Key result
In 37 clinical encounters, physicians used persuasive communication to convince anticoagulation-naive patients with atrial fibrillation to accept DOACs, which were prescribed in 92% of cases.
Why the study?
For patients with AF, initiating anticoagulation involves choosing between warfarin and DOACs, but how physicians engage patients in this decision was unknown.
Observational (n=37)
Physicians often use persuasive communication to encourage DOAC use over warfarin in AF patients but struggle to address out-of-pocket cost concerns, potentially leading to financial burden or nonadherence.
Answers are grounded in this paper and cite their sources.
Clinicians should prepare cost information before DOAC discussions to support adherence; leaves open optimal strategies for cost transparency in anticoagulation decisions.
Importance: For 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. Objective: To describe the content of discussions between patients with AF and physicians regarding choice of anticoagulation. Design, Setting, and Participants: This qualitative content analysis included clinical encounters between physicians and anticoagulation-naive patients discussing anticoagulation initiation between 2014 and 2020. Main Outcomes and Measures: Themes identified through content analysis. Results: Of 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 Relevance: This 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.
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Martinez et al. (2022) conducted an observational in Atrial fibrillation (n=37). Patient-physician discussions regarding choice of anticoagulation was evaluated on Themes identified through content analysis. In 37 clinical encounters, physicians used persuasive communication to convince anticoagulation-naive patients with atrial fibrillation to accept DOACs, which were prescribed in 92% of cases.
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