Practices, beliefs, and attitudes of clinicians in prescribing direct oral anticoagulants for obese adults with atrial fibrillation

Abstract

Background: Atrial fibrillation (AF) and obesity affect over 60 and 650 million people, respectively. Aim: To explore clinician practices, beliefs, and attitudes towards the use of direct oral anticoagulants (DOACs) in obese individuals with AF.Methods: An exploratory qualitative interview study of clinicians, with expertise in DOAC use in individuals with AF. Data was analysed in NVIVO using thematic analysis.Results: Fifteen clinicians including cardiologists (n=5), hospital pharmacists (n=5), general practitioners (n=2), a haematologist, a neurologist and a clinical pharmacologist participated. Interviews lasted for an average of 31 ± 9 minutes. Key themes revealed were: (1) Health system factors in decision-making: Disparities between rural and metropolitan geographic areas, with regards to access, availability of health services, and time limitations for in-patient decision making, were described. (2) Condition related factors in decision-making: Clinicians questioned the significance of obesity as part of decision-making due to the practical limitations of dose modification, and the rarity of the extreme obese cohort.(3) Decision-making in the context of uncertainty: Clinicians reported limited availability, reliability and awareness of primary evidence including limited guidance from clinical guidelines for DOAC use in obesity. Conclusion: The interplay between obesity and AF, in the context of a challenging healthcare environment, impacts DOAC prescription decision-making. This study highlights limitations in availability, reliability, and awareness of evidence. The intrinsic complexity of the obese cohort coupled with limited guidance from clinical practice guidelines, equates to an urgent need for contemporary research to improve the quality of evidence to guide informed shared decision-making.