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BMC Primary Care
Published in: BMC Primary Care 1/2017

Open Access 01-12-2017 | Research article

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

Authors: Gemma Mas Dalmau, Elisenda Sant Arderiu, María Belén Enfedaque Montes, Ivan Solà, Sandra Pequeño Saco, Pablo Alonso Coello

Published in: BMC Primary Care | Issue 1/2017

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Abstract

Background

Oral 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.

Methods

We 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.

Results

We 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.

Conclusion

Physicians’ 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.
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Literature
1.
Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, Gillum RF, Kim YH, McAnulty Jr JH, Zheng ZJ, Forouzanfar MH, Naghavi M, Mensah GA, Ezzati M, Murray CJ. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837–47.CrossRefPubMed
2.
Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112(8):1142–7.CrossRefPubMed
3.
Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001;285(18):2370–5.CrossRefPubMed
4.
Cairns JA, Connolly SJ. Nonrheumatic atrial fibrillation. Risk of stroke and role of antithrombotic therapy. Circulation. 1991;84(2):469–81. Review.CrossRefPubMed
5.
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med. 1987;147(9):1561–4.CrossRefPubMed
6.
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M,Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P; Authors/Task Force Members; Document Reviewers. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)Developed with thespecial contribution of the European Heart Rhythm Association (EHRA) of the ESCEndorsed by the European Stroke Organisation (ESO). Eur Heart J. 2016 Aug 27.
7.
Tsai LM, Chen JH, Tsao CJ. Relation of left atrial spontaneous echo contrast with prethrombotic state in atrial fibrillation associated with systemic hypertension, idiopathic dilated cardiomyopathy, or no identifiable cause (lone). Am J Cardiol. 1998;81(10):1249–52.CrossRefPubMed
8.
Boysen G, Connolly S, Esekowitz M, Hart R, James K, Kistler P, Kronmal R, Petersen P, Singer D. Risk Factors for Stroke and Efficacy of Antithrombotic Therapy in Atrial Fibrillation Analysis of Pooled Data From Five Randomized Controlled Trials. Arch Intern Med. 1994;154(13):1449–57.
9.
Stewart S, Murphy NF, Walker A, McGuire A, McMurray JJ. Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK. Heart. 2004;90(3):286–92. Erratum in: Heart. 2007 Nov;93(11):1472. Murphy, N [corrected to Murphy, N F].CrossRefPubMedPubMedCentral
10.
Casciano JP, Dotiwala ZJ, Martin BC, Kwong WJ. The costs of warfarin underuse and nonadherence in patients with atrial fibrillation: a commercial insurer perspective. J Manag Care Pharm. 2013;19(4):302–16.PubMed
11.
Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146(12):857–67.CrossRefPubMed
12.
January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland Jr JC, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW, ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130(23):2071–104.CrossRefPubMed
13.
Kakkar AK, Mueller I, Bassand JP, Fitzmaurice DA, Goldhaber SZ, Goto S, Haas S, Hacke W, Lip GY, Mantovani LG, Turpie AG, van Eickels M, Misselwitz F, Rushton-Smith S, Kayani G, Wilkinson P, Verheugt FW, GARFIELD Registry Investigators. Risk p, 14rofiles and antithrombotic treatment of patients newly diagnosed with atrial fibrillation at risk of stroke: perspectives from the international, observational, prospective GARFIELD registry. PLoS One. 2013;8(5):e63479.CrossRefPubMedPubMedCentral
14.
Tulner LR, Van Campen JP, Kuper IM, Gijsen GJ, Koks CH, Mac Gillavry MR, van Tinteren H, Beijnen JH, Brandjes DP. Reasons for undertreatment with oral anticoagulants in frail geriatric outpatients with atrial fibrillation: a prospective, descriptive study. Drugs Aging. 2010;27(1):39–50.CrossRefPubMed
15.
Bungard T, Ghali W, Teo K, McAlister F, Tsuyuki R. Why do patients with atrial fibrillation not receive warfarin? Arch Int Med. 2000;160:41–6.CrossRef
16.
Sudlow M, Thomson R, Thwaites B, Rodgers H, Kenny RA. Prevalence of atrial fibrillation and eligibility for anticoagulants in the community. Lancet. 1998;352:116771.CrossRef
17.
Lip GY, Golding DJ, Nazir M, Beevers DG, Child DL, Fletcher RI. A survey of atrial fibrillation in general practice: the West Birmingham Atrial Fibrillation Project. Br J Gen Pract. 1997;47(418):285–9.PubMedPubMedCentral
18.
Singer DE, Albers GW, Dalen JE, Fang MC, Go AS, Halperin JL, Lip GY, Manning WJ, American College of Chest Physicians. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):546S–92S.CrossRefPubMed
19.
Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, Lewis BS, Parkhomenko A, Yamashita T, Antman EM. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955–62. doi:10.​1016/​S0140-6736(13)62343-0. Epub 2013 Dec 4.CrossRefPubMed
20.
