A total of 35 PCPs were invited to participate in this study, of which 8 of them declined to take part due to their busy schedules. 9 IDIs and 4 FGDs were conducted with 27 participants until idea saturation was reached, with no new code emerging from the data.
The demographic characteristics and practice profiles of the 27 PCPs are shown in Table 1.
Table 1
Characteristics of participating PCPs
Characteristic
|
n
|
Gender
|
|
Male
|
10
|
Female
|
17
|
Age (in years)
|
|
Age ≤ 35
|
7
|
Age > 35–50
|
17
|
Age > 50
|
3
|
Highest postgraduate qualification
|
|
Bachelor of Medicine, Bachelor of Surgery (MBBS)
|
5
|
Doctor of Medicine (MD)
|
1
|
Graduate Diploma in Family Medicine (GDFM)
|
6
|
Master of Medicine in Family Medicine (MMed)
|
11
|
Fellowship (FCFPS)
|
4
|
Clinical practice setting
|
|
Polyclinic
|
21
|
General practitioner clinic
|
5
|
Locum
|
1
|
Years of practice
|
|
< 10
|
9
|
10–19
|
13
|
> 19
|
5
|
The findings are summarized and presented in Fig. 1 according to the Generalist Wheel theoretical framework, focusing on the clinician domain and its interface with the “patient”, the “disease and treatment” and the “healthcare system and policy” domains.
Clinician personal attributes
Formal and informal training
PCPs attributed their higher confidence in anticoagulant initiation and switch to specialized training courses and on-the-job learning from experienced senior physicians.
“I think that postgraduate training or specialized family physician training courses would empower primary care doctors to accept and increasingly perform the role of initiation of anticoagulation.” P25, GP.
“I feel that training is also helpful in the sense that if a senior is starting a patient on NOAC and calls one or two colleagues to watch the consult, just for 10 minutes and see how they go about making that decision” P24, polyclinic PCP.
Prior experience in managing atrial fibrillation
Many PCPs, including those with postgraduate training, lacked personal experience in managing AF, which led to their uncertainty in anticoagulant therapy.
“Whenever the primary care doctors have not done it very much, there’s some hesitancy to it because we are not too sure what to do and we don’t have that kind of experience behind us.” P3, polyclinic PCP with Family Medicine postgraduate qualification.
“I do start on Aspirin, but for anticoagulants, I think the main factor that I won’t start is just I am not so comfortable with it yet.” P10, polyclinic PCP with Family Medicine postgraduate qualification.
Some PCPs highlighted the clinical challenges in picking up mitral stenosis, a condition which is a contraindication for NOACs. A few PCPs indicated that continuing medical education (CME) would help build their confidence in switching anticoagulants.
“I don’t think my clinical skills are so good in picking up mitral stenosis; a diastolic murmur. So, I’m not confident…I mean for novel oral anticoagulants.” P19, polyclinic PCP.
“if you ask me to start anticoagulants, I’m not so comfortable in starting, but if I’m asked to follow up on a patient who is on anticoagulants, or having to switch the patient from warfarin to NOAC, I think with CME and teaching, for me, I think I’m still okay with doing that.” P15, polyclinic PCP.
Patient clinical risk-stratification and engagement
Clinical assessment and risk-stratification
The patient profile, co-morbid conditions and demographics were taken into consideration by PCPs while making decisions about anticoagulants. PCPs relied on the CHA2DS2-VASc score and the HASBLED score to calculate the risk of stroke and bleeding, which also influenced their decision-making in initiating anticoagulants.
“I guess the current quality of life of the patient, … also the demography will also be of some importance. If the patient is extremely old, even if they are still cognitively intact, sometimes, the benefit may not outweigh the risk.” P2, GP.
“I think the CHA 2 DS 2 -VASc score is the most important factor. So, the risk of stroke would determine how much I want to push for the patient to be started. HASBLED score, I guess has some impact on my decision making, but we do know that HASBLED score is not really a contraindication for atrial fibrillation.” P23, polyclinic PCP.
Patient and family engagement
Most PCPs sought to involve their patients in shared decision-making regarding anticoagulants. Some PCPs also engaged patient’s family members to help the patient in this decision-making process.
“good to have a shared decision-making process, where the patient himself also participates in this decision to start the medication. Also, because the population may be changing, we also start to realize that the patient, they themselves want to be able to be given a choice to decide.” P20, private GP.
“if it’s the typical elderly individual, when it comes to such major decisions…. I usually ask them to come together with one or two of their children….at least they can get some assurance that one, you know they are doing the right decisions two, you know, sometimes if they do not understand what the physician says, their family may be able to put it in simpler terms for them.” P21, GP.
Patient rapport
Some PCPs acknowledged that their rapport with the patient would enable them to convince patients to follow their recommendation regarding anticoagulants.
“if the doctor has good rapport, I think there’s a higher chance that they can convince patients to go on, because the patient trusts you and your decision-making skills.” P3, polyclinic PCP.
