Exploring barriers to optimal anticoagulation for atrial fibrillation: interviews with clinicians

Carole Decker,¹ Linda Garavalia,² Brian Garavalia,¹ Teresa Simon,³ Matthew Loeb,⁴ John Spertus⁶, William Daniel<sup>5

1</sup>Mid America Heart Institute at Saint Luke's Hospital in Kansas City Missouri, University of Missouri-Kansas City School of Nursing, ²University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, ³Bristol-Myers Squibb, Princeton, NJ, ⁴Plaza Primary Care and Geriatrics, ⁵Saint Luke's Cardiovascular Consultants, Kansas City, MO, ⁶Mid America Heart Institute at Saint Luke's Hospital in Kansas City Missouri, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA

Background: Warfarin, the most commonly used antithrombotic agent for stroke prophylaxis in atrial fibrillation (AF), requires regular monitoring, frequent dosage adjustments, and dietary restrictions. Clinicians' perceptions of barriers to optimal AF management are an important factor in treatment. Anticoagulation management for AF is overseen by both cardiology and internal medicine (IM) practices. Thus, gaining the perspective of specialists and generalists is essential in understanding barriers to treatment. We used qualitative research methods to define key issues in the prescription of warfarin therapy for AF by cardiology specialists and IM physicians.
Methods and results: Clinicians were interviewed to identify barriers to warfarin treatment in a large Midwestern city. Interviews were conducted until thematic saturation occurred. Content analysis yielded several themes. The most salient theme that emerged from clinician interviews was use of characteristics other than the patient's CHADS₂ score to enact a treatment plan, such as the patient's social situation and past medication-taking behavior. Other themes included patient knowledge, real-world problems, breakdown in communication, and clinician reluctance.
Conclusion: Warfarin treatment is associated with many challenges. The barriers identified by clinicians highlight the unmet need associated with stroke prophylaxis in AF and the opportunity to improve anticoagulation treatment in AF. Social and lifestyle factors were important considerations in determining treatment.

Keywords: anticoagulants, atrial fibrillation, risk factors