Patients' and Healthcare Professionals' Perceptions of Direct Oral Anticoagulant Medicines Optimisation Primary Care: a Qualitative Study

Introduction- Long-term conditions such as atrial fibrillation (AF) are increasing in the United Kingdom (UK) and patients are increasingly offered direct oral anticoagulants (DOACs) instead of traditional warfarin. DOACs still require regular monitoring and clinical follow-up to maintain patient safety but little is known about their optimisation in primary care. This study aimed to understand the perceptions of healthcare practitioners and patients in relation to DOACs and medicine optimization. Methods- Qualitative semi-structured interviews were undertaken with a purposive sample of sixteen elderly AF patients taking DOACs, ten pharmacists and six general practitioners (GPs) recruited in Sheffield in 2018. Interview questions were developed from a systematic literature review and interviews were audio-recorded, transcribed and analysed using six stage thematic analysis. Findings- Participant views of DOACs varied, with patients and prescribers not attributing significant risk to them but pharmacists emphasized patient safety aspects. Patients lacked detailed DOAC knowledge and they struggled to recall medication reviews and appeared passive in reported medical consultations but maintained overriding trust in doctors during interactions with them. GPs valued healthcare professional collaborations (including pharmacists) due to workload and time pressures and assumed patients would be provided with medicines information and reviews by others. All three groups agreed that pharmacist medication reviews contributed positively to medicine optimisation, but this was threatened by barriers such as poor computer system integration, difficulty accessing some patient groups and inadequate referral of new DOAC patients to pharmacists. Pharmacists reported professional identity and role boundary concerns, duplicated tasks and poor patient engagement in medicine optimisation. Conclusion- Optimising DOACs in primary care is threatened by several enduring tensions related to lay health beliefs and entrenched attitudes about healthcare professional roles and perceived value. Ensuring the safe use of DOACs requires pharmacists’ roles, enhancing lay patient knowledge and risk perceptions about DOACs.