title: 'Rules of thumb' or reflective practice? Understanding senior physicians' decision-making about anti-thrombotic usage in atrial fibrillation.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  To improve understanding of physicians' behaviour and attitudes in respect to decision-making in AF and the use of anti-thrombotics.
  
  
  METHODS
  Semi-qualitative, questionnaire- and interview-based study.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors: Medical Department for the Elderly, The General Infirmary at Leeds, Leeds LS1 3EX, UK.
authors: N
authors: N
authors: Anderson
authors: R
authors: R
authors: Fuller
authors: N
authors: N
authors: Dudley
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D002309:Cardiology; D002983:Clinical Competence / Q000592:standards*; D003657:Decision Making; D003937:Diagnosis, Differential; D005194:Family Practice; D005260:Female; D005853:Geriatrics; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D011795:Surveys and Questionnaires; D014859:Warfarin / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D014859:Warfarin