A systematic review of clinicians' views and experiences of direct‐acting oral anticoagulants in the management of nonvalvular atrial fibrillation

Generalova, Daria; Cunningham, Scott; Leslie, Stephen J; Rushworth, Gordon F.; McIver, Laura; Stewart, Derek

doi:10.1111/bcp.13739

Cited by 20 publications

(28 citation statements)

References 31 publications

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“…This study adds to the limited evidence base of prescribers' experiences of DOACs, and is timely given that DOACs are now recommended first line for those with non-valvular AF. [1][2][3][4][5][6] However, given that data were collected in one remote and rural area of Scotland, the results may lack generalisability and transferability to other settings. Furthermore, the data were collected using a crosssectional survey methodology rather than through a qualitative approach (e.g.…”

Section: Discussionmentioning

confidence: 99%

“…The one systematic review, published in 2018, identified only ten studies, nine surveys and one qualitative study. 6 Survey participant numbers ranged from 38 to 450 (total of 1,246) with response rates of 9.0-35.9%, with outcome measures of oral anticoagulant of choice, factors influencing prescribing, and experiences. [7][8][9][10][11][12][13] While the one qualitative study provided rich data of physicians' decision-making processes regarding DOACs, the sample size of seven limits the likely transferability of findings.…”

Section: -4mentioning

confidence: 99%

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Prescribers’ perceptions of benefits and limitations of direct acting oral anticoagulants in non-valvular atrial fibrillation

Generalova¹,

Cunningham²,

Leslie³

et al. 2020

Pharm Pract (Granada)

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Background: There is an acknowledged lack of robust and rigorous research focusing on the perspectives of those prescribing direct acting oral anticoagulants (DOACs) for non-valvular atrial fibrillation (AF). Objective: The objective was to describe prescribers’ experiences of using DOACs in the management of non-valvular AF, including perceptions of benefits and limitations. Methods: A cross-sectional survey of prescribers in a remote and rural area of Scotland. Among other items, the questionnaire invited free-text description of positive and negative experiences of DOACs, and benefits and limitations. Responses were independently analysed by two researchers using a summative content analysis approach. This involved counting and comparison, via keywords and content, followed by interpretation and coding of the underlying context into themes. Results: One hundred and fifty-four responses were received, 120 (77.9%) from physicians, 18 (11.7%) from nurse prescribers and 10 (6.4%) from pharmacist prescribers (6 unidentified professions). Not having to monitor INR was the most cited benefit, particularly for prescribers and patients in remote and rural settings, followed by potentially improved patient adherence. These benefits were reflected in respondents’ descriptions of positive experiences and patient feedback. The main limitations were the lack of reversal agents, cost and inability to monitor anticoagulation status. Many described their experiences of adverse effects of DOACs including fatal and non-fatal bleeding, and upper gastrointestinal disturbances. Conclusions: While prescribers have positive experiences and perceive benefits of DOACs, issues such as adverse effects and inability to monitor anticoagulation status merit further monitoring and investigation. These issues are particularly relevant given the trajectory of increased prescribing of DOACs.

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Section: Discussionmentioning

confidence: 99%

Section: -4mentioning

confidence: 99%

Prescribers’ perceptions of benefits and limitations of direct acting oral anticoagulants in non-valvular atrial fibrillation

Generalova¹,

Cunningham²,

Leslie³

et al. 2020

Pharm Pract (Granada)

Self Cite

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“…In the case of Ireland, a survey of general practitioners (GP) identified lack of integration between primary and secondary care and knowledge gaps among prescribers with regard to prescribing decision-making and managing patients with AF prescribed NOACs (in the absence of INR monitoring requirements). [20][21][22] While there is an abundance of evidence from systematic trials and meta-analysis on the efficacy and effectiveness of safety of oral anticoagulation therapy in the management of AF, there is limited qualitative evidence capturing both the clinicians 25 and patients' views 6 simultaneously. Generating qualitative evidence provides the opportunity to add depth and ensuring focus on patient-level care.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

“…While there is an abundance of evidence from systematic trials and meta-analysis on the efficacy and effectiveness of safety of oral anticoagulation therapy in the management of AF, there is limited qualitative evidence capturing both the clinicians 25 and patients’ views 6 simultaneously. Generating qualitative evidence provides the opportunity to add depth and ensuring focus on patient-level care.…”

