Barriers and facilitators to optimal oral anticoagulant management: a scoping review

Oral anticoagulants (OACs) are high alert medications and require high-quality management to optimize health outcomes. The objective of this scoping review was to identify barriers and facilitators (B&Fs) associated with the quality of OAC management. We searched MEDLINE, EMBASE, and CINAHL databases until July 12, 2018, and cross-referenced the bibliographies of the retrieved studies. We included quantitative and qualitative studies that assessed B&Fs to OAC management. The study selection and data extraction processes were performed in duplicate. Analyses included measuring the prevalence of reported B&Fs from studies reporting quantitative data, identifying B&Fs in narrative analyses, and identifying their impact on important outcomes of OAC management. B&Fs were coded and aggregated to higher-level themes using a consensus approach. Factors were described as "key" if they were statistically associated with important outcomes in a randomized trial or observational study. We included 62 studies-three randomized clinical trials (RCTs), 46 observational studies (cross-sectional studies, cohort studies, and case-control studies), 11 qualitative studies, and two mixed-methods studies. Factors identified could be grouped into four themes-therapy-related, patient-related, healthcare provider-related, and health system-related. Key barriers to optimal OAC management were mostly patient-related, whereas interventions focused on education or implementing protocols were shown through RCTs to be effective at improving knowledge scores of OAC patients. While multiple barriers and some facilitators were identified in this review, none was proven to be associated with clinical outcomes. With this in mind, individual physicians may wish to address the key barriers in their practice as a quality improvement initiative but system-wide or policy changes should await high-quality evidence. Future trials should address these factors.Systematic review registration: PROSPERO CRD42017069043.