Balancing risk versus benefit: the elderly patient’s perspective on warfarin therapy
Warfarin therapy is underused in the target at-risk elderly population. Clinicians perceive that older patients are reluctant to use this therapy, however the perspective of patients or their carers has yet to be explored.
Objective: To explore in-depth the perspectives of elderly patients and/or their carers regarding the use of warfarin therapy.
Method: A qualitative study, using semi-structured group interviews was undertaken. The audio-taped discussions were transcribed verbatim, then thematically analysed to identify emergent themes. Group discussions were conducted at a major Sydney teaching hospital, over a 2-month period. Individuals aged 65 years or older (and/or their carers) who were using long-term (6 months) warfarin therapy were recruited by voluntary response to study flyers.
Results: 17 patients and carers (mean age 77.2 SD=7.5 years) participated in one of two focus groups. Five core themes emerged regarding warfarin therapy: inadequate knowledge and understanding about it, patients/carers variable experience of information provision, cycle of reactions to being on it, issues in its practical management, and the spectrum of experiences with it. Overall, participants were very accepting of the therapy, describing a high level of compliance, despite initial fears and anxieties, and a relative lack of knowledge. Patients felt somewhat abandoned in their management of warfarin due to the lack of ongoing support services in the community, and inadequate information provision.
Conclusions: Elderly patients and their carers appear to be quite accepting of warfarin therapy, in contrast to the perceptions of health care professionals. More effort is needed, however, in terms of information provision, particularly in the form of community-based services, to assist patients in the long-term management of warfarin.
2. Ang S, Peterson G, Friesen W, Vial J. Review of antithrombotic drug usage in atrial fibrillation. J Clin Pharm Ther. 1998;23:97-106.
3. Stewart F, Singh Y, Persson S, Gamble G, Braatvedt G. Atrial fibrillation: prevalence and management in an acute general medical unit. Aust NZ J Med. 1999;29:51-58.
4. Elliott R, Woodward M, Oborne C. Appropriateness of antithrombotic prescribing for elderly inpatients with atrial fibrillation. Pharm J. 1999;263:R10.
5. Jackson S, Peterson G, Vial J, Daud R, Ang S. Outcomes in the management of atrial fibrillation: clinical trial results can apply in practice. Intern Med J. 2001;31:329-336.
6. Bajorek B, Krass I, Ogle S, Duguid M, Shenfield G. The impact of age on antithrombotic use in elderly patients with non-valvular atrial fibrillation. Australas J Ageing. 2002;21:36-41.
7. Chang H, Bell J, Devoo D, Kirk J, Wasson J. Physician variation in anticoagulating patients with atrial fibrillation. Arch Intern Med. 1990;150:81-84.
8. Kutner M, Nixon G, Silverstone F. Physicians' attitudes toward oral anticoagulants and antiplatelet agents for stroke prevention in elderly patients with atrial fibrillation. Arch Intern Med. 1991;151:1950-1953.
9. McCrory D, Matchar D, Samsa G, Sanders L, Pritchett E. Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly. Arch Intern Med. 1995;155(3):277-281.
10. Munschauer F, Priore R, Hens M, Castilone A. Thromboembolism prophylaxis in chronic atrial fibrillation: practice patterns in community and tertiary-care hospitals. Stroke. 1997;28:72-76.
11. Howitt A, Armstrong D. Implementing evidence based medicine in general practice: audit and qualitative study of antithrombotic treatment for atrial fibrillation. BMJ. 1999;318:1324-1327.
12. Gottlieb L, Salem-Schatz S. Anticoagulation in atrial fibrillation: does efficacy in clinical trials translate into effectiveness in practice? Arch Intern Med. 1994;154:1945-1953.
13. Morgan D, Kreuger R. When to use focus groups and why? In: Morgan D, editor. Successful focus groups. London: Sage; 1993.
14. White Y, Grenyer B. The biopsychosocial impact of end-stage renal disease: the experience of dialysis patients and their partners. J Adv Nurs.1999;30:1312-1320.
15. Husserl E. Ideas: general introduction to pure phenomenology. Evanston, Illinois: Northwestern University Press; 1931.
16. Moustakas C. Phenomenological research methods. Thousand Oaks, California: Sage; 1994.
17. Kidd P, Parshall M. Getting the focus and the group: enhancing analytical rigor in focus group research. Qual Health Res. 2000;10:293-308.
18. McCrory D, Matchar D, Samsa G, Sanders L, Pritchett E. Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly. Arch Intern Med. 1995;155:277-281.
19. Lip G, Zarifis J, Watson R, Beevers D. Physician variation in the management of patients with atrial fibrillation. Heart. 1996;75:200-205.
20. Peterson G, Boom K, Jackson S, Vial J. Doctors' beliefs on the use of antithrombotic therapy in atrial fibrillation: identifying barriers to stroke prevention. Intern Med J. 2002;32:15-23.
21. Arnsten J, Gelfand J, Singer D. Determinants of compliance with anticoagulation: a case-control study. Am J Med. 1997;103:11-17.
22. Man-Son-Hing M, Laupacis A, O'Connor A, Wells G. Warfarin for atrial fibrillation: the patient's perspective. Arch Intern Med. 1996;156:1841-1848.
23. Peyrot M, McMurry J, Kruger D. A biopsychosocial model of glycemic control in diabetes: stress, coping and regimen adherence. J Health Soc Beh. 1999;40(2):141-158.
24. Barber N, Parsons J, Clifford S, Darracott R, Horne R. Patients' problems with new medication for chronic conditions. Qual Saf Health Care. 2004;13:172-175.
25. Coulter A, Entwistle V, Gilbert D. Sharing decisions with patients: is the information good enough? BMJ. 1999;318:318-322.
26. Dickinson D, Raynor D, Kennedy J, Bonaccorso S, Sturchio J. What information do patients need about medicines? BMJ. 2003;327:861.
27. Kyngas H. Patient education: perspective of adolescents with a chronic disease. J Clin Nurs. 2003;12(5):744-751.
28. Berry D, Michas I, Gillie T, Forster M. What do patients want to know about their medicines and what do doctors want to tell them? A comparative study. Psychol Health. 1997;12:467-480.
29. Britten N, Stevenson F, Barry C, Barber N, Bradley C. Misunderstandings in prescribing decisions in general practice: qualitative study. BMJ. 2000;320:484-488.