title: Patients' and physicians' perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review.
abstract: BACKGROUND
  Oral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients' and physicians' perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients' and physicians' perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse.
  
  
  METHODS
  We included studies that used qualitative or mixed methods and focused on patients' and/or physicians' perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach.
  
  
  RESULTS
  We included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding.
  
  
  CONCLUSIONS
  Physicians' and patients' perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation.
authors.affiliation: Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain. gmasd@santpau.cat.
authors.forename: Gemma
authors.initials: G
authors.lastname: Mas Dalmau
authors.affiliation: Consorci d'Atenció Primària de Salut de l'Eixample (CAPSE), CAP Casanova, Barcelona, Spain.
authors.forename: Elisenda
authors.initials: E
authors.lastname: Sant Arderiu
authors.affiliation: Institut Català de la Salut, SAP Litoral-esquerra, Barcelona, Spain.
authors.forename: María Belén
authors.initials: MB
authors.lastname: Enfedaque Montes
authors.affiliation: Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.|CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
authors.forename: Ivan
authors.initials: I
authors.lastname: Solà
authors.affiliation: Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.
authors.forename: Sandra
authors.initials: S
authors.lastname: Pequeño Saco
authors.affiliation: Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.|CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
authors.forename: Pablo
authors.initials: P
authors.lastname: Alonso Coello
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D001291:Attitude of Health Personnel; D005194:Family Practice; D005260:Female; D006801:Humans; D008297:Male; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D010465:Perception; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000639:trends*; D011379:Prognosis; D036301:Qualitative Research; D018570:Risk Assessment; D020521:Stroke / Q000517:prevention & control; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants
keywords: Atrial fibrillation; Attitudes; Oral-anticoagulation therapy; Patients; Perceptions; Physicians; Qualitative Research; Systematic Review