular atrial fibrillation in Turkey: AFTER-2 subgroup analysis.\n<i>Aging Clin Exp Res<\/i>. 2023;&nbsp;\n<b>35<\/b>&nbsp;(8): 1695-1704","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/3-63\/v3#referee-comment-3512","order":4,"name":"referee-comment-3512","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This project is funded by the National Institute for Health and Care Research (NIHR) under its \u2018Global Health Research Units and Groups\u2019 (Grant Reference Number 17\/63\/121). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":5,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}