Anticoagulant use in older persons at risk for falls: therapeutic dilemmas-a clinical review

PURPOSE

The aim of this clinical narrative review was to summarise the existing knowledge on the use of anticoagulants and potential adverse events in older people at risk of falls with a history of atrial fibrillation or venous thromboembolism. The review also offers practical steps prescribers can take when (de-)prescribing anticoagulants to maximise safety.

METHODS

Literature searches were conducted using PubMed, Embase and Scopus. Additional articles were identified by searching reference lists.

RESULTS

Anticoagulants are often underused in older people due to concerns about the risk of falls and intracranial haemorrhage. However, evidence suggests that the absolute risk is low and outweighed by the reduction in stroke risk. DOACs are now recommended first line for most patients due to their favourable safety profile. Off-label dose reduction of DOACs is not recommended due to reduced efficacy with limited reduction in bleeding risk. Medication review and falls prevention strategies should be implemented before prescribing anticoagulation. Deprescribing should be considered in severe frailty, limited life expectancy and increased bleeding risk (e.g., cerebral microbleeds).

CONCLUSION

When considering whether to (de-)prescribe anticoagulants, it is important to consider the risks associated with stopping therapy in addition to potential adverse events. Shared decision-making with the patient and their carers is crucial as patient and prescriber views often differ.

A Survey of Saudi General Practitioners on the Use of Thromboprophylaxis Guidelines and Risk Assessment Tools in Atrial Fibrillation

Clinical practice guidelines advise patients with atrial fibrillation who are at risk for stroke to undergo thromboprophylaxis with oral anticoagulants. However, it is noted that guidelines are not always followed. We sought to learn how Saudi Arabian general practitioners (GPs) self-reported using risk assessment tools and atrial fibrillation clinical practice guidelines created by cardiology associations, as well as how GPs felt about the resources that were available. Through the use of a self-administered questionnaire, we carried out a cross-sectional survey. A total of two-hundred GPs participated in the study. The guidelines were frequently used when a clinical decision regarding anticoagulation therapy appeared difficult (n = 57, 28.4%). The most predominant strengths of participants' chosen clinical guidelines were clear recommendations (n = 56, 27.9%), easy-to-follow algorithms (n = 39, 16.9%), detailed recommendations supported by evidence (n = 34, 16.9%), and online availability (n = 27, 13.4%). Many respondents said they used a formal stroke risk assessment tool in addition to their clinical judgment as a GP for most decisions (60%). Most respondents preferred using the CHA2DS2-VASc (n = 106, 52.7%), CHA2DS2-VA (n = 45, 22.4%), CHADS2 (n = 35, 17.4%), and GARFIELD (n = 14, 7.0%). HAS-BLED (n = 100, 49.8%) and HEMORR2HAGES (n = 50, 24.9%) were the most frequently utilized formal tools for assessing the risk of bleeding among GPs. Over half of the participants referred to guidelines when deciding thromboprophylaxis in patients with atrial fibrillation. Additionally, many respondents used formal procedures for assessing the risks of bleeding and stroke in addition to their clinical judgement in their roles as GPs. The guideline was assessed as being extremely helpful overall by GPs who used it to make thromboprophylaxis decisions.

Informed Decision Making for Anticoagulation Therapy for Atrial Fibrillation

BACKGROUND

Patients with atrial fibrillation (AF) must decide between warfarin and direct oral anticoagulants (DOACs), a decision involving important tradeoffs. Our objective was to understand whether physicians engage patients in informed decision making for anticoagulants.

DESIGN

We performed an analysis of recorded conversations between physicians and anticoagulation-naïve patients in the Verilogue Point-of-Practice database. We assessed the presence of 7 elements of informed decision making, as well as a discussion of financial costs.

RESULTS

Of 37 encounters with 21 physicians, 92% resulted in a DOAC prescription and 8% resulted in a warfarin prescription. Seventy percent met criteria for discussion of pros and cons, 70% for discussion of the alternatives, 43% presented the decision, 30% included an assessment of patient understanding, 22% included an explanation of the patient's role in decision making, 22% included an assessment of patient preferences, and 19% included a discussion of uncertainty. Two encounters (5%) included all 7 elements and 9 (24%) included none. Physicians discussed treatment costs with patients in 43% of encounters.

LIMITATIONS

We assessed informed decision making in a single encounter. Physicians and patients may have had other discussions that were not captured in our data.

