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Physician variation in anticoagulating patients with atrial fibrillation. Dartmouth Primary Care COOP Project
H J Chang1, J R Bell, D B Deroo
1Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH 03756.
Insights
Physician specialty influences oral anticoagulant treatment decisions for atrial fibrillation patients. Cardiologists are less likely to prescribe anticoagulation, differing from family physicians due to varied risk perceptions.
Area of Science:
- Cardiology
- Internal Medicine
- General Practice
Background:
- Atrial fibrillation (AF) management requires careful consideration of anticoagulation to prevent stroke.
- Variations in clinical practice among different physician specialties can impact patient outcomes.
Purpose of the Study:
- To investigate variations in oral anticoagulant treatment decisions for atrial fibrillation among family physicians, general internists, and cardiologists.
- To identify factors influencing these treatment variations, including perceived risks of embolism and hemorrhage.
Main Methods:
- Retrospective analysis of treatment decisions for atrial fibrillation patients.
- Comparison of anticoagulation prescribing patterns across three physician specialties.
- Assessment of physician-estimated risks for embolization and hemorrhage.
Main Results:
- General agreement on anticoagulation for AF patients with mitral valve disease or alcohol abuse history.
- Substantial disagreement for other AF patient categories.
- Cardiologists perceived lower embolization risks compared to other specialists.
- Physician specialty correlated with anticoagulation decisions; cardiologists were least likely, family practitioners most likely, to prescribe in nonrheumatic AF.
Conclusions:
- Significant variations exist in oral anticoagulant prescribing for atrial fibrillation based on physician specialty.
- Differences in perceived risks of systemic embolism appear to drive these treatment variations.
- Further research is needed to standardize anticoagulation guidelines across specialties.
Abstract:
We investigated variations in the oral anticoagulant treatment of atrial fibrillation by physicians in three specialties: family physicians (or general practitioners), general internists, and cardiologists. Results showed general agreement in the anticoagulation decision regarding patients with either mitral valve disease or a history of chronic alcohol abuse, but substantial disagreement in other categories of patients. Estimations of the risk of embolization and risk of hemorrhage differed widely among all physicians, cardiologists generally rating the embolization risks lower than the other physicians. A physician's treatment decision was strongly related to the relative risk of embolism vs hemorrhage derived for each case. A relationship between physician specialty and treatment decision was also demonstrated, with cardiologists least likely, and family practitioners most likely, to institute anticoagulation in nonrheumatic patients with atrial fibrillation. The reason for this variation appears to be differences in the estimated risk of systemic embolism.