Impact of stated barriers on proposed warfarin prescription for atrial fibrillation: a survey of Canadian physicians
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ORIGINAL CLINICAL INVESTIGATION
Open Access
Impact of stated barriers on proposed warfarin prescription for atrial fibrillation: a survey of Canadian physicians Stuart G Nicholls1, Jamie C Brehaut1,2*, Rubab G Arim2, Kelly Carroll2, Richard Perez3, Kaveh G Shojania4, Jeremy M Grimshaw2,5 and Roy M Poses6,7
Abstract Background: Atrial fibrillation (AF) is a common cardiac arrhythmia, and leading cause of ischemic stroke. Despite proven effectiveness, warfarin remains an under-used treatment in atrial fibrillation patients. We sought to study, across three physician specialties, a range of factors that have been argued to have a disproportionate effect on treatment decisions. Methods: Cross-sectional survey of Canadian Family Doctors (FD: n = 500), Geriatricians (G: n = 149), and Internal Medicine specialists (IMS: n = 500). Of these, 1032 physicians were contactable, and 335 completed and usable responses were received. Survey questions and clinical vignettes asked about the frequency with which they see patients with atrial fibrillation, treatment practices, and barriers to the prescription of anticoagulants. Results: Stated prescribing practices did not significantly differ between physician groups. Falls risk, bleeding risk and poor patient adherence were all highly cited barriers to prescribing warfarin. Fewer geriatricians indicated that history of patient falls would be a reason for not treating with warfarin (G: 47%; FD: 71%; IMS: 72%), and significantly fewer changed reported practice in the presence of falls risk (χ2 (6) = 45.446, p < 0.01). Experience of a patient having a stroke whilst not on warfarin had a significant impact on vignette decisions; physicians who had had patients who experienced a stroke were more likely to prescribe warfarin (χ2 (3) =10.7, p = 0.013). Conclusions: Barriers to treatment of atrial fibrillation with warfarin affect physician specialties to different extents. Prior experience of a patient suffering a stroke when not prescribed warfarin is positively associated with intention to prescribe warfarin, even in the presence of falls risk.
Introduction Atrial fibrillation (AF) is a common cardiac arrhythmia, affecting 5% of the population over the age of 65 [1,2] and around 1% in individuals >20 years of age [3]. AF is a leading cause of ischemic stroke, [4] increasing the risk of stroke six-fold [5] and is estimated to account for approximately 15% of all strokes [6,7]. Consequently, management of AF involves preventing AF-related complications such as stroke. * Correspondence: [email protected] 1 Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada 2 Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada Full list of author information is available at the end of the article
Management of AF often relies on the administration of antithrombotic therapy. Until very recently, such therapy has chiefly taken the form of antipl
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