CONCLUSIONS

Physicians often presented the alternatives but did not generally engage patients in informed decision making. The high rate of DOAC prescriptions is likely the result of physician preferences, as patient preferences were rarely assessed.

IMPLICATIONS

Strategies to support physicians in engaging patients in informed decision making for anticoagulation are needed.

HIGHLIGHTS

While physicians discussed the alternatives and presented pros and cons with patients, they rarely assessed patient preferences, explained the patient's role in decision making, or addressed uncertainty.The cost of treatment with DOACs versus warfarin was discussed by physicians in less than half of encounters, limiting patients' ability to make informed decisions for anticoagulation.Only 2 encounters (5%) fulfilled all 7 elements of informed decision making.

Trust and activation in defining patient-clinician interactions for chronic disease management

OBJECTIVE

Patient-clinician relationship quality and patient activation can both improve patient health outcomes, but prior work has primarily examined these factors independently. We examine how these two factors shape patient behavior in the setting of ambulatory heart failure care, where serial intensification of multiple medications is central to chronic care delivery.

METHODS

We used content analysis to analyze 22 in-depth patient interviews and 32 audio-recorded clinic visits collected for the EPIC-HF Trial. This was a secondary analysis providing qualitative depth to the parent RCT.

RESULTS

We identified a typology of patient activation and patient-clinician relationship quality, with four types: Supported, Skeptical, Deferential, and Unempowered. Types were sensitive to time and context; a given patient might occupy multiple types throughout the course of a single clinic visit. The effects of patient-activation and the patient-clinician relationship appeared to be bidirectional, with each influencing the other.

CONCLUSION

Patient-clinician relationship quality and patient activation are dominant in shaping clinical interactions and disease management. This interaction is dynamic, and patients may change types depending on time, place, or context.

PRACTICE IMPLICATIONS

These findings suggest that both patient activation and high relationship quality work together to create a supportive environment for chronic care, where intermittent skepticism, deference or empowerment may be useful at particular times or in certain situations.

Treated with preventive anticoagulation therapy in atrial fibrillation: The patients' perspective

AIM

The aim of this study was to explore patients' experiences of preventive anticoagulation therapy in atrial fibrillation.

DESIGN

This was a descriptive qualitative study based on interviews.

METHODS

Individual interviews with 15 patients, 6 women and 9 men, treated with preventive oral anticoagulant due to atrial fibrillation, were conducted. The interviews were analysed with qualitative content analysis.

RESULTS

Based on the analysis, the theme Managing a necessary evil emerged. The theme comprised the three categories: Coping with anxiety and changes in daily life, Having confidence in care and Being a partner or only a receiver of treatment. Patients described it like being faced with a situation where a treatment perceived as vital was weighed against undesirable consequences and risks. Patients trusted caregivers and had confidence in care, but there was a risk of being a receiver of care instead of becoming a partner.

Use of thromboprophylaxis guidelines and risk stratification tools in atrial fibrillation: A survey of general practitioners in Australia

RATIONALE AND OBJECTIVES

Clinical guidelines produced by cardiology societies (henceforth referred to simply as 'clinical guidelines') recommend thromboprophylaxis with oral anticoagulants (OACs) in patients with atrial fibrillation (AF) who have moderate-to-high stroke risk. However, deviations from these recommendations are observed, especially in the primary healthcare setting. The primary aims of this study were to evaluate the self-reported use of AF clinical guidelines and risk stratification tools among Australian general practitioners (GPs), and their perceptions regarding the available resources.

METHOD

We conducted an online survey of Australian GPs. Descriptive statistics were used to summarise the findings.

RESULTS

Responses from 115 GPs were included for analysis. Respondents reported various ways of accessing thromboprophylaxis-related information (n = 113), including clinical guidelines (13.3%), 'Therapeutic Guidelines^© ' (37.2%) and Royal Australian College of General Practitioners websites (16.8%). Of those who reported reasons against accessing information from clinical guidelines (n = 97), the most frequent issues were: too many AF guidelines to choose from (34.0%; 33/97), different guidelines for different diseases (32.0%; 31/97), time-consuming to read guidelines (21.6%; 21/97), disagreements between different guideline recommendations (20.0%; 19/97), conflict with criteria for government subsidy (17.5%; 17/97) and GPs' busy schedules (15.5%; 15/97). When assessing patients' risk of stroke (n = 112) and bleeding (n = 111), the majority of the respondents reported primarily relying on a formal stroke risk (67.0%) and bleeding risk (55.0%) assessment tools, respectively. Respondents reported using formal stroke and bleeding risk assessment tools mainly when newly initiating patients on therapy (72.4%; 76/105 and 65.3%; 65/101, respectively).

