Clinicians’ views and experiences of prescribing oral anticoagulants for stroke prevention in atrial fibrillation: A qualitative meta-synthesis

Background: Globally, over 33 million people have atrial fibrillation (AF). In eligible patients, oral anticoagulation (OAC) is recommended for stroke risk reduction. Despite recent increases in OAC prescribing, global under-prescription to high-risk AF patients and inappropriate prescription to low-risk patients is leading to unnecessary risk of stroke and haemorrhage. This meta-synthesis explored clinicians’ beliefs and experiences regarding OAC prescription to AF patients, highlighting barriers to stroke prevention and informing future clinician-focused interventions. Methods and results: A qualitative meta-synthesis exploring clinicians’ views and experiences of prescribing OACs for stroke prevention in AF patients. Databases including MEDLINE, EMBASE, PsychINFO and CINAHL were searched to June 2018, with a further Medline search to February 2020. Thematic synthesis was performed with data coding, descriptive theme categorisation and generation of analytical themes. From 3499 records, 101 full text papers were screened, with 13 eligible studies identified. Four analytical themes were found to affect clinicians’ prescribing: (i) ‘Clinicians’ intellectual and emotional responses to the evidence’; (ii) ‘Prescribing in primary and secondary care’; (iii) ‘Clinicians’ views of how patients’ characteristics and opinions influence prescribing’; and (iv) ‘Clinicians’ views on their interactions with patients’. Conclusions: This review highlights focal points for future clinician-focused interventions to improve guideline-adherent OAC prescription in AF patients. Interventions should aim to improve clinicians’ knowledge around NOAC prescription and stroke and haemorrhage risk assessment tools as well as their emotional responses to difficult prescribing scenarios. Multidisciplinary interventions promoting cohesive care and input from different clinicians to overcome time-related barriers may increase guideline-adherent OAC prescription for AF patients.