Section: Introductionmentioning

confidence: 99%

World Café approach: exploring the future vision of oral anticoagulants for patients with atrial fibrillation (AF) in Ireland

et al. 2020

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ObjectivesTo explore and reflect on the current anticoagulation therapy offered to patients with atrial fibrillation (AF), potential challenges and the future vision for oral anticoagulants for patients with AF and healthcare professionals in Ireland.DesignA multistakeholder focus group using a World Café approach.ParticipantsNine participants from academic, clinical and health backgrounds attended the focus group together with a facilitator.ResultsEnhanced patient empowerment; more effective use of technology and developing system-based medical care pathways would provide improved supports for AF management. The challenges in providing these include cost and access issues, the doctor–patient relationship and the provision of education. While consensus for developing evidence-based pathways to maximise efficiency and effectiveness of AF treatment was evident, it would require a shared vision between stakeholders of integrated care. The benefits of embracing technological advances for clinicians and patients were evident; however, clinicians indicate this can increase pressure on already stretched resources; coupled with institutional barriers (including scarce resources) arising from the complex nature of anticoagulation for patients with AF, which emerged strongly. Including the unpredictable nature of warfarin, hidden costs associated with monitoring, adverse clinical effects, different patient cohorts (including those prescribed anticoagulant for the first time vs those switching from warfarin to a new oral anticoagulant (NOAC)), non-adherence concerns and undesirable impacts on patients’ daily lives.ConclusionsWhile anticoagulation therapy for patients with AF using NOACs has been widely adopted and is diffusing into routine practice, significant operationalisation issues and barriers to effective treatment/management persist. The reflections reported in this study are a catalyst for future discussion and research.

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“…They may also either decline or default follow up by specialists. PCPs' perspectives speci cally on NOACs become critical in the management of these patients with AF but little is known of their prescribing behavior of this class of medications (16).…”

Section: Introductionmentioning

confidence: 99%

Factors Influencing Primary Care Physicians’ Prescribing Behavior of Anticoagulant Therapy for the Management of Patients With Non-valvular Atrial Fibrillation in the Community: a Qualitative Research Study

Chaterji

Lian

Lee

et al. 2021

Preprint

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Background: Oral anticoagulant therapy use in patients with atrial fibrillation (AF) remains suboptimal despite the availability of both warfarin and non-vitamin K antagonist oral anticoagulants (NOACs). Primary care physicians’ (PCP) decision-making to initiate and select appropriate anticoagulant medication is pivotal in reducing complications among patients with AF.Aim: This study explored the factors influencing PCPs’ decision-making in anticoagulant initiation and adjustment for patients with non-valvular AF. Design of study: Qualitative research based on the theoretical framework of the Generalist Wheel of Knowledge, Understanding and Inquiry. Method: In-depth interviews or focus group discussions were conducted with 27 PCPs in general practice in urban Singapore. The audio-recordings were transcribed, audited and coded to identify themes, which are framed according to the “clinician”, “patient”, “medical condition and treatment” and “healthcare system and policy” domains.Results: Personal training and experience with anticoagulant therapy; understanding patient risk-stratification; AF detection during clinical practice; medication cost; clinical support services for anticoagulation monitoring and constraints in existing care model influenced PCPs in their anticoagulant prescription. PCPs preferred to seek guidance from cardiologists in managing patients with newly diagnosed AF and attempted to engage their patients in decision-making regarding anticoagulant therapy. They perceived sub-specialized primary care clinics focusing on AF co-management with cardiologists as an ideal setting for initiation and maintenance of anticoagulant therapy.Conclusion: PCPs’ decisions on anticoagulant therapy is influenced by personal attributes, patients, clinical presentations, anticoagulant properties and healthcare system. Their proposed care model to address the barriers awaits feasibility and acceptance assessment in future research.

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A systematic review of clinicians' views and experiences of direct‐acting oral anticoagulants in the management of nonvalvular atrial fibrillation

Abstract: There is a limited evidence base of clinicians' perspectives of DOACs, necessitating further research, particularly given the trajectory of increased use worldwide.

Cited by 20 publications

References 31 publications

Prescribers’ perceptions of benefits and limitations of direct acting oral anticoagulants in non-valvular atrial fibrillation

Prescribers’ perceptions of benefits and limitations of direct acting oral anticoagulants in non-valvular atrial fibrillation

World Café approach: exploring the future vision of oral anticoagulants for patients with atrial fibrillation (AF) in Ireland

Factors Influencing Primary Care Physicians’ Prescribing Behavior of Anticoagulant Therapy for the Management of Patients With Non-valvular Atrial Fibrillation in the Community: a Qualitative Research Study

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