Why isn't warfarin prescribed to patients with nonrheumatic atrial fibrillation?
OBJECTIVE
To determine the opinions of selected physicians in our community about use of warfarin for patients with nonrheumatic atrial fibrillation, and to determine the relation of the physicians' opinions to their practices.


METHODS
Survey of physicians, using eight hypothetical clinical vignettes to characterize physicians' opinions about use of warfarin in patients with nonrheumatic atrial fibrillation, according to patient age, risk of bleeding, and risk of stroke.


METHODS
Two teaching hospitals and five community-based practices.


METHODS
Eighty physicians who cared for 189 consecutive patients with nonrheumatic atrial fibrillation.


RESULTS
The survey response rate was 73%. Nearly all responding physicians (90%) recommended warfarin for at least one vignette. However, physicians recommended warfarin less often for vignettes depicting 85-year-old patients than for matched vignettes depicting 65-year-old patients (odds ratio [OR] 0.03; 95% confidence interval [CI] 0.01, 0.08), and less often for cases with specified risk factors for bleeding than for matched cases without the risk factors (OR 0.01; 95% CI 0.004, 0.03); warfarin was recommended more often for cases with a recent stroke than for matched cases without this history (OR 8.2; 95% CI 3.6, 18). In practice, warfarin was prescribed more often (p < or = .05) by physicians reporting good personal experience and by those who had favorable opinions about its use. However, even physicians with good experience and favorable opinions did not prescribe warfarin to half of their patents for whom warfarin was independently judged appropriate.


CONCLUSIONS
Physicians' opinions frequently opposed warfarin for older patients with nonrheumatic atrial fibrillation, and for those with bleeding risk factors. Physicians' opinions, as well as other barriers to warfarin therapy, most likely contribute to its infrequent prescription.
Beyth
R J
RJ
Division of General Internal Medicine, Cleveland Veterans Affairs Medical Center, OH 44106, USA.
Antani
M R
MR
Covinsky
K E
KE
Miller
D G
DG
Chren
M M
MM
Quinn
L M
LM
Landefeld
C S
CS
D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D001291:Attitude of Health Personnel; D002561:Cerebrovascular Disorders / Q000517:prevention & control*; D003430:Cross-Sectional Studies; D017723:Drug Utilization Review; D005260:Female; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D012307:Risk Factors; D014859:Warfarin / Q000627:therapeutic use*
D000925:Anticoagulants; D014859:Warfarin