Exploring barriers to optimal anticoagulation for atrial fibrillation: interviews with clinicians

Decker, Carole; Garavalia, Linda; Garavalia, Brian; Simon, Teresa A.; M, Loeb; Spertus, John A.; Daniel, William C.

doi:10.2147/jmdh.s33045

Cited by 22 publications

(29 citation statements)

References 19 publications

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“…1). A total of nine articles corresponding to eight studies were included [28–36]. We also included a still unpublished study conducted by our group [37].…”

Section: Resultsmentioning

confidence: 99%

“…We also included a still unpublished study conducted by our group [37]. Two of the nine studies collected data both from patients and physicians [29, 37], four collected data from patients only [28, 32, 33, 35], and three from physicians only [31, 34, 36]. In four studies, the quality assessed was excellent [29–31, 35, 37] and in five was moderate [28, 32–34, 36].…”

Section: Resultsmentioning

confidence: 99%

“…Grounded theory.excellent-Patients2112 men/9 womenBajorek et al 2007, 2009 [29, 30]AustraliaQualitative: PhenomenologyFocus groupsThematic analysisexcellent-Physicians2012 men/8 women[Geriatricians, Cardiologists, General medicine (consultants or registrars),General Practice]-Nurses-Pharmacist(6 Geriatric6 Cardiologists/General Medicine8 General Practice)-Patients14-CarersSolà et al 2009 [37]SpainMixed: quantitative and qualitativeFocus groupsContent analysisexcellentPhysicians[General Practice, Cardiologists and Internal Medicine]23 (15 General Practice, 5 Cardiologist, 3 Internal Medicine)12 men/11 womenPatients2315 men/8 womenLipman et al 2004 [29]United KingdomQualitativeSemi-structured Interview.Framework methodexcellent-Physicians[General Practices with an active interest in research or evidence-based medicine]119 men/2 womenAnderson et al 2006 [34]United KingdomMixed: quantitative and qualitativeQuestionnaire and semi-structured interviewInterpretative. Grounded theory.moderate-Physicians14[Cardiologists, Geriatric or general medicine (consultants or Specialist Registrars)]5 Cardiologists,9 Geriatric or General medicineDecker et al 2012 [36]United StatesQualitativeSemi-structured Interview.Content analysismoderate-Physicians[Cardiologists and internal medicine)-Nurses practioner23(18 Cardiologist5 Internal Medicine) …”

Section: Methodsmentioning

confidence: 99%

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Patients’ and physicians’ perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review

et al. 2017

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BackgroundOral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients’ and physicians’ perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients’ and physicians’ perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse.MethodsWe included studies that used qualitative or mixed methods and focused on patients’ and/or physicians’ perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach.ResultsWe included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding.ConclusionPhysicians’ and patients’ perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0574-0) contains supplementary material, which is available to authorized users.

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“…1). A total of nine articles corresponding to eight studies were included [28–36]. We also included a still unpublished study conducted by our group [37].…”

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

Patients’ and physicians’ perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review

et al. 2017

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“…6,7 Surveys exploring this gap have identified the pivotal physician-related factor to be an insufficiently balanced evaluation of the risk versus benefit of oral anticoagulant therapy. 8 Patients differ in their underlying risk for ischemic stroke and their risk of major bleeding from anticoagulants. Studies in community settings have demonstrated that inappropriate treatment is common and there is wide variation in adherence to practice guidelines.…”

mentioning

confidence: 99%

Integrating Real-Time Clinical Information to Provide Estimates of Net Clinical Benefit of Antithrombotic Therapy for Patients With Atrial Fibrillation

Eckman

Wise

Speer

et al. 2014

Circ: Cardiovascular Quality and Outcomes

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Background-Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS 2 or the CHA 2 DS 2 VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy. Methods and Results-This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatment and treatment recommended by an Atrial Fibrillation Decision Support Tool. Current treatment was discordant from treatment recommended by the Atrial Fibrillation Decision Support Tool in 931 patients. A clinically significant gain in quality-adjusted life expectancy (defined as ≥0.1 qualityadjusted life-years) was projected in 832 patients. Subgroups were examined. For example, oral anticoagulant therapy was recommended for 188 who currently were receiving no antithrombotic therapy. For the entire cohort, a total of 736 quality-adjusted life-years could be gained were treatment changed to that recommended by the Atrial Fibrillation Decision Support Tool. Conclusions-Use of a decision support tool that integrates patient-specific stroke and bleeding risk could result in significant gains in quality-adjusted life expectancy for a primary care population of patients with atrial fibrillation.(Circ Cardiovasc Qual Outcomes. 2014;7:680-686.)

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“…This study concurrently explored the perspectives of four groups of health professionals on decision-making around antithrombotic therapy in patients with AF, particularly concerning warfarin and NOACs as treatment options [24][25][26][27]. At the time of the study, in the decision-making around antithrombotic therapy, assessment of bleeding risk and measures of anticoagulant control (e.g.…”

Section: Discussionmentioning

confidence: 99%

Decision-making around antithrombotics for stroke prevention in atrial fibrillation: the health professionals’ views

Wang

Bajorek

2016

Int J Clin Pharm

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Background For stroke prevention in patients with atrial fibrillation (AF), the decision-making around antithrombotic therapy has been complicated by older age, multiple comorbidities, polypharmacy and the different pharmacological properties of warfarin and the nonvitamin K antagonist oral anticoagulants (NOACs). The complexity of decision-making has been associated with a reluctance by health professionals to use antithrombotic therapy, leading to poor clinical outcomes. In order to improve stroke prevention in patients with AF, the contemporary perspectives of health professionals on the decision-making around antithrombotic therapy needs exploration. Objective To elicit emerging themes describing health professionals' perspectives on the decision-making around antithrombotic therapy for stroke prevention in patients with AF. Setting Sydney metropolitan area of New South Wales, Australia. Method A qualitative study based on face-to-face interviews was conducted from August to October 2014. Seven pharmacists, seven specialists, six general practitioners and six nurses practising in the Sydney metropolitan area and managing antithrombotic therapy for AF were interviewed until theme saturation was achieved in each subgroup. Interview transcripts were analysed using manual inductive coding. Main outcome measure Emerging themes describing health professionals' perspectives on the decision-making around antithrombotic therapy for stroke prevention in patients with AF. Results Three overarching themes emerged. (1) Comprehensive assessment is necessary for decision-making but is not always implemented. Health professionals mostly focused on stroke risk assessment, not on the bleeding risk and medication safety issues. (2) Health professionals from different disciplines have different preferences for antithrombotic therapies. Although the majority of health professionals considered warfarin as the first-line therapy, NOACs were preferred by neurologists and haematologists. (3) Health professionals focused on different aspects of the decision making process: GPs and specialists were concerned about the appropriate prescription of antithrombotics, while pharmacists and nurses focused on daily medication management by patients. Conclusion The decision-making process appears to be partially preference based rather than systematic, and health professionals from various disciplines focus on different parts of the decision-making process.

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Exploring barriers to optimal anticoagulation for atrial fibrillation: interviews with clinicians

Cited by 22 publications

References 19 publications

Patients’ and physicians’ perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review

Patients’ and physicians’ perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review

Integrating Real-Time Clinical Information to Provide Estimates of Net Clinical Benefit of Antithrombotic Therapy for Patients With Atrial Fibrillation

Decision-making around antithrombotics for stroke prevention in atrial fibrillation: the health professionals’ views

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