A community survey of patients with atrial fibrillation: associated disabilities and treatment preferences

BACKGROUND

Anticoagulants are effective in preventing stroke in those with atrial fibrillation, but most patients remain untreated.

AIM

To investigate the prevalence of disability, cognitive impairment, and problems with compliance in a representative sample of the elderly with atrial fibrillation, and to determine whether they would want treatment and how they would like services to be arranged.

METHOD

In a survey of a random sample of 4843 elderly subjects, those with atrial fibrillation were identified using electrocardiograms. Views on treatment were obtained using a structured interview. Disability was assessed using the Office of Population Censuses and Surveys Disability Scale and cognitive status using the Mini Mental State Examination. General practitioners were asked, via questionnaire, for their views on each subject's compliance.

RESULTS

Two hundred and seven elderly people with atrial fibrillation were identified. Almost all subjects expressed a willingness to undertake treatment to prevent stroke and preferred blood testing performed outside of hospital. Disability (82.7%), cognitive impairment (25.7%), and problems with compliance (25.0%) were common, but the prevalence of these difficulties was not substantially different from the general elderly population, and in many cases they could be overcome (e.g. only 10% of subjects had problems with compliance and no-one who could help them to comply).

CONCLUSIONS

Most elderly people with atrial fibrillation would accept treatment to prevent stroke. Disability, cognitive impairment, and problems with compliance may make it difficult to treat this patient group. An increase in the use of anticoagulants should be accompanied by the development of services appropriate to this frail population.

AIDS funding. The national lottery

The government's funding of AIDS and HIV services in England is inequitable. Spending per patient in North Thames is four times that in Manchester. Deaths from AIDS in North Thames are significantly lower than in other parts of England.

Critical behavior of a strain percolation model for metals

Extensive simulations of a strain percolation model for a deforming metal have been performed to examine its strain behavior. We find that the total strain exhibits critical power-law behavior that is well explained by two-dimensional percolation theory. Near the critical point, most of the strained cells organize themselves around a state having the minimum or at least marginally stable strain regardless of the initial conditions. A strain much greater than the minimum stable strain generally decays to a lower value when transmitted to an unstrained cell. The universal behavior of the total strain in the system is a consequence of the self-organizing character of the strain in the critical cluster. Although the probability distributions for the total strain and cluster size appear to exhibit nonuniversal behavior, this may merely represent a transient response before crossover to a true asymptotic, universal behavior occurs. Other critical aspects of the model are also discussed.

Factors influencing oral anticoagulant prescribing decisions for patients with atrial fibrillation: a systematic review of qualitative and quantitative evidence

Introduction

Despite their efficacy in reducing stroke risk in patients with atrial fibrillation (AF), oral anticoagulants (OACs) remain under-prescribed [1]. Until recently, warfarin has been the dominant OAC. The introduction of direct oral anticoagulants (DOACs) led to changes in anticoagulant prescribing patterns, with an increase in OAC prescribing and a shift towards DOACs [2]. Treatment decisions for OACs are complicated, and require a discussion between clinicians and patients when deciding on a treatment [1].

Aim

To investigate the main factors that influence initial and ongoing OAC prescribing decisions for patients with AF according to patient and health professional views.

Methods

A systematic review was conducted according to the Toolkit for Mixed-Methods Reviews, and was registered on PROSPERO: CRD42019145406. Medline, CINAHL, Scopus, EMBASE, Web of Knowledge and PsychInfo were searched in August, 2019. Primary qualitative and quantitative studies, published between 2009 and 2019, exploring patient and health professional perceptions, views and experiences of OACs in AF were included. McMaster critical appraisal tool for quantitative studies and Critical Appraisal Skills Programme (CASP) checklist for qualitative studies were used for quality assessment. The review followed a convergent integrated approach to data extraction and analysis, which involves extracting and analysing results of quantitative and qualitative studies at the same time using the same method. A data extraction form was adapted from Joanna-Briggs Institute (JBI) mixed-methods extraction form. Study author interpretation of quantitative data was summarised as qualitative statements which were coded together with primary qualitative data using NVIVO 12 software; codes were applied to each sentence in the findings, and were grouped into a hierarchical tree structure

Results

The systematic review included 62 papers (58 studies) discussing clinical and non-clinical factors influencing decisions to initiate OACs, the choice between warfarin and DOACs, and the choice between individual OACs. The balance of stroke and bleeding risks was the most influential when making the decision to initiate anticoagulation according to both patients and health professionals. Convenience-related factors, such as monitoring requirements, dosing regimens, and interactions impacted the choice between warfarin and DOACs, whereas, reversibility and dosing regimen influenced the choice between individual medications according to the views of both groups. Health professional specialty and years of experience affected all aspects of treatments, with specialists and senior clinicians more willing to initiate anticoagulation and choose DOACs. Even though health professionals often expressed that patient views were considered when deciding on a treatment, patients generally said that they followed their physician’s recommendations without questioning.

Conclusion

The review revealed similarities and differences across patient and professional views, experiences, and preferences of anticoagulation. The main discrepancies were related to the decision-making process, and whether patient views are being considered when prescribing. Combining quantitative and qualitative evidence helped explore a wide range of views of OAC and AF, however the review only included published research papers in English, which might have led to exclusion of valuable evidence. More research is needed to explore the factors driving the choice between OACs, especially the choice between individual DOACs.

References

1. Noseworthy PA, Brito JP, Kunneman M, Hargraves IG, Zeballos-Palacios C, Montori VM, Ting HH. Shared decision-making in atrial fibrillation: navigating complex issues in partnership with the patient. Journal of Interventional Cardiac Electrophysiology. 2019;56(2):159–163.

2. Loo, S.Y., Dell'Aniello, S., Huiart, L. and Renoux, C. Trends in the prescription of novel oral anticoagulants in UK primary care. British Journal of Clinical Pharmacology. 2017; 83(9): 2096–2106.