Identification of AF and issues on the commencement of anticoagulant therapy
Detection of AF
PCPs occasionally detect AF incidentally during physical examination. They would refer symptomatic patients with giddiness or breathlessness to the hospital Accident and Emergency (A&E) department for further management.
“the first thing is whether it’s incidental finding or not, for example usually it’s incidental finding when we check blood pressure …. we found that there’s irregular pulse. So, the patient is otherwise well.” P4, polyclinic PCP.
“if the patient is unstable or symptomatic….and you find out it’s because of AF, I will refer to A&E department.” P13, polyclinic PCP.
Cost
Almost all PCPs mentioned cost as a significant factor influencing their anticoagulant prescription for NOACs. Moreover, the cost of NOACs is substantially higher than warfarin as illustrated in the quote below from P2. However, some PCPs acknowledged that patients on warfarin also incurred additional costs for the periodic INR monitoring at the laboratories.
“I would say cost is a very big factor ….in our clinic we are selling 1 tablet of NOAC at around $4 to $5. That would be approximately S$2000 a year, just for one medication. So, if they were to be taking warfarin, maybe it will be even less than S$100.” P2, GP.
“a big part would be money you see, because the NOACs tend to be more expensive. Warfarin tends to be cheaper, however, you know coming to do blood tests every 3-monthly might be quite costly as well.” P21, GP.
Concerns about NOACs
PCPs had concerns about NOACs, such as the lack of monitoring and the lack of antidotes.
“it takes 24 hours for the drug to wear off and there is no real antidote, except for dabigatran …The second would be…we don’t really know how anticoagulated they really are…. because there is no way to measure” P2, GP.
Contraindications to NOACs
While most PCPs were aware of contraindications to NOACs, such as renal impairment and liver disease, they were concerned about missing the diagnosis of mitral stenosis. Some of them would rely on echocardiogram to identify mitral stenosis.
“we do know that if they have any abnormal liver or kidney function, they shouldn’t be on certain medications like the NOACs.” P20, GP.
“I must admit that I myself have not converted anyone from warfarin to NOACs. The first things that I would be concerned with is to find out whether there has been a history of 2D Echo done. To see whether there is any significant mitral stenosis.” P17, polyclinic PCP.
Issues with warfarin as the alternative
Multiple issues with warfarin such as labile INR, diet and drug interactions were raised by PCPs. These issues may trigger PCPs to switch to NOACs.
“if the patient is taking a number of medications and there is drug interactions, and also, the patient doesn’t tend to come back regularly for follow up… In those cases, I may actually switch the patient to NOAC, if they don’t have any contraindications.” P15, polyclinic PCP.
Supporting healthcare services and proposed model of care delivery
Allied health personnel
PCPs practising in public polyclinics suggested enlisting the services of the Medical Social Workers (MSWs) in financial counselling and the pharmacists in medication counselling. MSWs also counsel patients on their eligibility based on their socioeconomic background and render assistance those who are unable to afford the more expensive NOACs.
“The other allied services that we can tag on is the social workers…. so that they can counsel the patient and find out whether the patient is eligible for different financial subsidies that are available, so that they can start on the medicine.” P6, polyclinic PCP.
“I feel that the allied team will be very useful. I mean the pharmacists can help a lot in terms of counselling because we may not have that much time to counsel the patient and to elicit the patient’s other concerns” P8, polyclinic PCP.
Institutional policies
PCPs are guided by their institutional policies regarding starting anticoagulants. They follow the instructions in the electronic doctor training manual provided by the institution for reference.
“We still cannot start warfarin, even if we detect a new AF, because we don’t have the policy to manage them here, to reach the adequate INR targets…because it takes time to do this” P6, polyclinic PCP.
Availability of anticoagulant
The PCPs who practice in private GP clinics reported that their prescriptions were influenced by available anticoagulants in the formulary or stock of their practice.
“I work in a group practice, it also depends what my group carries, like we only have Xarelto, for example. Xarelto and like warfarin 5 mg or 3 mg. So, you just have to play around with whatever you have” P21, GP.
Access to the specialists for further evaluation
Most PCPs would seek the guidance of the cardiologist in managing patients with newly diagnosed atrial fibrillation. This is usually in the form of a referral to the cardiology clinic.
“because of the accessibility of tertiary care, specialist care in Singapore, usually upon diagnosis, I would prefer to refer to the tertiary care first, you see. Because sometimes you do need to find the underlying cause of the AF. Rule out things like whether it’s due to a heart problem. So, usually these tests can only be done in the tertiary setting and it can be done pretty fast, sometimes.” P21, GP.
However, two PCPs interviewed for this study manage specialized AF clinics in their respective primary care practice in collaboration with cardiologists. They also have access to facilities to perform 2D Echocardiograms. This in turn empowered the PCPs to start anticoagulants in the primary care setting.
“So, we have atrial fibrillation clinic, which is run in conjunction with the cardiologists. We have access to specialist opinion via phone call or message very, very readily if we need some advice. If not, then we have access to order 2D Echo and all these on our own, without referring directly. We can do all these things in the primary care setting and start anticoagulants” P23, polyclinic PCP.