Table 2:

Domain 1: Themes, subthemes, and representative quotations from ED Physicians about their beliefs and considerations leading to OAC prescribing practices for new-onset AF at ED discharge

Theme	Subtheme	Representative Quotation
Practice Patterns	Cardiology Consult	Interviewer: Do you discharge patients on warfarin from the ED? Physician: Not without a specialty consultation. [If] they feel that they can see the [patient] to complete their workup and discharge and arrange post follow up—I would, but only after getting that specialty consultation on a new onset AF. In terms of anticoagulation, usually I talk to the cardiologist who will be involved with the patient to try and figure what kind anticoagulation to do for the patient. Whether they need an echocardiogram prior to starting the anticoagulation or [anticoagulation] prior if they wanted to cardiovert them or something. I tend to not get into the world of anticoagulation unless they have a very high CHADS score, in which case usually a cardiologist has been consulted, and then we discuss whether we want to send them out on an anticoagulation strategy.
Beliefs	Burden of OAC on the Patient	Taking something like warfarin is incredibly taxing on people. They have to have weekly or at least biweekly INR checks and they have to follow a strict diet and they have to take medicines that don't interact with their warfarin. I mean, you're really comparing coumadin versus the novel oral anticoagulants and its sort of a no-brainer for compliance. I mean coumadin is very difficult to take because it's very sensitive to diet, other medications, it can go up or down, [and] it needs to be monitored very carefully. You have none of these issues with the new medications, so it's pretty easy.
	Lack of Treatment Continuity/Communication with PCP	I think one of the biggest problems we have is a lack of communication, too many chefs in the kitchen. I also think it's a waste of my time to do all the research and try to do the right thing and then to send them to somebody who feels uncomfortable with my plan. Anticoagulation—I leave [it] entirely up to the consultants because they'll be the ones who are managing it long term and once we get someone stabilized, well anticoagulation is good, [but] it's not like if we don't give it the next hour or two, they get progressively worse.
	Initiating OAC in the ED can be beneficial to medication adherence	I think we make an impact after discharge if we start the anticoagulation. I think that there is a potentially real impact from that and a number of patients that are going to take the medication and continue to take the medication.
Barriers	Experience & Comfort	Lack of [a] reversal agent for GI bleed and intracranial hemorrhage is a major downside. With the elderly population, who often have atrial fibrillation—I think that's the biggest consideration, for me at least— just the risks of falls and the fact that the novel anticoagulants don't have a reversal agent. So that's my sort of uncomfortableness with that. I'm more comfortable with coumadin but I am becoming comfortable with the novel anticoagulants. I've prescribed them before. I feel that I have a lot more comfort with coumadin; and the new ones you can't really monitor it too much, unless you [measure] a factor Xa. I think I'm more open to start a novel anticoagulant in AF for stroke prevention, clot prevention whatever, than I am for someone who has an actual clot. So I think that that would be my ideal patient because like I had mentioned before, I'm not as familiar or comfortable with initiating those medications. [A]t this point in my practice, I'm sticking with aspirin or coumadin depending on their CHADS score.
	Insurance Coverage	The problem is that, you know, [NOACs] are really costly. Some insurance companies will not cover that. So it really depends on what you know about their insurance status. I'd rather know one way or the other [about their insurance coverage],…[rather] than just write someone a script and then have them find out the next morning, "Oh, I can't fill this,” and then days would go by without anything, right? [For example]…the conversation really revolved around whether or not her insurance would cover rivaroxaban [a NOAC] because I've had the personal experience of seeing other patients bounce back that had been given a prescription for rivaroxaban but then they came back saying, "My insurance doesn't pay for this” and “can you put me on another drug?" If insurance was not an issue, I would just go to rivaroxaban or the [other] novel oral anticoagulants because the risk of dangerous bleeding is less and you don't have the monitoring issues that you have with coumadin, but this whole issue of coverage is really important because it makes no sense to give a prescription to a patient when they can't, if they're not covered and they can't afford it.
Patient Factors	Co-Morbidities	So if they have CHF, high blood pressure, endstage diabetes, previous history of stroke and then, you’ll [consider] whether or not you're going to [put] somebody on aspirin versus busting out some more aggressive anticoagulation.
	Bleeding Risk	The thing I like about warfarin is that there are ways to reverse it. If you start bleeding on warfarin, there are certainly good ways to reverse it. [With] other newer novel anticoagulation agents, there aren't great reversal agents. With a lot of the new or novel oral anticoagulants, or NOAC medications, they're thought to be, at least in some trials, a little bit more effective and a little bit safer. [If] somebody is at high risk of falling, then [we] maybe just want to do aspirin because the risk of them having a major bleeding episode after a fall may be too high. But at that point it's much more of a discussion with the patient and their family regarding … what they feel is acceptable for them given the risks and benefits of their current situation.
	Follow-Up Care	[I]t's not practical to start people on stuff that needs chronic follow-up. That's not what the ED typically does. I feel like we do tend to admit a lot of these people because we're uncomfortable with them because they don't have good follow-up. I definitely need to have somebody follow [a patient] up if I'm going to discharge them home, you know, for atrial fibrillation. I won't discharge them if they don't have a primary care doctor in general. Very good follow-up first and foremost because warfarin necessitates INR measurements, and [a] regular physician, or at least access to anticoagulation clinic to do those measurements and to kind of follow [and] make recommendations about dosage adjustments. We are not very well equipped in the ED to deal with chronic disease so a lot of the barriers have to do with ongoing medical management and its dynamic situation. So there really is a crucial need for follow-up with these patients in an appropriate setting.
	Social Status and Support	You have to [be] a fairly organized person or at least have a strong family system plus a good PCP who can manage all that stuff for you. [I]f we're going to send them out on Lovenox and coumadin, are they going to be able to administer those medications, do they have insurance that is going to be able to cover it, or can they afford those medications? [T]here are some patients that might have an elevated [CHADS] score but have another reason that we might not want to anticoagulate them, and there is also sometimes a follow-up issue; that is that they don't have primary care physician, the ability to pay for certain medications, there are some social insurance and follow up issues that differ patient to patient.
	Preferences	I think a decision aid could be [helpful]…if it proposed an oral anticoagulant that is not cost prohibitive,…could help in a shared decision-making discussion on patient preferences, increased compliance with an oral anticoagulant, and if the inclusion criteria included the study group [I] always have [a] shared decision-making conversation, but I think I would say that more often than not, that patients are okay with [NOACs] and they prefer not having to have their INR checked.