Center for Policy & Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.
Center for Policy & Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR; OHSU-PSU School of Public Health, Portland, OR.
Ann Emerg Med. 2019 Dec;74(6):759-771. doi: 10.1016/j.annemergmed.2019.03.026. Epub 2019 May 9.
Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation.
From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians' attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians.
Three broad domains emerged from our analyses. (1) Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2) Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3) Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors.
The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.
尽管临床指南建议对有中风高风险的房颤患者进行口服抗凝治疗，但急诊医生在为新诊断的房颤患者开具处方时并不一致。我们采访了急诊医生，以深入了解影响为从急诊出院的新发房颤患者开具口服抗凝药处方的主题。
2015 年 9 月至 2017 年 1 月，我们对 18 名在过去 30 天内评估过新发房颤患者的急诊主治医生进行了半结构式定性访谈，采用有目的的抽样方法。访谈提示检查了医生对口服抗凝治疗处方的态度和当前的临床指南。我们使用建构主义扎根理论方法来分析数据并制定急诊医生处方实践理论。
我们的分析产生了三个广泛的领域。（1）口服抗凝药处方实践：影响从急诊室开出口服抗凝药的潜在主题包括医生的实践模式、信念和障碍（包括经验、舒适度和保险覆盖范围）以及患者因素（包括合并症、出血风险和社会关注）。最终，这些主题表明医生在为房颤患者开具口服抗凝药时感到不适和无能为力。（2）口服抗凝药处方指南的使用：无论经验如何，大多数急诊医生在治疗患者时都没有报告使用临床指南。（3）改善处方的建议：医生建议制定一种经过验证、可靠、简单、易于获取且针对特定人群的指南，该指南考虑患者的社会因素。
在急诊室开具口服抗凝药的决定很复杂。要提高指南的依从性，需要采取多方面的方法，包括系统层面的改进、医生教育以及开发特定于急诊室的工具和指南。