CONCLUSION

Among our small sample of Australian GPs, most did not access thromboprophylaxis-related information directly from AF-specific clinical guidelines developed by cardiology societies. Although the majority reported using formal stroke and bleeding assessment tools, these were typically used on OAC initiation only. More focus is needed on formal risk reassessment as clinically indicated and at regular review.

Heart Rhythm Society Atrial Fibrillation Centers of Excellence Study: A survey analysis of stakeholder practices, needs, and barriers

BACKGROUND

An integrated, coordinated, and patient-centered approach to atrial fibrillation (AF) care delivery may improve outcomes and reduce cost.

OBJECTIVE

The purpose of this study was to gain a better understanding from key stakeholder groups on current practices, needs, and potential barriers to implementing optimal integrated AF care.

METHODS

A series of comprehensive questionnaires were designed by the Heart Rhythm Society Atrial Fibrillation Centers of Excellence (CoE) Task Force to conduct surveys with physicians, advanced practice professionals, patients, and hospital administrators. Data collected focused on the following areas: access to care, stroke prevention, education, AF quality improvement, and AF CoE needs and barriers. Survey responses were collated and analyzed by the Task Force.

RESULTS

The surveys identified 5 major unmet needs: (1) Standardized protocols, order sets, or care pathways in the emergency department or inpatient setting were uncommon (36%-42%). (2) All stakeholders agreed stroke prevention was a top priority; however, prior bleeding or risk of bleeding was the most frequent barrier for initiation. (3) Patients indicated that education on modifiable causes, AF-related complications, and lowering stroke risk is most important. (4) Less than half (43%) of the health care systems track patients with AF or treatment status. Patients reported that stroke and heart failure prevention and access to procedures were priority areas for an AF CoE. The most common barriers to implementing AF CoE identified by clinicians were administrative support (69%) and cost (52%); administrators reported physical space (43%).

CONCLUSION

On the basis of the findings of this study, the Task Force identified high priority areas to develop initiatives to aid the implementation of AF CoE.

Reasons for non-adherence to thromboprophylaxis prescribing guidelines in atrial fibrillation in Western Australia: A qualitative descriptive study of general practitioners' views

BACKGROUND

A significant proportion of the atrial fibrillation (AF) population attending Australian primary care is not receiving guideline-adherent oral anticoagulant (OAC) treatment. This study aimed to explore reasons for non-adherence to thromboprophylaxis guidelines in AF from the perspectives of general practitioners (GPs) and to map these reasons to the Capability, Opportunity, Motivation-Behaviour (COM-B) model to identify potential opportunities to support practice change.

METHODS

An exploratory qualitative descriptive study among GPs practising in Western Australia was conducted using semi-structured interviews, from November 2020 to February 2021. The Framework Method was employed to facilitate thematic analysis, using NVivo software. Interview responses were also mapped to the COM-B model.

RESULTS

Nine of the 10 GPs initially consented participated in the semi-structured interview (Male = 56%, median age = 52 years, data saturation reached with 6 participants). Two themes emerged from analysis of the interview transcripts: (1) GPs' decision-making process and (2) Patient refusal to take OACs. The COM-B model mapping identified behavioural factors that could impact adherence: capability (GPs' knowledge and understanding of AF guideline recommendations), opportunity (access to a cardiologist, and patients' refusal to take OACs), and motivation (using formal bleeding risk assessment tools).

CONCLUSION

GPs identified various reasons contributing to non-adherence to thromboprophylaxis guidelines in patients with AF. Multifaceted interventions should consider behavioural opportunities to improve adherence, including education and training, electronic decision support, clinical audits by allied health professionals, partnership between general practices and local hospitals, and cardiologist-led interventions to support GPs. Further studies are needed to capture patients' reasons for refusing OACs.

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

OBJECTIVE

To examine the extent of, and factors associated with, patient engagement in shared decision-making (SDM) for stroke prevention among patients with atrial fibrillation (AF).

METHODS

We used data from the Systematic Assessment of Geriatric Elements-Atrial Fibrillation study which includes older ( ≥65 years) patients with AF and a CHA2DS2-VASc≥2. Participants reported engagement in SDM by answering whether they actively participated in choosing to take an oral anticoagulant (OAC) for their condition. Multiple logistic regression was used to assess associations between sociodemographic, clinical, geriatric, and psychosocial factors and patient engagement in SDM.

