National Physician Survey for Nonvalvular Atrial Fibrillation (NVAF) Anticoagulation Comparing Knowledge, Attitudes and Practice of Cardiologist to PCPs

Abstract

Introduction: NVAF is estimated to affect between 6.4 and 7.4 million Americans in 2018, and increases the risk of stroke 5-fold. To mitigate this risk, guidelines recommend anticoagulating AF patients unless their stroke risk is very low. Despite these recommendations, 30.0-60.0% of NVAF patients do not receive indicated anticoagulation. To better understand why this may be, we surveyed PCPs and cardiologists nationwide on their attitudes, knowledge and practices toward managing NVAF with warfarin and direct-acting oral anticoagulants (DOACs). Methods: We surveyed 1,000 PCPs and 500 cardiologists selected randomly from a master list of the American Medical Association, using a paper based, anonymous, self-administered, mailed scannable survey. The survey contained questions on key demographics and data concerning attitudes, knowledge and practices related to prescribing DOACs. The surveys went out in the fall/winter of 2017-8 with a $10 incentive gift card. Survey responses were scanned into an Excel database and analyzed using SAS 9.3 (Cary, NC) for descriptive and inferential statistics. Results: Two hundred and forty-nine providers (167 PCPs, 82 cardiologists) participated in the study with a response rate of 18.8% (249/1320). Respondent mean years ±SD of experience since completing residency was 23.2 ± 13.8. Relative to cardiologists, less PCPs use CHADsVASC (36.8% vs. 74.4%) (p < 0.0001); more have never used HAS-BLED, HEMORR2HAGES, or ATRIA (38.5% vs. 9.8%) (p < .0001); more felt that their lack of knowledge/experience with DOACs was a barrier to prescribing the agents (p = 0.005); and more reported that they could use additional education on DOACs (87.0% vs. 47.0%) (p < 0.0001). Overall, cardiologists were more concerned about ischemic stroke outcomes, while PCPs were more concerned with GI bleeding. Cardiologists also felt that clinical trial data were most helpful in choosing the most appropriate DOAC for their patients, while PCPs felt that Real World Data was most useful. Conclusions: Cardiologists were more concerned with ischemic stroke while anticoagulating patients and utilized screening instruments like CHADsVASC in a majority of their patients. PCPs were concerned with GI bleeds when anticoagulating but nearly 40.0% utilized no screening tools to assess bleeding risk. Our findings show that future education about DOACs would be warranted especially with PCPs.

Anticoagulation Stewardship to Bridge the Implementation Gap in Perioperative Anticoagulation Management

“… 19 The risk aversion is not uniform among providers. 14 Some specialists or even patients may attribute much higher value to stroke prevention, whereas the surgeon, PCP, and anesthesiologist may place a higher value on avoiding bleeding complications. The large number of specialties with interest in perioperative anticoagulation underscores the relevance of this topic, yet it also highlights the diversity of opinion on the topic.…”

“… 11 Unfortunately, there still remain gaps in guideline implementation in health care, 12 including in the application of guidelines for patients who need perioperative anticoagulation care. 13 Thus, between disciplines there is frequent heterogeneity on the degree of utilization of thrombotic and bleeding risk assessment, 13 14 utilization of longer than necessary anticoagulation interruption remains common, and use of bridging in scenarios where it is not recommended remains prevalent. 15 A similar implementation gap in the field of antimicrobial management led to the development of multidisciplinary teams known as antimicrobial stewardship programs.…”

Clinical Impact of Switching or Continuation of Apixaban or Rivaroxaban among Patients with Non-Valvular Atrial Fibrillation

“…Non-valvular AF (NVAF)-AF without rheumatic valvular disease is the most common type of AF and a strong independent predictor of stroke [6,7]. Vitamin K antagonists, such as warfarin, were the standard therapy for stroke prevention in NVAF patients until recently.…”

Knowledge, attitude, and practice of atrial fibrillation in high altitude areas

“…In the realm of AF research, understanding the knowledge, attitudes, and associated practices of the general population in highaltitude regions regarding AF can facilitate the development of tailored health education and intervention strategies, aimed at enhancing early detection, management, and prevention of AF. However, despite a few existing studies exploring KAP in the context of AF, these have predominantly centered around healthcare professionals and patients, with a notable absence of geographically tailored investigations (12)(13)(14). Thus, there remains a noticeable scarcity of research that delves into the KAP dimensions of AF among individuals residing in highaltitude regions, emphasizing the significant avenue for further exploration in this realm.…”