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Published on: February 26, 2013
'Rules of thumb' or reflective practice? Understanding senior physicians' decision-making about anti-thrombotic usage
N Anderson1, R Fuller, N Dudley
1Medical Department for the Elderly, The General Infirmary at Leeds, Leeds LS1 3EX, UK.
Insights
Physician prescribing of anti-thrombotics for atrial fibrillation (AF) varied significantly due to uncertainty about stroke and bleeding risks. Understanding these factors is crucial for guideline adherence and patient safety in AF management.
Area of Science:
- Cardiology
- Clinical Medicine
- Evidence-Based Practice
Background:
- National Institute for Health and Clinical Excellence (NICE) guidelines emphasize stroke risk assessment and anti-thrombotic therapy in Atrial Fibrillation (AF).
- Understanding physician decision-making regarding anti-thrombotic use in AF is critical for guideline implementation.
Purpose of the Study:
- To explore physician behaviors and attitudes concerning decision-making in Atrial Fibrillation (AF).
- To investigate the factors influencing the use of anti-thrombotic therapies in AF patients.
Main Methods:
- A semi-qualitative study utilizing questionnaires and semi-structured interviews.
- Fourteen senior physicians evaluated clinical vignettes and discussed their anti-thrombotic prescribing choices in AF.
- Grounded theory analysis was applied to interview transcripts to identify key themes.
Main Results:
- Significant variation was observed in anti-thrombotic treatment recommendations among physicians.
- Physicians showed variability in prescribing warfarin, influenced by factors like history of falls versus intracerebral hemorrhage.
- Qualitative analysis revealed pervasive uncertainty and concerns regarding risk-benefit knowledge in AF decision-making.
Conclusions:
- Physician agreement on anti-thrombotic choice for AF was notably low, with diverse perceptions of stroke and bleeding risks.
- Uncertainty, knowledge gaps, and differing patient involvement approaches contribute to prescribing variability in AF.
- Addressing physician uncertainty and standardizing risk perception are essential for optimizing anti-thrombotic therapy in AF.
Background:
The recently published Atrial Fibrillation (AF) Guidelines from the National Institute for Health and Clinical Excellence (NICE) highlight the importance of assessing stroke risk and using appropriate anti-thrombotic therapy.
Aim:
To improve understanding of physicians' behaviour and attitudes in respect to decision-making in AF and the use of anti-thrombotics.
Design:
Semi-qualitative, questionnaire- and interview-based study.
Methods:
Five clinical vignettes relating to treatment choices for AF and stroke prevention illustrating a range of risk and benefit were examined by 14 senior physicians (consultants or specialist registrars) in Cardiology, General Medicine and Geriatric Medicine, who then recommended anti-thrombotic treatment. A semi-structured interview explored their decision-making and prescribing in AF, with qualitative analysis of interview transcripts using grounded theory.
Results:
There was marked variation in the choice of anti-thrombotic treatment. Respondents were more likely to prescribe warfarin to patients with a previous intracerebral haemorrhage than to a patient with a history of falls. A key theme on qualitative analysis revealed that decision-making in AF is often associated with uncertainty and concerns about knowledge of risk and benefit.
Discussion:
In this study, doctors rarely agreed on the choice of anti-thrombotics in AF, and their perceptions of stroke and bleeding risk showed considerable variation. Uncertainty, doubt, concerns about knowledge and varied approach to the role of patients in decision-making are all significant themes in the considerable variability in anti-thrombotic prescribing.
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