Stroke Prophylaxis for Atrial Fibrillation? To Prescribe or Not to Prescribe—A Qualitative Study on the Decisionmaking Process of Emergency Department Providers - 25/11/19
, Tahroma Alligood, MPH a, b, Cassandra Robinson, MS, LPN b, Josephine Livingston, MD, MBBS a, Benjamin C. Sun, MD, MPP cAbstract |
Study objective |
Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation.
Methods |
From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians’ attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians.
Results |
Three broad domains emerged from our analyses. (1) Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2) Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3) Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors.
Conclusion |
The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.
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| Please see page 760 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Clare L. Atzema, MD, MSc. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: BK, TA, CR, and BCS designed the study. BK and BCS conceived the study and obtained research funding. BK, TA, and CR supervised the conduct of the study. BK, TA, CR, and JL undertook data collection. BK, TA, and JL undertook recruitment of providers with the Clinical Research Investigative Studies Program research assistants. JL conducted provider interviews. CR, TA, and BCS contributed to analysis and interpretation of the data, drafted and revised the initial article, and approved the final article as submitted. CR managed the data. BK and CR coded and analyzed the data. BK drafted the article, and all authors contributed substantially to its revision. BK takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This study was funded by the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI) Emergency Care K12 Grant (5K12HL108974), NHLBI KO8 (grant 1K08HL140105), and the Oregon Clinical and Translational Research Institute (grant UL1 RR024140). Dr. Kea reports being the site investigator for Ortho-Clinical Diagnostics. No fees were directly received. Dr. Sun reports consulting for Medtronic. |
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| The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the NHLBI. The study sponsors had no involvement in design, data collection, analysis, drafting of the article, or decision to submit for publication. |
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Vol 74 - N° 6
P. 759-771 - décembre 2019 Retour au numéro
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