Underuse of VKAs: How Physician, Patient Perceptions Shape Practice
A new systematic review of qualitative studies, the first of its kind, has identified physician and patient concerns about the use of vitamin K antagonists (VKAs) in atrial fibrillation (AF). The study was published online on January 13 2017 in BMC Family Practice.1
Despite being the most frequently prescribed drug class for preventing stroke in patients with AF, VKAs are still underutilized. Common explanations for underuse include drug-drug interactions and the need for frequent monitoring. How physicians and patients think about the benefits and risks of VKAs may also be an important factor, according to background information in the study article.
Gemma Mas Dalmau, MD, of the Biomedical Research Institute (Barcelona, Spain), and colleagues searched four different databases from inception until May 2013, for articles published in English, Spanish, German, or French. The review included nine articles about qualitative or mixed methods studies (4 high quality, five moderate quality) that evaluated physicians’ and patients’ perceptions about VKAs.
The studies with physician participants included family physicians, cardiologists, geriatrics and internal medicine physicians.
Researchers identified three themes shared by patients and physicians.
1. Information needed to reinforce anticoagulation use. Physicians noted that current anticoagulation guidelines are ambiguous and that research does not always clarify uncertainty about the balance between risks and benefits of VKA therapy—a treatment with “narrow therapeutic margins,” as the study article paraphrases physicians’ comments. They pointed out a lack of information on VKA use in elderly populations—groups more likely to need anticoagulants but under-represented in trials. There were issues noted, too, between the approach to VKA therapy among specialists and hospital-based physicians and that of primary care physicians, with poor communication between these groups identified as part of the problem. Patients felt they received inadequate or insufficient information on VKA therapy and some said that the decision to prescribe VKA therapy was made unilaterally by their physicians.
2. Balance of benefits and risks with VKA use. Physicians had no doubts about benefits of VKAs, but voiced concern about their use in at-risk patients, such as the elderly, alcohol abusers, psychiatric patients, patients at risk for falls, patients who live in certain social environments, and noncompliant patients. Many patients said they elected VKA treatment when they understood their stroke risk and the need for anticoagulation. Patients who were not taking VKAs based their decision not to be treated on the experience of family members, friends, and acquaintances
3. Roles in decision-making and therapy management. In the majority of studies, most physicians said they shared decision making about treatment with patients. Family physicians emphasized the need for better communication between primary care and specialists. Patients had variable perceptions about their own role in decision-making, with some feeling more responsible for their own care than others.
Researchers also identified three themes among patients that were not shared with physicians. The first concerned knowledge and understanding of VKA therapy. Understanding the need for and the role of VKAs was better among younger than older patients and varied according to condition, ie, patients with thromboembolism displayed better understanding than those with AF. The second theme had to do with impact on daily life. Patients voiced concerns about daily management (dietary restrictions, drug-drug interactions, alcohol consumption), the need for monitoring, bleeding risk, bruising, and limitations on activities). The third theme was about satisfaction with therapy. Patients reported improved satisfaction when they received information directly from the physician on an individual basis. They reported dissatisfaction with a lack of information given to them, the quality and level of information that is provided by family physicians, and costs and inconvenience related to monitoring.
The authors highlighted the discrepancy in the perception of shared decision-making between physicians and patients. Many physicians reported that they engaged in shared decision making, while patients tended to report a more paternalistic experience--a dichotomy that leaves open the question of what actually takes place in clinical practice.
“Improving the quality and usability of clinical guidelines, the information provided to patients (eg, linking decision aids and guidelines), developing tools to facilitate shared decision-making, and enhancing the coordination between primary care and hospital care could help improve the underuse of this important treatment option in patients with atrial fibrillation,” they concluded.
They noted that the study could not explore differences in attitudes between family practitioners and specialists, or investigate perceptions about newer direct anticoagulants.
Take Home Points
►First review of qualitative review about physician and patient concerns with VKAs suggest physicians’ major difficulties include uncertainty about the risks and benefits in certain cases, need for individualized decision-making, and delegation of responsibility
►Patients emphasize lack of information and understanding about VKAs
►Results show a discrepancy in perception about shared decision-making between physicians and patients
►Improving clinical guidelines, information provided to patients, and using evidence-based decision aids for shared decision-making may improve underuse of VKAs.
The authors report no conflicts of interest
Mas Dalmau G, Sant Arderiu E, Enfedaque Montes MB, et al. Patients' and physicians' perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review. BMC Fam Pract. 2017 Jan 13;18(1):3. doi: 10.1186/s12875-016-0574-0.