RESULTS

A total of 807 participants (mean age 75 years; 48% female) on an OAC were studied. Of these, 61% engaged in SDM. Older participants (≥80 years) and those cognitively impaired were less likely to engage in SDM, while those very knowledgeable of their AF associated stroke risk were more likely to do so than respective comparison groups.

CONCLUSIONS

A considerable proportion of older adults with AF did not engage in SDM for stroke prevention with older patients and those cognitively impaired less likely to do so. Clinicians should identify patients who are less likely to engage in SDM, promote patient engagement, and foster better patient-provider communication which may enhance long-term patient outcomes.

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

Atrial fibrillation is the most common arrhythmia. It increases the risk of thromboembolism by up to fivefold. Guidelines provide evidence-based recommendations to effectively mitigate thromboembolic events using oral anticoagulants while minimizing the risk of bleeding. This review focuses on non-adherence to contemporary guidelines and the factors associated with guideline non-adherence. The extent of guideline non-adherence differs according to geographic region, healthcare setting, and risk stratification tools used. Guideline adherence has gradually improved over recent years, but a significant proportion of patients are still not receiving guideline-recommended therapy. Physician-related and patient-related factors (such as patient refusals, bleeding risk, older age, and recurrent falls) also contribute to guideline non-adherence, especially to undertreatment. Quality improvement initiatives that focus on undertreatment, especially in the primary healthcare setting, may help to improve guideline adherence.

Grounded theory: what makes a grounded theory study?

Grounded theory (GT) is both a research method and a research methodology. There are several different ways of doing GT which reflect the different viewpoints of the originators. For those who are new to this approach to conducting qualitative research, this can be confusing. In this article, we outline the key characteristics of GT and describe the role of the literature review in three common GT approaches, illustrated using exemplar studies.

Frontiers of Upstream Stroke Prevention and Reduced Stroke Inequity Through Predicting, Preventing, and Managing Hypertension and Atrial Fibrillation: A Call to Action From the Value in Healthcare Initiative's Predict & Prevent Learning Collaborative

Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.

The anti-clot treatment scale (ACTS): validation of the translated Arabic version among patients undergoing warfarin therapy in Saudi Arabia

Background

Long-term anticoagulation therapy, particularly with warfarin, is usually associated with poor adherence and low patient satisfaction. However, previous studies have highlighted the possibility that individual perceptions of warfarin differ according to cultural practices. This study validated the psychometric properties of the translated Arabic version of the Anti-Clot Treatment Scale (ACTS) for patients on warfarin therapy in Saudi Arabia.

Methods

A cross-sectional multicenter study was conducted at the three main medical centers in Riyadh. Stratified sampling was employed to recruit Arabic-speaking patients who had been taking warfarin for a minimum of 3 months for any indication. The patients completed the specific ACTS along with the generic Treatment Satisfaction Questionnaire for Medication (TSQM 1.4) at two clinic visits. The psychometric performance of the ACTS was evaluated using well-established criteria: feasibility, reliability, and validity.

Results

One hundred thirty-six patients participated in the study (mean age: 50.68 ± 14.6 years; range: 19–97). Overall, the patients reported moderate Burdens and Benefits scores (44 ± 9.9 and 11.92 ± 2.4, respectively) compared to the reference range for each subscale (12–60 and 3–15, respectively); however, they reported lower Burdens scores than other populations. Consistent with the original ACTS validation study, the criteria for acceptability (data targeting, floor/ceiling effects, and skewness) were satisfied; in fact, the Arabic version exhibited better item- and scale-level distributions of data than versions in other languages. The ACTS subscales also demonstrated satisfactory test-retest reliability with significant intraclass correlation coefficients ((ICC ≥ 0.5); p < 0.001) and good internal consistency (all Cronbach’s alpha values exceeded 0.7). Exploratory factor analysis supported the 2-factor loading model. Interestingly, the Arabic version exhibited greater convergent validity with the TSQM subdomains (r = 0.61).

Conclusions

This study provides convincing evidence that the Arabic versions of both the ACTS Burdens and ACTS Benefits scales are equivalent to other versions in terms of psychometric performance, as measured using reliability and validity criteria. These properties support the great potential of the Arabic ACTS to accurately reflect patient satisfaction, identify aspects of treatment that need improvement in clinical practice, and compare treatment satisfaction across different anticoagulant therapies or cultures in research.