Wadhera RK, Russell CE, Piazza G. Cardiology patient page. Warfarin versus novel oral anticoagulants: how to choose? Circulation. 2014;130(22):e191–3.CrossRefPubMed
21.
22.
Larsen TB, Skjøth F, Nielsen PB, Kjældgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.CrossRefPubMedPubMedCentral
23.
Wilke T, Groth A, Pfannkuche M, Harks O, Fuchs A, Maywald U, Krabbe B. Real life anticoagulation treatment of patients with atrial fibrillation in Germany: extent and causes of anticoagulant under-use. J Thromb Thrombolysis. 2015;40(1):97–107.CrossRefPubMed
24.
Wilke T, Groth A, Mueller S, Pfannkuche M, Verheyen F, Linder R, Maywald U, Kohlmann T, Feng YS, Breithardt G, Bauersachs R. Oral anticoagulation use by patients with atrial fibrillation in Germany. Adherence to guidelines, causes of anticoagulation under-use and its clinical outcomes, based on claims-data of 183,448 patients. Thromb Haemost. 2012;107(6):1053–65.CrossRefPubMed
25.
Borg Xuereb C, Shaw RL, Lane DA. Patients’ and health professionals’ views and experiences of atrial fibrillation and oral-anticoagulant therapy: a qualitative meta-synthesis. Patient Educ Couns. 2012;88(2):330–7.CrossRefPubMed
26.
27.
28.
Howitt A, Armstrong D. Implementing evidence based medicine in general practice: audit and qualitative study of antithrombotic treatment for atrial fibrillation. Br Med J. 1999;318:1324–7.CrossRef
29.
Bajorek BV, Ogle SJ, Duguid MJ, Shenfield GM, Krass I. Management of warfarin in atrial fibrillation: views of health professionals, older patients and their carers. Med J Aust. 2007;186(4):175–80.PubMed
30.
Bajorek BV, Ogle SJ, Duguid MJ, Shenfield GM, Krass I. Balancing risk versus benefit: the elderly patient’s perspective on warfarin therapy. Pharm Pract. 2009;7(2):113–23.
31.
Lipman T, Murtagh MJ, Thomson R. How research-conscious GPs make decisions about anticoagulation in patients with atrial fibrillation: a qualitative study. Fam Pract. 2004;21(3):290–8.CrossRefPubMed
32.
Fuller R, Dudley N, Blacktop J. Avoidance hierarchies and preferences for anticoagulation-semi-qualitative analysis of older patients’ views about stroke prevention and the use of warfarin. Age Ageing. 2004;33(6):608–11.CrossRefPubMed
33.
Wilt D, Murray M, Donatti C. Patient perspectives on taking vitamin K antagonists: a qualitative study in the UK, USA and Spain. Expert Rev Pharmacoecon Outcomes Res. 2009;9(5):467–474(8).CrossRef
34.
Anderson N, Fuller R, Dudley N. ‘Rules of Thumb’ or reflective practice? Understanding senior physicians’ decision-making about anti-thrombotic usage in atrial fibrillation. Qjm an Int J Med. 2007;100(5):263–9.CrossRef
35.
Dantas GC, Thompson BV, Manson JA, Tracy CS, Tracy US, Upshur REG. Patients’ perspectives on taking warfarin: qualitative study in family Practice. BMC Fam Pract. 2004;5:15.CrossRefPubMedPubMedCentral
36.
Decker C, Garavalia L, Garavalia B, et al. Exploring barriers to optimal anticoagulation for atrial fibrillation: interviews with clinicians. J Multidiscip Healthc. 2012;5:129–35.CrossRefPubMedPubMedCentral
37.
Alonso-Coello P, Montori VM, Solà I, Schünemann HJ, Devereaux P, Charles C, Roura M, Díaz MG, Souto JC, Alonso R, Oliver S, Ruiz R, Coll-Vinent B, Diez AI, Gich I, Guyatt G. Values and preferences in oral anticoagulation in patients with atrial fibrillation, physicians' and patients' perspectives: protocol for a two-phase study. BMC Health Serv Res. 2008;8:221. doi:10.​1186/​1472-6963-8-221.
38.
Ogilvie IM, Newton N, Welner SA, Cowell W, Lip GY. Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med. 2010;123(7):638–645.e4.CrossRefPubMed
39.
Algoritsas T, Heen AF, Brandt L, Alonso-Coello P, Kristiansen A, Akl EA, Neumann I, Tikkinen KA, Weijden T, Elwyn G, Montori VM, Guyatt GH, Vandvik PO. Decision aids that really promote shared decision making: the pace quickens. BMJ. 2015;350:g7624.CrossRef
40.
Hernández Madrid A, Potpara TS, Dagres N, Chen J, Larsen TB, Estner H, Todd D, Bongiorni MG, Sciaraffia E, Proclemer A, Cheggour S, Amara W, Blomstrom-Lundqvist C. Differences in attitude, education, and knowledge about oral anticoagulation therapy among patients with atrial fibrillation in Europe: result of a self-assessment patient survey conducted by the European Heart Rhythm Association. Europace. 2016;18(3):463–7.CrossRefPubMed
41.
Wilke T, Bauer S, Mueller S, Kohlmann T, Bauersachs R. Patient Preferences for Oral Anticoagulation Therapy in Atrial Fibrillation: A Systematic Literature Review. Patient. 2016 Jul 26.
42.
Carlsen B, Norheim OF. “What lies beneath it all?”--an interview study of GPs’ attitudes to the use of guidelines. BMC Health Serv Res. 2008;8:218.CrossRefPubMedPubMedCentral
Metadata
Title
Patients’ and physicians’ perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review
Authors
Gemma Mas Dalmau
Elisenda Sant Arderiu
María Belén Enfedaque Montes
Ivan Solà
Sandra Pequeño Saco
Pablo Alonso Coello
Publication date
01-12-2017
Publisher
BioMed Central
Published in
BMC Primary Care / Issue 1/2017
Electronic ISSN: 2731-4553
DOI
https://doi.org/10.1186/s12875-016-0574-0

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