What is Patient Centered About Anticoagulation?

We've all been there — a patient who has new atrial fibrillation needs anticoagulation and we figure that since we've used the CHADS2¹ or CHADS2-Vasc² scoring system, we've done our homework and made the best recommendation for our patient, right?

Unfortunately, compliance to anticoagulation is quite low,³ and there is widespread communication failure that prevents the best outcomes. For instance, have you considered that regular trips to the anticoag clinic could be cost-prohibitive to a patient? What about the patient who is absolutely petrified of bleeding? Or the one who can't stand needles?

In short, as you will soon see described in this article, there are many things, we as providers need to consider when starting a potentially life-altering drug (or drugs) for anticoagulation. In this way, anticoagulation choices are completely dependent on patient-centeredness.

In each section below, there are several tenets of patient centered care highlighted from the ACC Health Policy Statement on Patient-Centered Care.

Do We Anticoagulate and How?

Personalized Medicine and/or Collaborative Care Planning

First up, do we even anticoagulate? This is always the critical question with no clear-cut answer. Much has been published about outcomes and statistics, but we all know that no single patient represents the overall statistics. When taking into account the patient as the key decision maker, issues such as frailty, ability to get to and from the clinic, finances, language barriers, along with all the clinical variables such as bleeding risks, kidney dysfunction (for some of the newer agents), and co-administered drugs.

Table 1. Things to Consider When Prescribing An Anticoagulant

• Costs: Both of the drug, office co-pays, and transportation to and from the office
• Insurance coverage of the intended drug
• Language barriers
• Cultural Barriers
• Experiential Barriers (what the patient has seen in friends and family)
• Literacy and Educational Barriers
• Frailty
• Thromboembolic Risk
• Bleeding Risk
• Renal and/or Hepatic Function
• Use of co-administered drugs which may result in under or over anticoagulation
• Dietary Restrictions
• Avoidance of Some Physical Activities (i.e. High-impact sports)

Take for instance the low-literacy, heavy smoker with COPD who has an exacerbation every month requiring antibiotics (many of which interact with warfarin). In this case, choosing to anticoagulate or not depends heavily on choosing the regimen that has the least likelihood of harm, and the highest likelihood of compliance to reduce stroke risk.

You Want ME to Take Rat Poison?

Health Literacy/Cultural Competency

Another interesting issue when looking at things from the patient side is the potential for cultural and language barriers. Quite innocently, I once prescribed warfarin for a Russian-speaking patient who did some "checking" with his friends and online and decided that I had prescribed rat poison and was officially trying to kill him and he wouldn't ever come back to see me again.

While it is true that warfarin in high doses can be lethal (for rats and humans alike), the goal here is to use a therapeutic dose to do just that — therapy — and prevent the risk of thromboembolism. As such, it is important to quickly dispel any myths — and sometimes ahead of time before embarking on the anticoagulation path.

Choosing Your Drug of Choice

Shared Decision Making

For many, not worrying about dosing and blood draws is the top priority. This paves the way for newer anticoagulants. However, each has their own set of issues and drug interactions and needs to be chosen wisely. Some have higher bleeding risks in the elderly, especially when renal dysfunction is present. As such, a careful discussion of all options with your patient is critical to making the best choice together. Empowering your patient to choose when there is no "wrong answer," is critical in obtaining "buy-in," engagement, and compliance. Finally, a frank discussion about cost is critical, especially as most new drugs are branded and usually more expensive, and many are not initially covered by some insurance plans.

Engaging Patients: Shared Decision Making With Technology

One of the many tenets of patient-centered care is patient engagement, and usually via a route of education. Nearly every American knows of or has seen someone who has suffered the ill effects of a stroke. As such, for many, the fear of this clinical manifestation is enough to drive compliance. But for others, especially those who have seen the effects of blood thinners in terms of intracerebral hemorrhage or other clinical disasters, a very thorough pro and con discussion is needed. A great practice is to calculate one's risk of thromboembolic event, and then, perhaps use the HAS-BLED score to help determine one's likelihood of bleeding. A great way to do this at the point of care is using the ACC's AnticoagEvaluator App, which allows you to put in patient variables and shows the stroke reduction and bleeding risk for each anticoagulant, when data is available (see figured).

Self-Monitoring to help with Self-Management: Another Way to Engage

Another major issue for patients is monitoring. Depending on your patient, using warfarin may be the only option. As such, regular monitoring is essential, but a huge barrier to compliance for many. One way to address this is to consider setting up home monitoring. Here in Colorado, for many folks who live rurally in the mountains, weather makes regular follow-up visits impossible. As such, home monitoring is critical in the management of these patients, and for many, provides the empowerment and tools to remain engaged and in control of their own situation.

You Are Only the Guide

On the journey of anticoagulation, your clinical training, experience, and judgment should serve only as a guide for your patient. Ultimately, it is up to your patient to make the decision with you — in a shared fashion — about how and when to anticoagulate. When you take into account the above principles, your success in preventing thromboembolism should only increase and your patient-provider relationship should strengthen.

Further Reading

A summary of the key points from the ACC Health Policy Statement on Patient-Centered Care

References

1. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285:2864–70.
2. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010;137:263-72.
3. Fang MC, Stafford RS, Ruskin JN, Singer DE. National trends in antiarrhythmic and antithrombotic medication use in atrial fibrillation. Arch Intern Med 2004;16:55-60.

Keywords: Patient Compliance, Atrial Fibrillation, Hemorrhage, Ambulatory Care Facilities, Anticoagulants

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