This qualitative study describes the content of discussions between patients with atrial fibrillation and physicians regarding choice of anticoagulation.
Key Points
Question
How do physicians discuss initiation of anticoagulation with patients with atrial fibrillation in the clinical treatment setting?
Findings
In this qualitative analysis of 37 recorded clinical encounters, physicians emphasized the risk of stroke over the risk of bleeding, often using emotionally persuasive language. The benefits of direct oral anticoagulants were emphasized relative to the downsides of warfarin, and physicians discussed drug cost in less than half of encounters.
Meaning
Physician communication practices encouraged use of direct oral anticoagulants over warfarin, yet physician discussion of medication costs was inadequate; this may have negative consequences for patients who cannot afford them.
Abstract
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.
Introduction
Annually, nearly 800 000 people in the US experience a stroke, 15% of which are attributable to atrial fibrillation (AF).1 Appropriate anticoagulation can reduce this risk by more than 60%.2 Yet the decision to initiate anticoagulation is not always straightforward, as the benefit of stroke reduction must be weighed against the risk of potentially fatal bleeding.3 Patients face the additional decision of choosing warfarin or a direct oral anticoagulant (DOAC). These drugs differ in terms of cost, need for routine monitoring, and dietary restrictions.
How and what physicians communicate to patients regarding treatment options is highly influential in patient decision-making.4 For patients to make decisions consistent with their values and preferences, physicians must present accurate information about treatment risks and benefits.5,6 A study regarding human papillomavirus vaccination found that physicians often presented inconsistent messages, sometimes providing patients with inaccurate information.7 An analysis of encounters for percutaneous intervention in coronary artery disease found that physicians consistently overstated benefits while minimizing risks.8 A number of studies have assessed the cost-related content of medical encounters, finding that physicians’ presentation of cost-related issues is inadequate.9,10,11
Because patients with AF can expect to take anticoagulation treatment for many years, if not decades, patient understanding of risks and benefits is critical. It is for this reason that multiple professional societies support informed decision-making for anticoagulation.12 Yet the type of information physicians convey to patients when making anticoagulation decisions is largely unknown. The objective of our study was to describe themes associated with physician discussions of anticoagulation with patients with newly diagnosed AF.
Methods
Study Population
This study uses data from the Verilogue Point-of-Practice Database. These are recorded clinical encounters between physicians and patients, drawn from more than 600 US physician practices, typically used for marketing research. Participating physicians are given a monthly quota of encounters to record. Patients are recruited to participate by physicians or front desk staff and provide consent. Physicians are not informed which topics or aspects of the encounter are of interest. We asked Verilogue to search for encounters with anticoagulation-naive patients with AF between 2014 and 2020 wherein anticoagulation was either discussed or prescribed. Details on Verilogue as well as the sample used for this analysis were previously published.13 Physicians recorded patient race and ethnicity based on their knowledge of the patient and information contained in the patient’s medical record. Verilogue collects patient race and ethnicity so that researchers who use their data can assess differences in the content of clinical conversations by patient race and ethnicity. We did not consider patient race and ethnicity in our analysis but report it as a description of the sample. This study was approved by Cleveland Clinic’s Institutional Review Board. This study followed the Standards for Reporting Qualitative Research (SRQR) reporting guideline.
Qualitative Analysis
The theory guiding the analysis was social constructivism, which suggests that individuals create shared knowledge and reality through language and communication.14 Two study team members (H.M.H. and K.A.M.) coded 1 transcript together. They then separately coded 10 initial transcripts line by line to identify key themes. The open coding consisted of a deductive and inductive approach. Deductively, they examined the discussions of anticoagulation benefits and risks. Via inductive coding, other themes emerged. They compared coding and discussed encounters in-depth to achieve intercoder reliability and to come to agreement about a codebook that included all themes and codes identified in the first 10 transcripts. They double coded the remaining transcripts, adding to and adjusting the codebook until reaching thematic saturation. The study team discussed the analysis, reviewed the coding, and came to agreement about key findings.
