'Rules of thumb' or reflective practice? Understanding senior physicians' decision-making about anti-thrombotic usage in atrial fibrillation

Abstract

The recently published Atrial Fibrillation (AF) Guidelines from the National Institute for Health and Clinical Excellence (NICE) highlight the importance of assessing stroke risk and using appropriate anti-thrombotic therapy. To improve understanding of physicians' behaviour and attitudes in respect to decision-making in AF and the use of anti-thrombotics. Semi-qualitative, questionnaire- and interview-based study. Five clinical vignettes relating to treatment choices for AF and stroke prevention illustrating a range of risk and benefit were examined by 14 senior physicians (consultants or specialist registrars) in Cardiology, General Medicine and Geriatric Medicine, who then recommended anti-thrombotic treatment. A semi-structured interview explored their decision-making and prescribing in AF, with qualitative analysis of interview transcripts using grounded theory. There was marked variation in the choice of anti-thrombotic treatment. Respondents were more likely to prescribe warfarin to patients with a previous intracerebral haemorrhage than to a patient with a history of falls. A key theme on qualitative analysis revealed that decision-making in AF is often associated with uncertainty and concerns about knowledge of risk and benefit. In this study, doctors rarely agreed on the choice of anti-thrombotics in AF, and their perceptions of stroke and bleeding risk showed considerable variation. Uncertainty, doubt, concerns about knowledge and varied approach to the role of patients in decision-making are all significant themes in the considerable variability in anti-thrombotic prescribing.