Utilizing Theoretical Domains Framework to Determine Barriers to Evidence-Based Recommendations in Non-Valvular Atrial Fibrillation

Evan White; Sandra L Kane-Gill; Sandeep Jain; Charles Medico; Nicole Ansani; James C Coons

doi:10.1177/10600280241298947

Utilizing Theoretical Domains Framework to Determine Barriers to Evidence-Based Recommendations in Non-Valvular Atrial Fibrillation

Ann Pharmacother. 2024 Nov 26:10600280241298947. doi: 10.1177/10600280241298947. Online ahead of print.

Authors

Evan White¹, Sandra L Kane-Gill¹, Sandeep Jain², Charles Medico³, Nicole Ansani⁴, James C Coons^{1

5}

Affiliations

¹ School of Pharmacy, Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA, USA.
² Heart and Vascular Institute, UPMC, Pittsburgh, PA, USA.
³ Pfizer Medical Affairs, Pfizer, Inc, New York, NY, USA.
⁴ Pfizer, Inc, New York, NY, USA.
⁵ UPMC Presbyterian Hospital, Department of Pharmacy, Pittsburgh, PA, USA.

PMID: 39600143
DOI: 10.1177/10600280241298947

Abstract

Background: Implementation of evidence-based guidelines in patient care is inefficient. Only 14% of new research are routinely adopted into clinical practice. The atrial fibrillation (AF) practice guidelines recommend anticoagulation in men with a CHA₂DS₂-VASc score greater than or equal to 2 and in women with a CHA₂DS₂-VASc score greater than or equal to 3. Despite these recommendations, oral anticoagulation prescribing rates were found to be as low as 51%. Existing frameworks, such as the Theoretical Domain Framework (TDF), are used in implementation science to identify behavior changes to overcome barriers to guideline adoption.

Objective: In this project, we explored behavioral themes and barriers that prevented clinician adherence to evidence-based recommendations for patients with non-valvular atrial fibrillation (NVAF) and developed interventions to overcome those barriers.

Methods: Nine focused interviews were conducted with stakeholders across multiple disciplines involved with NVAF care. Interview questions were based on the TDF and designed to determine behavior changes necessary to increase appropriate anticoagulation prescribing and decrease unnecessary NVAF hospital admissions. The interviews were transcribed and coded using NVivo 12 qualitative data analysis software (released 2018). Themes were documented, and interventions were then developed to address the barriers.

Results: TDF interviews yielded 4 main barrier themes regarding appropriate NVAF management in 2 theoretical domains. These themes were lack of knowledge, cost of anticoagulation, patient refusal to take anticoagulation, and social determinants of health. The theoretical domains were knowledge and environmental context and resources.

Conclusion and relevance: Based on our limited interviews, the TDF framework informed potential barriers contributing to the underutilization of appropriate anticoagulation in patients with NVAF. Techniques for behavior change interventions may be applied to overcome the identified barriers.

Keywords: anticoagulation; atrial fibrillation; barriers; implementation science.