Results
Of 37 encounters, almost all (34 [92%]) resulted in a DOAC prescription, and 3 (8%) resulted in a warfarin prescription. There were no encounters in which an anticoagulant was discussed but not prescribed. Three patients (8%) were Asian, 3 (8%) were Black, 2 (5%) were Hispanic, and 25 (68%) were White; race and ethnicity data were missing for 4 patients (11%). Fifteen (41%) were female and 22 (59%) were male; 24 (65%) were aged 65 to 84 years. Twenty-one physicians conducted the encounters. Patient and physician characteristics are presented in the Table. Most physicians were cardiologists (14 [67%]) and male (19 [90%]). Fifty-seven percent of physicians (n = 12) contributed only 1 encounter, and 24% (n = 10) contributed only 2. The median (IQR) encounter length was 8.4 (5.0-17.2) minutes.
Table. Demographic Characteristics of Patients and Physicians From 37 Encounters.
| Characteristic | No. (%) |
|---|---|
| Patients | |
| No. | 37 |
| Gender | |
| Female | 15 (41) |
| Male | 22 (59) |
| Age, y | |
| 50-64 | 6 (16) |
| 65-74 | 14 (38) |
| 75-84 | 10 (27) |
| ≥85 | 7 (19) |
| Race and ethnicity | |
| Asian | 3 (8) |
| Black | 3 (8) |
| Hispanic | 2 (5) |
| White | 25 (68) |
| Missing | 4 (11) |
| Physicians | |
| No. | 21 |
| Specialty | |
| Cardiology | 14 (67) |
| Internal/family medicine | 7 (33) |
| Years in practice | |
| 3-10 | 2 (9) |
| 11-20 | 8 (38) |
| 21-30 | 4 (19) |
| ≥31 | 7 (33) |
| Gender | |
| Female | 2 (10) |
| Male | 19 (90) |
After open coding the initial 10 transcripts, the coders nearly reached saturation. By coding transcripts 11 to 20, the team confirmed they had reached saturation, and no new insights or themes emerged. To learn as much as possible from the data, the remaining 17 transcripts were also coded. The analysis revealed 4 major thematic categories and associated subcategories (Box).
Box. Major Themes and Subthemes Identified in Encounters Between Physicians and Their Anticoagulation-Naive Patients With Atrial Fibrillation During Which Anticoagulation Was Discussed and Prescribed.
Theme 1. Benefit vs Risk of Taking Anticoagulation
Subthemes
Imbalance in completeness of discussion of stroke risk vs bleeding risk
Emotional/persuasive language regarding strokes vs bleeds
Theme 2. Tradeoffs Between Warfarin and DOACs
Subthemes
Discussion of pros and cons
Emotional/persuasive language regarding DOACs vs warfarin
Mixed signals
Theme 3. Medication Costs
Subthemes
Lack of cost-related information with which to counsel patients
Provision of drug samples or coupons
Theme 4. Discussion of DOACs via Television
Subthemes
Physician use of DOAC commercials to orient patients to discussion
Patient concerns regarding advertisements for class action lawsuits
Benefit vs Risk of Taking Anticoagulation Agents
Imbalance in Completeness of Discussion of Stroke Risk vs Bleeding Risk
Most (but not all) physicians explained the benefit of anticoagulation therapy. In these cases, the physician stated that AF increases the risk of stroke, and anticoagulation lowers that risk. Fewer physicians presented information on bleeding risk. Physicians sometimes gave numeric risks of stroke but almost never provided numeric risk of bleeding. Some physicians presented stroke as an inevitable outcome of AF.
“[Anticoagulants] reduce your stroke rate from 10% a year down to 2%, and there are generally no side effects except that you bruise easier.”
“I am very uncomfortable not having you on [an anticoagulant] because you’re going to have a stroke.”
