Stroke Prophylaxis for Atrial Fibrillation? To Prescribe or Not to Prescribe—A Qualitative Study on the Decisionmaking Process of Emergency Department Providers

Bory Kea, Tahroma Alligood, Cassandra Robinson, Josephine Livingston, Benjamin Sun

Research output: Contribution to journalArticle

Abstract

Study objective: Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation. Methods: From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians’ attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians. Results: Three broad domains emerged from our analyses. (1)Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2)Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3)Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors. Conclusion: The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.

Original languageEnglish (US)
JournalAnnals of emergency medicine
DOIs
StatePublished - Jan 1 2019

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Atrial Fibrillation
Hospital Emergency Service
Stroke
Physicians
Guidelines
Emergencies
Interviews
Physicians' Practice Patterns
Medical Futility
Guideline Adherence
Insurance Coverage
Prescriptions
Comorbidity
Hemorrhage
Education
Population

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

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title = "Stroke Prophylaxis for Atrial Fibrillation? To Prescribe or Not to Prescribe—A Qualitative Study on the Decisionmaking Process of Emergency Department Providers",
abstract = "Study objective: Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation. Methods: From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians’ attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians. Results: Three broad domains emerged from our analyses. (1)Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2)Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3)Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors. Conclusion: The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.",
author = "Bory Kea and Tahroma Alligood and Cassandra Robinson and Josephine Livingston and Benjamin Sun",
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AU - Sun, Benjamin

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N2 - Study objective: Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation. Methods: From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians’ attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians. Results: Three broad domains emerged from our analyses. (1)Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2)Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3)Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors. Conclusion: The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.

AB - Study objective: Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation. Methods: From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians’ attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians. Results: Three broad domains emerged from our analyses. (1)Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2)Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3)Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors. Conclusion: The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.

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