Patient experiences of atrial fibrillation, stroke risk and anticoagulant choices: a qualitative study.

Problem

Atrial fibrillation (AF) is a cardiac condition affecting 1-2% of the UK population. AF confers a 5-fold increase in stroke risk. Oral anticoagulation treatment reduces stroke risk but increases bleeding risk. 15% of patients with AF in the UK at high risk of stroke are not on anticoagulant therapy. Involving patients in healthcare decisions is considered good practice. The National Institute for Health and Care Excellence support this in AF and have developed a patient decision aid. Limited understanding of AF and its associated risks is a potentially important barrier to patients sharing treatment decisions. Communicating treatment risks and benefits can be challenging. This study aims to explore patient experiences of atrial fibrillation focusing on understanding of the condition, perception of stroke risk and how this impacts on decision making regarding anticoagulation therapy. Study findings will suggest how patients can be supported in becoming involved in their treatment choices.

Approach

Patients with AF diagnosed within three years were recruited from three GP surgeries. Sampling aimed to ensure a mix of age, gender, and anticoagulation therapy. 20 qualitative semi-structured interviews were conducted using a topic guide, audio-recorded, anonymized and transcribed verbatim. A thematic analysis was undertaken: preliminary codes were developed by two researchers independently before discussion to agree a coding frame; codes were subsequently grouped into themes.

Findings

Data analysis is ongoing; full results will be available at conference, and emerging themes are discussed here. Presentation of AF: AF may be diagnosed incidentally or at a time of health crisis, for example at the time of a stroke. Often several new diagnoses and medications may be received at one time. Most patients described a paternalistic approach when recalling starting anticoagulation medication. Understanding of AF, stroke risk and medication: AF had a variable day-to-day impact on patients. The experience of symptoms attributed by the patient to AF was important in their sense of burden from the condition and of their perception of risk associated with AF. Patients had limited understanding of AF as a risk factor for stroke, and of the rationale for anticoagulation therapy. Interaction with healthcare services: Patients described their healthcare practitioners as busy and difficult to access. After initiation of anticoagulation therapy the decision was not revisited with a healthcare professional, although several patients described uncertainties about their medication and a desire to discuss them further.

Consequences

The context in which AF is diagnosed may be a barrier to patient involvement in decisions about starting anticoagulation. In this study, patients typically had very limited understanding of AF and its treatment, preventing meaningful involvement in their treatment decisions. Recognizing the importance of the circumstances surrounding the diagnosis and providing opportunities for reviewing treatment decisions in routine care may help to overcome these barriers.