Physicians de-emphasized bleeding as the major risk of anticoagulation, even in cases where patients asked the physician about potential adverse effects.
“Basically like with any drug, there’s always a chance for bleeding.”
“You know, you cut yourself shaving. You’re going to bleed. You fall down and hit your noggin, you might bleed. But you could also have a stroke. I think I would rather take the chance of cutting myself than having a stroke. A stroke is the worst thing in my mind I could ever have.”
Emotional/Persuasive Language Regarding Strokes vs Bleeds
Physicians emphasized the consequences of having a stroke through emotional language. They described how a stroke would affect the patient in terms of being unable to move, becoming a burden on their families, or dying. One physician described having a stroke as a “nightmare.”
“The whole idea is to prevent, God forbid, a stroke, okay? Because if a stroke happens we can’t do anything about it, but right now we can prevent it.”
“If you have a stroke—if you think you’re handicapped now—then you become paralyzed in one side of your body. You can’t swallow. You can’t move yourself. It’s only going to be worse.”
Physicians conveyed much more detail to patients about the negative outcomes of a stroke vs negative outcomes of a bleed. In multiple encounters, physicians used the word “always” to describe the bleeding risk associated with anticoagulation, as if this was a standard risk of taking medication.
“If there’s a small stroke then you may have a little bit of weakness in your arm, but if you have a big stroke, that’s when the whole side [is paralyzed] and you can’t move it. And so of course there’s always a little bleeding risk with the medication.”
In contrast, when physicians addressed bleeding risk, they conveyed less evocative examples (eg, “you may bruise more easily”). Some of them even made light of bleeding risk through humor.
“Physician: And, okay, try not to fall, right?
Patient: [Laughing] Right.
Physician: Wear a helmet, right?
Patient, referring to caregiver: Yes, that’s what he’s going to buy me when we leave.”
Tradeoffs Between Warfarin and DOACs
Discussion of Pros and Cons
Physicians described both warfarin and DOACs to most patients, and said they were similarly efficacious in terms of preventing strokes, with DOACs having a slightly more favorable bleeding profile. Yet the benefits of DOACs were emphasized against the drawbacks of warfarin, which were often exhaustively listed.
“There are two ways to treat [AF]. You can get the old warfarin, which is dirt cheap. I mean it will cost you pennies a day. But you have to have blood drawn all the time, and you have to watch what you eat, you can’t eat leafy green vegetables. If you love salad, you have to eat the same amount each week…besides the blood draws—your levels go all over the place. The new drugs, there’s no blood draws for it. You just take it and it works.”
“You’ve got to do blood tests all the time to make sure your levels are okay because the levels could go off. The newer ones, you don’t have to do any blood tests. They’re nice and steady. The chance of bleeding is only half of what it is on warfarin and a lot lower than your risk of a stroke. You don’t have to watch your foods with them.”
Emotional/Persuasive Language Regarding DOACs vs Warfarin
Physicians emphasized the newness of DOACs, with the implication that their newness makes them better than warfarin.
“There are two types of blood thinners. One is called warfarin, you may have heard of that. It’s been around for about 6000 years now.”
Discussion of warfarin was generally negative. Multiple physicians told patients that warfarin is the active ingredient in rat poison.
“I’ll just tell this to you because somebody else will, and I don’t like saying this, but it’s true, it’s the main ingredient in rat poison.”
“There’s a medicine called warfarin that, you know, people sometimes refer to as rat poison because we use it for rat poison as well.”
Mixed Signals
Physicians sometimes conveyed confusing messages about the tradeoffs of DOACs vs warfarin. While they would say the drugs were similar in terms of preventing strokes, and that warfarin was cheaper, in the same encounter they would mention that warfarin is rat poison. One physician implied that warfarin may not even be cheaper than DOACs after accounting for blood draws.
