Barriers and enablers to adherence to anticoagulation in heart failure with atrial fibrillation: patient and provider perspectives.
OBJECTIVE
The purpose of this study was to elucidate the barriers and enablers to adherence to anticoagulation in individuals with chronic heart failure (CHF) with concomitant atrial fibrillation (AF) from the perspective of patients and providers.


BACKGROUND
CHF and AF commonly coexist and are associated with increased stroke risk and mortality. Oral anticoagulation significantly reduces stroke risk and improves outcomes. Yet, in approximately 30% of cases, anticoagulation is not commenced for a variety of reasons.


METHODS
Qualitative study using narrative inquiry.


METHODS
Data from face-to-face individual interviews with patients and information retrieved from healthcare file note review documented the clinician perspective. This study is a synthesis of the two data sources, obtained during patient clinical assessments as part of the Atrial Fibrillation And Stroke Thromboprophylaxis in hEart failuRe (AFASTER) Study.


RESULTS
Patient choice and preference were important factors in anticoagulation decisions, including treatment burden, unfavourable or intolerable side effects and patient refusal. Financial barriers included cost of travel, medication cost and reimbursement. Psychological factors included psychiatric illness, cognitive impairment and depression. Social barriers included homelessness and the absence of a caregiver or lack of caregiver assistance. Clinician reticence included fear of falls, frailty, age, fear of bleeding and the challenges of multimorbidity. Facilitators to successful prescription and adherence were caregiver support, reminders and routine, self-testing and the use of technology.


CONCLUSIONS
Many barriers remain to high-risk individuals being prescribed anticoagulation for stroke prevention. There are a number of enabling factors that facilitate prescription and optimise treatment adherence. Nurses should challenge these treatment barriers and seek enabling factors to optimise therapy.


CONCLUSIONS
Nurses can help patients and caregivers to understand complex anticoagulant risk-benefit information, and act as a patient advocate when making complex stroke prevention decisions.
Centre for Cardiovascular & Chronic Care, University of Technology Sydney, Sydney, Australia.
Caleb
http://orcid.org/0000-0002-2417-2216
C
Ferguson
Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia.
Sally C
SC
Inglis
Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia.
Phillip J
http://orcid.org/0000-0002-5006-2037
PJ
Newton
St Vincent's Health Australia (Sydney) & Australian Catholic University, North Sydney, NSW, Australia.
Sandy
S
Middleton
Heart Transplant Program, St Vincent's Hospital, Sydney and Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia.
Peter S
PS
Macdonald
Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia.|School of Nursing, Johns Hopkins University, Baltimore, MD, USA.
Patricia M
PM
Davidson
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy / Q000523:psychology; D005260:Female; D006297:Health Services Accessibility; D006333:Heart Failure / Q000150:complications / Q000188:drug therapy / Q000523:psychology; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D057240:Patient Preference; D010818:Practice Patterns, Physicians'; D036301:Qualitative Research; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000517:prevention & control*; D014859:Warfarin / Q000627:therapeutic use*
D000925:Anticoagulants; D014859:Warfarin
anticoagulation; atrial fibrillation; caregiver; heart failure; medication adherence; stroke prevention; thromboprophylaxis