Clinicians’ views and experiences of prescribing oral anticoagulants for stroke prevention in atrial fibrillation: A qualitative meta-synthesis

Abstract

Background Globally, over 33 million people have atrial fibrillation (AF). In eligible patients, oral anticoagulation (OAC) is recommended for stroke risk reduction. Despite recent increases in OAC prescribing, global under-prescription to high-risk AF patients and inappropriate prescription to low-risk patients is leading to unnecessary risk of stroke and haemorrhage. This metasynthesis explored clinicians' beliefs and experiences regarding OAC prescription to AF patients, highlighting barriers to stroke prevention and informing future clinician-focused interventions. Methods and results A qualitative meta-synthesis exploring clinicians' views and experiences of prescribing OACs for stroke prevention in AF patients. Databases including MEDLINE, EMBASE, Psy-chINFO and CINAHL were searched to June 2018, with a further Medline search to February 2020. Thematic synthesis was performed with data coding, descriptive theme categorisation and generation of analytical themes. From 3499 records, 101 full text papers were screened, with 13 eligible studies identified. Four analytical themes were found to affect clinicians' prescribing: (i) 'Clinicians' intellectual and emotional responses to the evidence'; (ii) 'Prescribing in primary and secondary care'; (iii) 'Clinicians' views of how patients' characteristics and opinions influence prescribing'; and (iv) 'Clinicians' views on their interactions with patients'. Conclusions This review highlights focal points for future clinician-focused interventions to improve guideline-adherent OAC prescription in AF patients. Interventions should aim to improve

Atrial fibrillation in low- and middle-income countries: a narrative review

“…This is potentialized by the possibility of being held accountable for harmful effects of the drug. 118 Some strategies must be considered to increase adequate OAC use in patients with AF, including educational interventions, providing adequate support for OAC management with warfarin and higher availability and access to NOAC. Future studies using both quantitative and qualitative methodologies are needed to further specify the reasons for the incorrect use of antiplatelets for stroke prevention, disclosing opportunities for effective interventions.…”

The impact of atrial fibrillation and long-term oral anticoagulant use on all-cause and cardiovascular mortality: A 12-year evaluation of the prospective Brazilian Study of Stroke Mortality and Morbidity

“…As previously described in the literature, the underuse of OAC in individuals who would primarily benefit from this medication may occur for many reasons. 11,[28][29][30] Besides formal contraindications for the OAC therapy, it has been reported advanced age with higher risk of bleeding, more severe comorbidities with low predicted overall survival, low patient´s compliance, insufficient structure in the public health facilities to perform regular international normalized ratio monitoring, doctor´s concern about the low patient´s comprehension of AF and the risk of complications as bleeding as important barriers to the use of OAC , including for the secondary prevention of stroke. 11,[28][29][30] In the public health context, it is important to know the inter-regional differences to better understand the occurrence of chronic and disabling conditions.…”

Patient Perspectives on Factors Affecting Direct Oral Anticoagulant Use for Stroke Prevention in Atrial Fibrillation

“…Consequently, prescribing decisions were seen to be influenced by prescriber preferences, which could be a barrier to DOAC use if warfarin was favoured. 41 Some suggested that longer consultations were needed but noted it would not be feasible due to a shortage of clinicians in the healthcare service. Required additional time was also noted to add extra spending in already perceived cost-conscious healthcare system.…”