The effect of age and quality of life on doctors' decisions to anticoagulate patients with atrial fibrillation

Age and Ageing,  May, 1998  by Mark Sudlow,  Richard Thomson,  Helen Rodgers,  Stella Livinstone,  Rose Anne Kenny

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Introduction

Several large randomized controlled trials have demonstrated that treating selected patients who have nonvalvular atrial fibrillation (NVAF) with anticoagulants reduces their risk of stroke [1-7]. There has been considerable debate as to how these results ought to be incorporated into practice and particularly about the selection of patients for treatment [8-10]. Large numbers of patients, who on strictly medical criteria might be appropriate for treatment, are not receiving it [11-13]. The reasons for this are unclear, but semistructured interviews with clinicians that we carried out before embarking on this survey demonstrated that a range of factors were considered when deciding whether treatment should be offered. These included patient's age, quality of life, place of residence and handicap. Such considerations may have an important effect on the number of patients treated. For example, as the median age of those with NVAF is 75 years [14], a widespread feeling amongst clinicians that a patient above this age should not be treated could halve the total number of patients with NVAF given anticoagulants. We carried out a questionnaire survey to explore whether age or medico-social factors might influence the clinical practice of general practitioners and consultants with regard to anticoagulation of patients with NVAF and whether these factors influenced general practitioners and consultants to a different extent.

Methods

A 50'% random sample of the general practitioners (n = 824) and all hospital consultants with a commitment to general medicine (including specialists also involved in acute general medical admissions), cardiology, care of the elderly, haematology, neurology and renal medicine (n = 207), in the former Northern Region, were sent a questionnaire seeking their views on the use of anticoagulants in patients with atrial fibrillation. Two reminders were sent to non-responders.

We report respondents' views on which patients with NVAF should not be treated with anticoagulants. Respondents were asked to grade their responses to a series of statements on a five-point Lickert scale which ranged from `strongly agree' to `strongly disagree' (see Table 1). Amongst the groups described were patients in three age bands, with two levels of quality of life, four degrees of handicap (based on the Oxford Handicap Scale [15]) and living in three different types of accommodation. We should emphasize that we were not asking clinicians whether they thought these groups of patients were more likely to have other contraindications to treatment (such as dementia, falls or poor compliance), hut, separately, whether they felt that patients in these groups ought not to be treated because of their age, their quality of life, their degree of handicap or their place of residence itself.

Table 1. Questions asked of clinicians in the survey: "In my
opinion, patients with nonvalvular atrial fibrillation and the
following features should not be anticoagulated with warfarin"

Age (years)
  65-74
  75-84
  85+
Reduction in quality of life
  Mild
  Severe
Handicap (chronic symptoms from any other disease)
  None
  Symptoms leading to some restriction in lifestyle
  Symptoms leading to significant restriction in lifestyle or
   partial dependence on others
  Symptoms preventing independent existence
Place of residence
  Sheltered accommodation
  Residential care
  Nursing home

The significance of differences between general practitioners and consultants was calculated by comparing the proportion agreeing or strongly agreeing with each statement using [chi square] with Yates' correction or Fisher's exact test where appropriate.

Results

Overall response rates from general practitioners and consultants were 56% (459/824) and 79% (163/207) respectively, General practitioner fundholders and general practitioners from training practices were slightly more likely to respond than other general practitioners [152 of 247 fundholders responded (61.5%) compared with 304 of 577 non-fundholders (52.7%) and 163 of 248 from training practices (65.7%) compared with 293 of 575 (50.9%) from other practices (P [is less than] 0.05 in both cases)]. The results are summarized in Table 2.

Table 2. Responses to the statement: "In my opinion, patients with non-valvular atrial fibrillation and the following features should not be anticoagulated with warfarin"

                                    Percentage responding

                                    General practitioner

                                   Agree/          Disagree/
Patient characteristic             strongly        strongly
                                   agree           disagree

Age (years)
  65-74                             7.9(a)           52.1
  75-84                            19.4(a)           36.1
  [is greater than or
    equal to] 85                   46.1              20.2
Change in quality of life
  Mild reduction                    6.1              48.5
  Severe reduction                 38.4(a)           25.3
Chronic symptoms from any
 other disease
  None                              8.0              58.7
  Some restriction in lifestyle     5.9              56.0
  Significant restriction in
   lifestyle/
    partial dependence on others   16.3              38.0
  Preventing independent
   existence                       24.3              30.6
Living arrangements
  Sheltered accommodation           2.4              60.7
  Residential care                  4.7              58.3
  Nursing home                      9.2              55.4

                                      Hospital consultant

                                   Agree/          Disagree/
Patient characteristic             strongly        strongly
                                   agree           disagree

Age (years)
  65-74                             2.0(a)          84.3
  75-84                             9.1(a)          64.7
  [is greater than or
   equal to] 85                    42.9             28.6
Change in quality of life
  Mild reduction                    5.2             68.2
  Severe reduction                 45.8(a)          22.6
Chronic symptoms from any
 other disease
  None                             11.8             69.0
  Some restriction in lifestyle     5.9             76.5
  Significant restriction
   in lifestyle/
    partial dependence on others   16.9             50.6
Preventing independent existence   22.1             37.7
Living arrangements
  Sheltered accommodation           2.6             78.7
  Residential care                  3.9             72.9
  Nursing home                     12.3             59.4