'Rules of thumb' or reflective practice? Understanding senior physicians' decision-making about anti-thrombotic usage in atrial fibrillation

Background: The recently published Atrial Fibrillation (AF) Guidelines from the National Institute for Health and Clinical Excellence (NICE) highlight the importance of assessing stroke risk and using appropriate anti-thrombotic therapy. Aim: To improve understanding of physicians' behaviour and attitudes in respect to decision-making in AF and the use of anti-thrombotics. Design: Semi-qualitative, questionnaire- and interview-based study. Methods: Five clinical vignettes relating to treatment choices for AF and stroke prevention illustrating a range of risk and benefit were examined by 14 senior physicians (consultants or specialist registrars) in Cardiology, General Medicine and Geriatric Medicine, who then recommended anti-thrombotic treatment. A semi-structured interview explored their decision-making and prescribing in AF, with qualitative analysis of interview transcripts using grounded theory. Results: There was marked variation in the choice of anti-thrombotic treatment. Respondents were more likely to prescribe warfarin to patients with a previous intracerebral haemorrhage than to a patient with a history of falls. A key theme on qualitative analysis revealed that decision-making in AF is often associated with uncertainty and concerns about knowledge of risk and benefit. Discussion: In this study, doctors rarely agreed on the choice of anti-thrombotics in AF, and their perceptions of stroke and bleeding risk showed considerable variation. Uncertainty, doubt, concerns about knowledge and varied approach to the role of patients in decision-making are all significant themes in the considerable variability in anti-thrombotic prescribing.