Patients’ perspectives on factors affecting their involvement in decision-making on oral anticoagulant therapy for stroke prevention in non-valvular atrial fibrillation

Abstract

Introduction: Acknowledging patients' preferences andaddressing their concerns is thought to improve patients'satisfaction with consultations, resulting in improved adherence and health benefits [1]. Adherence to oral anticoagulant (OA) therapy in non-valvular atrial fibrillation (NVAF)is crucial to prevent AF-related strokes. Previous researchon anticoagulation in NVAF indicated that decision-makingwas dominated by prescribers, but patients offered severaltherapy options reported being involved [2]. Identifying thepatient's perspective on factors affecting their involvementcould help to deliver more patient-centred care in the management of AF. Aim(s): To explore patients' perspectives and experiences concerning factors affecting their involvement indecision-making about OA therapy for stroke prevention inNVAF. Method(s): Semi-structured face-to-face interviews wereconducted with patients in three health economies in theNorth of England between August 2018 and April 2019.An interview topic guide based on narrative review findings [2] was developed and refined by a Patient and PublicInvolvement (PPI) group to ensure clarity. Theoretical sampling was used to recruit adults (>18 years) diagnosed withNVAF, prescribed OA (vitamin K antagonist or direct oralanticoagulant (DOAC)), and able to give written consent. Upto 30 potential participants were approached by a memberof their direct care team (nurse or pharmacist) in secondaryand primary care anticoagulation or arrhythmia clinics. PPImembers recruited patients from a local patient support group. Data collection continued until data saturation wasachieved. Audio recorded interviews were transcribed verbatim and analysed using the Framework method. Result(s): A total of 21 patient with median (IQR) age of73 years (65-78 years) were interviewed. Eleven patients tookDOACs. The median (IQR) time of taking OA was 3 years(4 weeks-7 years), warfarin 7 years (3-9 years) and DOAC1 year (4 weeks-4 years). Interviews lasted between 15 and48 minutes (average 27 minutes). Three themes were identified during analysis (Figure 1). Patients described therapydecisions being made by just the clinician, jointly with theclinician, and in few cases by the patient alone. The lack ofinvolvement resulted from patients perceiving that there wasonly a choice between accepting and refusing the therapy,and clinician's role was to make decisions. Limited consultation times, lack of continuous relationship with a clinicianand knowledge about OAs options discouraged patientsfrom being involved and some patients reported difficultieswith the prescribed therapy. Patients that were involved considered safety of therapy options and impact on daily life. Conclusion(s): Limited consultation time, patient's perception of clinician's role, quality of patient-clinician relationship, and patients' awareness of therapy options were mainfactors influencing the level of patient involvement in thedecision-making. Support from both organisation and clinicians(e.g., longer consultations, availability of different therapy options) is needed to facilitate greater patient involvement, whichcould prevent difficulties encountered by some patients. Themain strength of this study was recruitment of participantsfrom three health economies differing in anticoagulation service provision models, which enabled greater insight intopotential barriers. However, the sample was lacking ethnic diversity and could have potential of recall bias.