BMJ 1999;318:1324-1327 ( 15 May )

General Practice

Implementing evidence based medicine in general practice: audit and qualitative study of antithrombotic treatment for atrial fibrillation

Alistair Howitt, principal in general practice, a David Armstrong, reader in sociology as applied to medicine. b

a Warders Medical Centre, Tonbridge, Kent TN9 1LA, b Department of General Practice, Guy's, King's And St Thomas' School of Medicine, London SE11 6SP

Correspondence to: Dr Howitt ajhowitt{at}warders.co.uk

Objective: To determine the extent to which implementation of an evidence based treatment, antithrombotic treatment in atrial fibrillation, is possible in general practice.
Design: Audit and qualitative study of patients with atrial fibrillation and an educational intervention for patients judged eligible for antithrombotic treatment.
Setting: South east England.
Subjects: 56 patients with a history of atrial fibrillation.
Interventions: Assessment and interview to ascertain patients' views on antithrombotic treatment.
Main outcome measures: Number of patients receiving antithrombotic treatment.
Results: Out of 13 239 patients, 132 had a history of atrial fibrillation of which 100 were at risk of thromboembolism. After the study, 52 patients were taking warfarin. Of the remaining 48 patients (of whom 41 were taking aspirin), eight were too ill to participate, 16 were unable to consent, four refused the interview, and 20 declined warfarin. Patients declining warfarin were inclined to seek a higher level of benefit than those taking it, as measured by the minimal clinically important difference. Qualitative data obtained during the interviews suggested that patients' health beliefs were important factors in determining their choice of treatment.
Conclusion: Patients' unwillingness to take warfarin seemed to be a major factor in limiting the number who would eventually take it.


Key messages

  • After a structured intervention only half of a group of apparently eligible patients ended up taking warfarin for their atrial fibrillation

  • Implementation of warfarin treatment for patients with atrial fibrillation was constrained by patients who were either too ill to take the drug or were unable to give consent

  • These constraints are compounded by the unwillingness of patients to reduce their risk by taking a proved drug

  • The number needed to treat, a key statistic in evidence based medicine, probably often overestimates the value of treatment in routine general practice and may not be sufficient to persuade patients of the benefit of treatment




© BMJ 1999
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to StumbleUpon StumbleUpon   Add to Technorati Technorati    What's this?

Relevant Articles

Antithrombotic treatment for atrial fibrillation
Gregory Peterson, Alistair Howitt, and David Armstrong
BMJ 1999 319: 708. [Extract] [Full Text]

Patients and other influences
BMJ 1999 318: 0. [Full Text] [PDF]

Patients and other influences
BMJ 1999 318: 0. [Full Text] [PDF]

Patients' health beliefs constrain uptake of evidence based medicine
BMJ 1999 318: 0. [Full Text]

This article has been cited by other articles:

