Optimisation of direct oral anticoagulants (DOACs) for older patients with atrial fibrillation: a qualitative study of patient and healthcare practitioner perspectives

The Problem

Direct oral anticoagulants (DOACs) are high risk drugs which are prescribed for patients with atrial fibrillation. Suboptimal prescribing, adherence, monitoring and patient education could result in adverse events especially in older patients.

Aim: To understand patient and practitioner perceptions of DOAC optimisation for atrial fibrillation.

The Approach

Maximum variation sample of patients, aged ³ 65 years with atrial fibrillation, GPs, practice based pharmacists and community pharmacists were recruited. Semi-structured, face-to-face, taped individual interviews undertaken in 2018. Six stage thematic analysis was undertaken facilitated by NVivo software (V12).

The Learning

Thirty-two participants were interviewed comprising 10 pharmacists, 6 GPs and 16 patients aged between 67 to 89 years. Greater satisfaction and preference, including lower perceived risk was associated with DOACs over warfarin. Operational failures in primary care including overworked GPs, poorly integrated computer systems between healthcare settings, and communication gaps were reported by GPs and pharmacists to hinder optimisation of DOACs. GPs assumed that medication information and patient education would be provided by the initiating healthcare professionals from other healthcare settings and they often expected pharmacists to bridge this gap during medication reviews and the new medicines service. However, patients preferred relational continuity with their doctors over other healthcare professionals such as the community pharmacist. Consequently, patients’ understanding and knowledge about atrial fibrillation and DOAC therapy were found wanting.

Why it matters

This study shows a gap in the safe care of older patients receiving high risk drugs like DOACs in primary care. Healthcare professionals and patients perceive DOACs as low risk and this impacts on how healthcare is provided and received. Patient engagement and co-production of medication related information with healthcare professionals could facilitate patient education. Furthermore, improving healthcare work systems such as the integration of computer systems to provide seamless communication across various healthcare settings could promote medicines optimisation.

Yeyenta Osasu, Richard Cooper, Caroline Mitchell

Academic Unit of Primary Medical Care

The Medical School, University of Sheffield