A piece of improvement work I’ve been involved in has thrown up some questions for me around anticoagulation in atrial fibrillation (AF). Quality and Outcomes Framework data indicates that we are undertreating people with AF in terms of anticoagulation, and as a result, they are unnecessarily being put at risk of having a stroke. [1]

Looking at this in more detail, it seems that many of the patients who are currently not on anticoagulation, are frail, elderly, housebound patients with significant multimorbidity. [1] The question I have been struggling with is, am I right to recommend anticoagulation for this cohort?

Shared decision-making tools incorporating risk scores such as CHADSVASC and HASBLED are helpful to a certain extent, but my own experience is that patients (and doctors) find it difficult to balance these risks and interpret them within the context of their own life (or their patients’ lives). I discussed this issue with a colleague and we had quite differing views on the matter, and as a result, our approach to counselling patients was also very different.

Below are four different approaches I’ve heard being used when counselling patients around anticoagulation in AF, all of which are similar, but there are slight nuances in the way the facts are presented, which may lead the patient to make a decision one way or the other:

Doctor A—”the presenter of facts”

Your risk of stroke is X and your risk of bleeding is Y—you need to weigh this up and come to a decision about whether you would like to take a medication to reduce your risk of having a stroke. You have to accept that there is a chance you could bleed on the medication, most commonly it can cause bleeding from the stomach, but there is also a small risk of you having a bleed in the brain.

Doctor B—“the anticoagulation champion”

Your risk of stroke is X and your risk of bleeding is Y—however strokes related to AF can be severely disabling or even fatal. If you do have a bleed, it is most likely a bleed from the stomach and this is reversible in most circumstances, whereas there is usually little that can be done to reverse the effects of a stroke.

Doctor C—”the too much medicine” activist

Your risk of stroke is X and your risk of bleeding is Y. Given that you already have a lot of other health problems, I’m unsure as to whether the benefits of treatment outweigh the risks in your case. If you have a bleed while on this treatment, it could be treated, but in some circumstances it could be fatal.

Doctor D—”the shared decision-maker”

Your risk of stroke is X and your risk of bleeding is Y. It is possible to take anticoagulant medication to reduce the risk of you having a stroke but you have to consider what is important to you at this stage. Is taking another tablet something that you feel is worthwhile? How important is it for you not to have a stroke? Are you happy to accept the risk of potentially having a bleed at the expense of preventing a stroke?

There are all sorts of conscious and unconscious biases that may affect the way we present information to our patients. For example, does being involved in an improvement project aiming to improve anticoagulation rates in AF influence my approach to counselling patients? Or if I had personal experience of a patient, friend, or relative, who had suffered a stroke secondary to AF, would that make me more inclined to recommend anticoagulation to my patients? The truth is that it probably would. We rarely just present the facts to patients—our own values, which are shaped by both our personal and clinical experience have a strong influence on our approach. This is true of all areas of medicine, particularly those areas where the weighing up of risks and benefits is not so clear-cut.

This takes me back to the original question of whether we should be recommending anticoagulation to elderly, frail patients with multimorbidity. Exploring what matters to the patient (approach D) and then helping them affirm their decision (using approaches B or C) feels like a sensible way of dealing with the uncertainty around risk vs benefit, and also ensures that patient preferences (as opposed to physician preferences) are guiding the clinical decision. Our biases will always exist and personally I think the best way of dealing with them is to acknowledge their existence, and then proactively ensure that they are not the overriding factor in what should be a shared decision between patient and doctor. In practice this might involve the use of shared decision aids, employing the use of multidisciplinary decision-making in patients with complex multimorbidity, and most of all, keeping the person in mind rather than treating single diseases based solely on clinical guidelines which often fail to take account of the wider bio-psychosocial model. [2]

References:

1. Vanbeselaere V, Truyers C, Elli S et al. Association between atrial fibrillation, anticoagulation, risk of cerebrovascular events and multimorbidity in general practice: a registry-based study.BMC Cardiovasc Disord. 2016 Mar 28;16:61. doi: 10.1186/s12872-016-0235-1.

2. Dalmau G, Arderiu E, Montes M et al. Patients’ and physicians’ perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review. BMC Fam Pract. 2017; 8:3 doi:  10.1186/s12875-016-0574-0