Background: Extensive data demonstrate the efficacy of anticoagulants in preventing strokes in patients with non-valvular atrial fibrillation (AF). However, many patients are not prescribed guideline recommended anticoagulant therapy.
Objectives: To identify themes underlying anticoagulant underutilization in patients with AF and compare and contrast prescribing preferences between cardiologists and general practitioners.
Methods: Providers practicing within the University of Utah Health system provided informed consent to be interviewed. A semi-structured interview template was used to guide the 15-minute interviews focusing on provider demographics and anticoagulant prescribing practices for patients with AF. Interviews were transcribed verbatim. Two reviewers independently read the transcripts and labeled passages of text corresponding with key concepts and themes. The number of interviews conducted was determined by saturation, or when major themes were established and no new themes emerged from further interviews.
Results: From the eleven practitioners interviewed, seven practiced in cardiology and four in general practice. The most prominent reasons cited for not prescribing anticoagulation for stroke prevention in AF patients were intracranial bleeds, followed by gastrointestinal bleeds. Other common factors for not prescribing or discontinuing anticoagulants were increased age, thrombocytopenia or chemotherapy, noncompliance, and comorbidities. Patient refusal of anticoagulants was due to a fear of bleeding, medication burden, or a negative reputation with warfarin. Providers had a similar prescribing strategy, including using CHA2DS2-VASc, having a shared decision-making discussion with the patient, and utilizing specialized anticoagulation clinics and pharmacists as resources.
Conclusion: Identifying major reasons directly from providers can be utilized to develop patient education addressing common fears and misconceptions, promote shared decision-making, and provide provider education and resources to achieve appropriate anticoagulant prescribing.Published in