“So the question is, can you afford to pay for the difference in these two medications? Though the warfarin is dirt cheap, inconvenient, doctor’s offices, frequent visits, you’ll pay for those blood draws, so you have to take that in consideration with the more expensive medication.”
Medication Costs
Lack of Cost-Related Information With Which to Counsel Patients
Physicians discussed medication costs with patients in less than half of encounters. Most told patients that DOACs were more expensive than warfarin. They sometimes asked patients what kind of insurance they had and what other name-brand drugs they took to attempt to elucidate the DOAC co-pay. No physician was able to give a definite answer about what a DOAC would cost or if insurance would cover it.
“It may cost a little bit more. I don’t know, uh, your insurance, how much, if it’s covered, but when you go to the pharmacy, they’ll let you know.”
Physicians proposed prescribing a different DOAC or warfarin if patients were unable to afford the originally prescribed DOAC.
“What’s your insurance coverage like for these drugs? If it’s crazy expensive, whatever the co-pay is or whatever, we can look and see if they approve a different drug.”
Another falsely reassured the patient regarding coverage.
“Here’s a problem, you have insurance, right? Does it cover medications? [Patient responds affirmatively.] Okay good. Because the new ones are very expensive but if you have insurance they’re all covered by the regular insurances.”
Provision of Drug Samples or Coupons
Physicians provided coupons and free samples of DOACs to patients to allay uncertainty about costs.
“So what I will do is give you some samples of Eliquis and then have you take a prescription to the drug store. And the drug store can tell you how much it’s going to cost and if it requires prior authorization…. Every plan is different. We never know who’s going to need it. We’ll give you some samples so you get started on it now while that part gets worked out.”
Physicians acknowledged that these patients may ultimately have to switch to warfarin.
“We’ll give you some samples so you get started on it now while that part gets worked out. If it turns out not covered by the insurance, then we’ll switch over to warfarin.”
Discussion of DOACs via Television
Physician Use of DOAC Commercials to Orient Patients to Discussion
Physicians used direct-to-consumer (DTC) advertising about DOACs to orient patients to the issue of anticoagulation as well as the advantages of DOACs over warfarin, even going so far as to recommend patients watch DOAC commercials to learn more about AF.
“You probably have seen TV commercials for some of the new blood thinners that are used to prevent stroke from atrial fibrillation.”
“So, all the ones you see on TV in the commercials—Xarelto, Pradaxa, Eliquis? Those are the kind of medications we’re going to go with.”
“When they talk about atrial fibrillation on the television, listen to what it says.”
Patient Concerns Regarding Advertisements for Class Action Lawsuits
Some patients expressed trepidation regarding DOACs because of television advertisements for class action lawsuits. Physicians were generally dismissive of these concerns.
“There have been no lawsuits. They’re on there just gathering names, so in case later they show that there’s been a problem with the medicines, these guys, they’re just being [expletive].”
Discussion
In this qualitative content analysis of clinical encounters of physicians counseling patients about anticoagulation, physicians emphasized the benefit of stroke risk reduction while minimizing the risk of bleeding and emphasized the advantages of DOACs over warfarin. Drug costs were discussed less than half the time, and no physician had a clear answer for patients about how much they would pay. Physicians used DTC television advertisements for DOACs to orient patients to the benefits of anticoagulation and the benefits of DOACs over warfarin.
Multiple studies have documented suboptimal rates of anticoagulation among patients who would benefit.15,16 This may be why physicians presented information about strokes and bleeds differently—because they did not want patients to weight them equally in decision-making. When discussing strokes, physicians used frightening language and imagery describing stroke as a “nightmare” and the “worst thing that could happen.” Conversely, physicians minimized risk of bleeding, sometimes framing it in humorous terms, warning patients about incurring minor injuries. While we lacked information on patient stroke risk, physicians likely thought that the risk of stroke was high enough that persuasive communication was warranted.
