A total of 16 individuals (eight male, eight female) were selected (nationwide) to participate in phase 1 of the study. Of these, 56% patients (n = 9) were aged 60–70 years and 44% of patients (n = 7) were aged 70–80 years. Regarding their OAC medication, 31% of patients (n = 5) had been switched by their HCP from VKA to DOAC therapy, 25% (n = 4) had been initiated on DOAC therapy by their HCP and 44% patients (n = 7) were treated with VKAs. All individuals took part in an in-depth interview.
A total of 19,959 individuals aged ≥ 50 years were recruited from the general population to take part in the survey in phase 2 of the study, of which 10,826 started the online survey. The total number of patients with AF within this population was 453 (8%), of which 54 patients did not complete the survey and 43 were excluded due to comorbidities. A further 163 of 453 patients were not currently using a VKA or DOAC, three indicated that they used both a VKA and a DOAC and 76 were excluded as they had never used a DOAC before. Finally, two patients were excluded, as they fell outside of the set quota, one patient was using a VKA but was not using the thrombosis service (which was therefore considered an ‘Untrustworthy’ respondent as VKA usage is not possible without thrombosis service) and ten patients were removed from the cohort due to data cleaning. This resulted in 101 evaluable individuals; 68 patients (67%) were on VKA therapy and 33 (33%) were receiving DOACs. The patient characteristics of these 101 individuals are described in Fig. 1.
How Do Patients Rate Their Treatment?
Patients using acenocoumarol gave their treatment a mean score of 8.3 on a scale of 0–10, and those receiving fenprocoumon gave a mean treatment score of 7.9. The mean treatment score for the four DOACs ranged from 8.2 to 8.7. Patients who had switched from acenocoumarol to a DOAC (n = 16) gave a mean rating for their previous VKA therapy of 6.6, thus rating their previous VKA medication much lower than their current DOAC therapy.
What Barriers Do Patients Have Regarding Their Current Treatment?
For 17% of the 101 patients with AF, switching dosages is a barrier to adherence. Although the question ‘What is a barrier to adherence for you’ (or a similar question) was not asked explicitly, there was an open-ended question that led some respondents to respond along the lines of ‘Differing dosing makes it hard to be compliant.’ Responses on this were given in the ranking exercise, when respondents indicated that ‘having the same dosing every day’ was among the top 3 things most important to them. They were then asked why this was the case. Responses included comments such as: ‘It is harder to get the pills wrong, I think’ and ‘Easier to remember.’
Ranking the Different Aspects of OAC treatment – Implicit Importance
Patients were repeatedly (four times) prompted to choose between two product profiles, each consisting of a mix of both DOAC and VKA attributes, to establish the deciding factor for patients. DOAC attributes where generally preferred over VKA attributes, especially dosing schedule, lower chance of cerebral hemorrhage and no restrictions to diet were preferred.
Ranking the Different Aspects of OAC Treatment: Explicit Importance
In the ranking exercise, all 101 patients with AF (who were treated with either a VKA or a DOAC) evaluated the different VKA and DOAC product attributes specifically, ranking them from most important to least important. This resulted in the top three product attributes per patient group (Table 1). Although the attributes which feature in the top three are similar between the two groups, DOAC patients rated the two aspects ‘No INR check needed’ and ‘Once daily dosage (pill)’ as equally important, for both, 24% of DOAC patients put them in third place. Although 70% of all patients did not list experiencing a stroke, they still communicated that effective prevention of stroke was very important to them, while 7% of patients were especially concerned with higher treatment efficacy due to a previous history of stroke. Overall, 34% of VKA patients ranked ‘no thrombosis service checks’ in their top three attributes. When asked why they would like to not have the thrombosis service, 48% of these patients believed this would make it easier to fit their disease into daily life, and another 48% found the INR checks to be annoying or time-consuming. The perception of the thrombosis service differed greatly between VKA- and DOAC-treated patients, with 56% of patients on VKAs perceiving it as ‘Fine’ (vs. 23% of patients on DOAC). In contrast, 52% of DOAC recipients considered the thrombosis service to be ‘Time-consuming/difficult to fit into daily life’ (vs. 19% of VKA recipients) and 30% of DOAC recipients even considered it as ‘Horrible’ (vs. 9% of VKA recipients). Detailed perceptions on the thrombosis service by patients on VKA and DOAC are shown in Fig. 1.
Are VKA Patients Familiar with the Newer DOAC Treatments?
Of the patients on VKAs taking part in the survey, 63% said they were not at all familiar with the newer DOACs; 25% were hardly/not very familiar and 12% were fairly/very familiar with DOAC therapy. Educational level, age, or cardiologist involvement did not impact patient awareness level. VKA recipients rated the information their HCP gave them with mean score of 7.2 out of 10 (range, 2–10). Whether a cardiologist or GP presented them with their confirmed AF diagnosis had no impact on the score given by patients on VKA for the level of information they received (7.4 out of 10 for both cardiologist and GP). DOAC recipients rated the information from their HCP with a mean score of 7.9 out of 10 (range, 6–10). Both VKA and DOAC recipients indicated that they expected HCPs to outline all treatment options at the start of treatment and discuss any new possible medications if they become available (Fig. 2).
How Do VKA Patients Perceive the Newer DOAC Treatments?
Patients on VKA were shown a profile of DOAC therapy to assess their perception about this type of OAC, consisting of the most important and characteristic features of DOAC, and naming all available DOAC agents without emphasizing any particular one of them (Table 2). When presented with the DOAC description, 49% of patients on VKAs had a (very/mostly) positive response. When prompted for the reasons for their (very/mostly) positive response, 64% indicated that losing the thrombosis service contributed to their evaluation, 18% said it was because of the set daily dosage, and 15% stated that higher efficacy was the reason for their positive response. A total of 38% of patients on VKAs responded neutrally to the DOAC description. Of these, 73% of patients did so because they were unfamiliar with DOAC or felt that they lacked medication knowledge; 27% responded neutrally because they were content with their current VKA regimen. Finally, 13% of patients on VKAs had a (mostly/very) negatively response to the DOAC profile. This subgroup was relatively small (n = 9) and their reasons for responding (mostly/very) negatively varied, with a fear of mismatch with comorbidities (e.g., kidney or liver disorders) being mentioned by 33% of patients (n = 3).
Willingness to Switch
When presented with the DOAC profile (Table 2), 52% of patients on VKA said they would choose to switch to a DOAC. However, 43% of patients on VKA indicated that when they were asked whether or not they would switch to a DOAC they would always choose to stay on their current medication. Of these non-switchers, 66% indicated that they did not want to switch because they were content with their current medication, and 21% stated that they were afraid to switch medication, with concerns including adverse effects that they might experience with new products, or feeling safe due to their thrombosis service check-ups. Of note, patients who were open to switching to a DOAC at the same time also stated that were afraid of doing so (Fig. 3).