How do practitioners and older patients with non-valvular atrial fibrillation perceive the optimisation of direct oral anticoagulants? A qualitative study

Problem

Until relatively recently, warfarin was the drug of choice for stroke prevention in AF patients but the upward prescribing trend of DOACs for AF has significant consequences on NHS expenditure. DOAC optimisation in primary care is important to prevent potential adverse bleeding events and if adherence is suboptimal, their efficacy may be reduced. Older patients with AF are often co-morbid and likely to experience adverse events. For example chronic kidney disease or acute kidney injury due to concurrent illness necessitates dose adjustments, and lack of routine monitoring and healthcare contact may result in poorer adherence compared to warfarin. Study aims:To understand patient and practitioner perception of DOAC optimisation for atrial fibrillation

Approach

Purposive sample of six practices were identified, stratified by practices by size, population and area profiles. Maximum variety sample of patients, aged  65 years with NVAF, GPs, practice based pharmacists and community pharmacists were recruited. Semi-structured, face-to-face, taped individual interviews undertaken. Data were organised using NVivo Software (V12) and analysed thematically until data saturation.

Findings

Thirty-two participants were interviewed comprising 10 pharmacists, 6 GPs and 16 patients aged between 67 to 89 years. Themes identified from the patients’ perspectives included co-morbidities and competing health priorities; poor understanding of the illness and treatment; patients’ acceptance of illness and treatment as an inevitable consequence of ageing; and diminished risk perception of DOACs. Patients assumed DOACs were a safer alternative to warfarin and relied on their doctors’ medical decisions. Though patients received multiple anticoagulant leaflets, they could not readily re-call potential side effects of DOACs. There was a recognition of medication necessity amongst patient who took DOAC for secondary prevention of stroke but patients who took DOACs for primary stroke prevention and who had co-morbidities expressed vagueness in illness and treatment coherence. Most patients gave priority to their co-morbid illnesses for which there was a physical discomfort or burden. GPs expressed increasing confidence and preference for DOACs over warfarin, and they relied on their in-house computer re-call systems for routine medication reviews and blood tests. Practice pharmacists expressed caution and concern for patient safety, and need for checking patients' understanding and adherence regularly.

Consequences

Factors which hinder the optimisation of DOACs in older patients with AF were identified including co-morbidities, polypharmacy, poor understanding of AF and anticoagulant therapy. These, and increasing practitioner workload has resulted in a welcome acceptance for alternatives to warfarin because they require less medication management. However, diminished risk perception of DOACs, by patients and practitioners has implications for patient safety. It is the responsibility of all professionals, healthcare organisations and patients to ensure medicines use, including DOACs which are high risk drugs, is as safe as possible. Safe processes are required to ensure effective communication and meaningful reviews become routine practice.