Qualitative Analysis of Patient–Physician Discussions Regarding Anticoagulation for Atrial Fibrillation

Abstract

ImportanceFor patients with atrial fibrillation (AF), the decision to initiate anticoagulation involves the choice between warfarin or a direct oral anticoagulant (DOAC). How physicians engage patients in this decision is unknown.ObjectiveTo describe the content of discussions between patients with AF and physicians regarding choice of anticoagulation.Design, Setting, and ParticipantsThis qualitative content analysis included clinical encounters between physicians and anticoagulation-naive patients discussing anticoagulation initiation between 2014 and 2020.Main Outcomes and MeasuresThemes identified through content analysis.ResultsOf 37 encounters, almost all (34 [92%]) resulted in a prescription for a DOAC. Most (25 [68%]) patients were White; 15 (41%) were female and 22 (59%) were male; and 24 (65%) were aged 65 to 84 years. Twenty-one physicians conducted the included encounters, the majority of whom were cardiologists (14 [67%]) and male (19 [90%]). The analysis revealed 4 major categories and associated subcategories of themes associated with physician discussion of anticoagulation with anticoagulation-naive patients: (1) benefit vs risk of taking anticoagulation—in many cases, this involved an imbalance in completeness of discussion of stroke vs bleeding risk, and physicians often used emotional language; (2) tradeoffs between warfarin and DOACs—physicians typically discussed pros and cons, used persuasive language, and provided mixed signals, telling patients that warfarin and DOACs were basically equivalent, while simultaneously saying warfarin is rat poison; (3) medication costs—physicians often attempted to address patients’ questions about out-of-pocket costs but were unable to provide concrete answers, and they often provided free samples or coupons; and (4) DOACs in television commercials—physicians used direct-to-consumer pharmaceutical advertising about DOACs to orient patients to the issue of anticoagulation as well as the advantages of DOACs over warfarin. Patients and physicians also discussed class action lawsuits for DOACs that patients had seen on television.Conclusions and RelevanceThis qualitative analysis of anticoagulation discussions between physicians and patients during clinical encounters found that physicians engaged in persuasive communication to convince patients to accept anticoagulation with a DOAC, yet they were unable to address questions regarding medication costs. For patients who are ultimately unable to afford DOACs, this may lead to unnecessary financial burden or abandoning prescriptions at the pharmacy, placing them at continued risk of stroke.