While persuasive communication may be warranted in cases where the benefit of intervention vastly outweighs inaction,17 for some patients, eg, those at high risk of bleeding but lower risk of stroke, the choice to forgo an anticoagulant may be reasonable. Failure to provide objective information to these patients limits their decisional autonomy. It is for this reason that multiple professional societies recommend physicians engage patients in informed decision-making for anticoagulation.12 This includes individualized presentation of risk and benefit of anticoagulation and an exploration of patient values and preferences.18 None of the encounters we analyzed included a balanced discussion of risk vs benefit of anticoagulation. Moreover, physicians expressed their own feelings about having a stroke but never queried patients about their feelings.
In deciding whether to take warfarin or a DOAC, a key determinant is affordability. A recent study found that three-quarters of encounters for anticoagulation included some conversational element related to cost.19 To our knowledge, ours is the first study to report the content of such conversations. Physicians were unprepared to counsel patients on costs. Some recommended patients try to fill a DOAC prescription to find out the cost and offered to prescribe another DOAC or warfarin if the cost was prohibitive. However, physicians also pushed patients to choose DOACs over warfarin, referring to the latter as “rat poison.” Cost is the strongest predictor of abandoning a prescription at the pharmacy,20 and patients who are unable to pay for DOACs may understandably not want to take rat poison instead. In the absence of cost information, use of persuasive communication potentially opens the patient to harm. Physician use of tools that support informed decision-making can increase the frequency of cost conversations with patients.19 However, given myriad insurance plans and co-pay structures for brand-name drugs, it is unclear to what extent such tools can meaningfully improve the quality of decision-making for DOACs.
Physicians leveraged patients’ familiarity with television advertisements to help them understand the benefits of DOACs vs warfarin. To our knowledge, we are the first to report this phenomenon. Direct-to-consumer pharmaceutical advertising is a $6 billion dollar industry.21 These commercials are designed to sell DOACs, and therefore are inappropriate for use as a teaching tool. Various messaging and framing effects used in these commericals22 can lead patients to underestimate risks and overestimate benefits.23 Older age and compromised cognitive abilities also influence patients’ risk comprehension.24 Patients also brought up commercials, expressing concern about class action lawsuits, which physicians dismissed. Efforts are needed to understand the role of DTC advertising in anticoagulation discussions.
To our knowledge, ours is the first study to describe conversations in the clinical treatment setting between physicians and patients with AF discussing anticoagulation initiation. As this is a qualitative study, the findings are not intended to generalize to all encounters in which physicians discuss anticoagulation with patients. However, we identified a number of important themes that suggest that interventions to improve physician communication with anticoagulation-naive patients may be warranted. Strategies to support physicians in navigating cost-related uncertainty with patients are especially needed.
Limitations
This study had limitations. It can often take more than 1 encounter to convince an asymptomatic patient to take long-term anticoagulation therapy. However, we only had the transcript for a single encounter. We do not know whether this was the first conversation during which the physician discussed anticoagulation with that patient. Prior encounters that were not recorded may have included different information. We have limited information on patients and physicians represented in our data, including geographic region or practice type. While Verilogue recruits physicians from all regions of the US as well as from diverse practice settings, physicians who choose to participate may differ from physicians who do not participate. Finally, while Verilogue searched for encounters wherein anticoagulation was either discussed or prescribed, no encounters were identified where a physician discussed anticoagulation but did not prescribe it. It may be that when physicians thought an anticoagulant was unwarranted, they simply did not discuss it, which also threatens patient autonomy. This incidental finding warrants further investigation in other data sources, as our study was not designed to measure it.
Conclusions
In our qualitative study of anticoagulation discussions occurring in the clinical treatment setting, we found that physicians engaged in persuasive communication to convince patients to accept DOACs. Physicians often attempted to address drug costs but were unable to provide adequate information for informed decisions. While physicians’ intentions were certainly good, these approaches can rob patients of autonomy and could result in patient harm for those unable to afford DOACs.
Footnotes
DOAC indicates direct oral anticoagulant.
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