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Why isn’t warfarin prescribed to patients with nonrheumatic atrial fibrillation?

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Abstract

OBJECTIVE: To determine the opinions of selected physicians in our community about use of warfarin for patients with nonrheumatic atrial fibrillation, and to determine the relation of the physicians’ opinions to their practices.

DESIGN: Survey of physicians, using eight hypothetical clinical vignettes to characterize physicians’ opinions about use of warfarin in patients with nonrheumatic atrial fibrillation, according to patient age, risk of bleeding, and risk of stroke.

SETTING: Two teaching hospitals and five community-based practices.

PARTICIPANTS: Eighty physicians who cared for 189 consecutive patients with nonrheumatic atrial fibrillation.

MEASUREMENTS AND MAIN RESULTS: The survey response rate was 73%. Nearly all responding physicians (90%) recommended warfarin for at least one vignette. However, physicians recommended warfarin less often for vignettes depicting 85-year-old patients than for matched vignettes depicting 65-year-old patients (odds ratio [OR] 0.03; 95% confidence interval [CI] 0.01, 0.08), and less often for cases with specified risk factors for bleeding than for matched cases without the risk factors (OR 0.01; 95% CI 0.004, 0.03); warfarin was recommended more often for cases with a recent stroke than for matched cases without this history (OR 8.2; 95% CI 3.6, 18). In practice, warfarin was prescribed more often (p<-.05) by physicians reporting good personal experience and by those who had favorable opinions about its use. However, even physicians with good experience and favorable opinions did not prescribe warfarin to half of their patents for whom warfarin was independently judged appropriate.

CONCLUSIONS: Physicians’ opinions frequently opposed warfarin for older patients with nonrheumatic atrial fibrillation, and for those with bleeding risk factors. Physicians’ opinions, as well as other barriers to warfarin therapy, most likely contribute to its infrequent prescription.

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Author information

Author notes

  1. Meghal R. Antani MD

    Present address: the University of Minnesota, USA

  2. David G. Miller MD

    Present address: MetroHealth Medical Center, USA

Authors and Affiliations

  1. the Division of General Internal Medicine and Health Care Research, Department of Medicine, Cleveland Veterans Affairs Medical Center, and University Hospitals of Cleveland, Ohio

    Rebecca J. Beyth MD, Kenneth E. Covinsky MD, Linda M. Quinn MS &  C. Seth Landefeld MD

  2. Cleveland Neighborhood Health Centers, Inc., Ohio

    David G. Miller MD

  3. the Department of Dermatology, Cleveland Veterans Affairs Medical Center and University Hospitals of Cleveland, Ohio

    Mary-Margaret Chren MD

  4. Case Western Reserve University School of Medicine, Cleveland, Ohio

    Meghal R. Antani MD

Authors
  1. Rebecca J. Beyth MD
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  2. Meghal R. Antani MD
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  3. Kenneth E. Covinsky MD
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  4. David G. Miller MD
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  5. Mary-Margaret Chren MD
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  6. Linda M. Quinn MS
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  7. C. Seth Landefeld MD
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Additional information

Dr. Landefeld is a Senior Research Associate, Health Services Research and Development Service, Department of Veterans Affairs. Dr. Beyth is a Merck/American Federation for Aging Research Fellow in Geriatric Clinical Pharmacology. Dr. Covinsky is an awardee of the Research and Development Core, Claude D. Pepper Older Americans Independence Center, Case Western Reserve University.

Supported by an American College of Physicians’ George Morris Piersol Teaching and Research Scholarship (CSL), a John A. Hartford Foundation/American Federation for Aging Research Geriatric Pharmacology Scholarship (MRA), and by grants from the John A. Hartford Foundation (92307-G), the Case Western Reserve University Geriatric Recruitment Initiative and the National Institutes of Health (RO1 AG09657-01 and P60AG10418-03).

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Beyth, R.J., Antani, M.R., Covinsky, K.E. et al. Why isn’t warfarin prescribed to patients with nonrheumatic atrial fibrillation?. J Gen Intern Med 11, 721–728 (1996). https://doi.org/10.1007/BF02598985

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