Exploring patient–provider decision-making for use of anticoagulation for stroke prevention in atrial fibrillation: Results of the INFORM-AF study

Abstract

Background: Atrial fibrillation is associated with stroke, yet approximately 50% of patients are not treated with guideline-directed oral anticoagulants (OACs). Aims: Given that the etiology of this gap in care is not well understood, we explored decision-making by patients and physicians regarding OAC use for stroke prevention in atrial fibrillation. Methods and results: We conducted a descriptive qualitative study among providers (N=28) and their patients with atrial fibrillation for whom OACs were indicated (N=25). We used purposive sampling across three outpatient settings in which atrial fibrillation patients are commonly managed: primary care (n=14), geriatrics (n=10), and cardiology (n=4). Eligible patients were stratified by those prescribed OAC (n=13) and not prescribed OAC (n=12). Semi-structured, in-depth interviews assessed decision-making regarding risk and OAC use. Classical content analysis was used to code narratives and identify themes. Results among patients consisted of the overarching theme of trust in provider recommendations. Sub-themes included: awareness of increased risk of stroke with atrial fibrillation; willingness to accept medications recommended by their physician; and low demand for explanatory decision aids. Among physicians, the overarching theme was decisional conflict regarding the balance between stroke and bleeding risk, and the optimal medication to prescribe. Subthemes included: absence of decision aids for communication; and misperceptions around the assessment and management of stroke risk with atrial fibrillation. Conclusions: Patient involvement in decision-making around OAC use did not occur in this study of patients with atrial fibrillation. Improved access to decision aids may increase patient engagement in the decision-making process of OAC use for stroke prevention.

Factors Associated With Patient Engagement in Shared Decision-Making for Stroke Prevention Among Older Adults with Atrial Fibrillation

“…None of the participants were involved in the decision-making process regarding OAC use. (34) In contrast to the results of these studies, the majority (61%) of participants in our study reported that they had engaged in the decision regarding OAC therapy initiation. Differences between these studies and ours could be explained by differences in sample size, sociodemographic and clinical characteristics of the respective study populations, and the approach used to assess patient engagement regarding OAC therapy.…”

Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence

“…[20,35,54,58,70,76,80,85] Reports from qualitative studies indicate that prescribers use formal stroke risk assessment tools but few use formal bleeding assessment tools. [79,86] Instead, prescribers rely on informal and subjective bleeding risk assessments.…”

“…These include comorbidities, history of falls and bleeding, and age. [79,86,87] However, formal bleeding assessment tools such as HAS-BLED already consider comorbidities, prior history of bleeding, and age. [88] There may be a need to reassure physicians using findings such as that from a European registry-based study that indicated that the risk of stroke increases more than the risk of bleeding with advancing age, [89] and the fact that the risk of falls should not be the sole reason for withholding OACs.…”

Grounded theory: what makes a grounded theory study?

“…It gives insights in why particular phenomena occur or what underlying mechanisms are 1 . Over the past two years, the European Journal of Cardiovascular Nursing published 20 qualitative studies [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] . These studies used methods such as content analysis, ethnography, or phenomenology.…”