  • Lip, G Y H, Boos, C J (2008). Antithrombotic treatment in atrial fibrillation. Postgrad. Med. J. 84: 252-258 [Abstract] [Full text]  
  • Estes, N.A. M. III, Halperin, J. L., Calkins, H., Ezekowitz, M. D., Gitman, P., Go, A. S., McNamara, R. L., Messer, J. V., Ritchie, J. L., Romeo, S. J.W., Waldo, A. L., Wyse, D. G. (2008). ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation) Developed in Collaboration With the Heart Rhythm Society. J Am Coll Cardiol 51: 865-884 [Full text]  
  • Estes, N. A. M. III, Halperin, J. L., Calkins, H., Ezekowitz, M. D., Gitman, P., Go, A. S., McNamara, R. L., Messer, J. V., Ritchie, J. L., Romeo, S. J.W., Waldo, A. L., Wyse, D. G. (2008). ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation). Circulation 117: 1101-1120 [Full text]  
  • Thomson, R. G, Eccles, M. P, Steen, I N., Greenaway, J., Stobbart, L., Murtagh, M. J, May, C. R (2007). A patient decision aid to support shared decision-making on anti-thrombotic treatment of patients with atrial fibrillation: randomised controlled trial. Qual Saf Health Care 16: 216-223 [Abstract] [Full text]  
  • Holbrook, A., Labiris, R., Goldsmith, C. H., Ota, K., Harb, S., Sebaldt, R. J. (2007). Influence of decision aids on patient preferences for anticoagulant therapy: a randomized trial. CMAJ 176: 1583-1587 [Abstract] [Full text]  
  • Kalra, L, Lip, G Y H, on behalf of the Guideline Development Group for t, (2007). Antithrombotic treatment in atrial fibrillation. Heart 93: 39-44 [Full text]  
  • Kakar, P., Lane, D., Lip, G. Y. H. (2006). Bleeding risk stratification models in deciding on anticoagulation in patients with atrial fibrillation: a useful complement to stroke risk stratification schema.. Chest 130: 1296-1299 [Full text]  
  • Writing Committee Members, , Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., Halperin, J. L., Le Heuzey, J.-Y., Kay, G. N., Lowe, J. E., Olsson, S. B., Prystowsky, E. N., Tamargo, J. L., Wann, S., ACC/AHA Task Force Members, , Smith, S. C. Jr, Jacobs, A. K., Adams, C. D., Anderson, J. L., Antman, E. M., Halperin, J. L., Hunt, S. A., Nishimura, R., Ornato, J. P., Page, R. L., Riegel, B., ESC Committee for Practice Guidelines, , Priori, S. G., Blanc, J.-J., Budaj, A., Camm, A. J., Dean, V., Deckers, J. W., Despres, C., Dickstein, K., Lekakis, J., McGregor, K., Metra, M., Morais, J., Osterspey, A., Tamargo, J. L., Zamorano, J. L. (2006). ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace 8: 651-745 [Full text]  
  • Lip, G. Y.H., Lane, D., Van Walraven, C., Hart, R. G. (2006). Additive Role of Plasma von Willebrand Factor Levels to Clinical Factors for Risk Stratification of Patients With Atrial Fibrillation. Stroke 37: 2294-2300 [Abstract] [Full text]  
  • Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., Halperin, J. L., Le Heuzey, J.-Y., Kay, G. N., Lowe, J. E., Olsson, S. B., Prystowsky, E. N., Tamargo, J. L., Wann, S. (2006). ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society . J Am Coll Cardiol 48: 854-906 [Full text]  
  • Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., Halperin, J. L., Le Heuzey, J.-Y., Kay, G. N., Lowe, J. E., Olsson, S. B., Prystowsky, E. N., Tamargo, J. L., Wann, S. (2006). ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society . J Am Coll Cardiol 48: e149-e246 [Full text]  
  • Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., Halperin, J. L., Le Heuzey, J.-Y., Kay, G. N., Lowe, J. E., Olsson, S. B., Prystowsky, E. N., Tamargo, J. L., Wann, S., ACC/AHA TASK FORCE MEMBERS, , Smith, S. C. Jr, Jacobs, A. K., Adams, C. D., Anderson, J. L., Antman, E. M., Halperin, J. L., Hunt, S. A., Nishimura, R., Ornato, J. P., Page, R. L., Riegel, B., ESC COMMITTEE FOR PRACTICE GUIDELINES, , Priori, S. G., Blanc, J.-J., Budaj, A., Camm, A. J., Dean, V., Deckers, J. W., Despres, C., Dickstein, K., Lekakis, J., McGregor, K., Metra, M., Morais, J., Osterspey, A., Tamargo, J. L., Zamorano, J. L. (2006). ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114: e257-e354 [Full text]  
  • Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., Halperin, J. L., Le Heuzey, J.-Y., Kay, G. N., Lowe, J. E., Olsson, S. B., Prystowsky, E. N., Tamargo, J. L., Wann, S., ACC/AHA TASK FORCE MEMBERS, , Smith, S. C. Jr, Jacobs, A. K., Adams, C. D., Anderson, J. L., Antman, E. M., Halperin, J. L., Hunt, S. A., Nishimura, R., Ornato, J. P., Page, R. L., Riegel, B., ESC COMMITTEE FOR PRACTICE GUIDELINES, , Priori, S. G., Blanc, J.-J., Budaj, A., Camm, A. J., Dean, V., Deckers, J. W., Despres, C., Dickstein, K., Lekakis, J., McGregor, K., Metra, M., Morais, J., Osterspey, A., Tamargo, J. L., Zamorano, J. L. (2006). ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114: 700-752 [Full text]  
  • Authors/Task Force Members, , Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., Halperin, J. L., Le Heuzey, J.-Y., Kay, G. N., Lowe, J. E., Olsson, S. B., Prystowsky, E. N., Tamargo, J. L., Wann, S., ESC Committee for Practice Guidelines, , Priori, S. G., Blanc, J.-J., Budaj, A., Camm, A. J., Dean, V., Deckers, J. W., Despres, C., Dickstein, K., Lekakis, J., McGregor, K., Metra, M., Morais, J., Osterspey, A., Tamargo, J. L., Zamorano, J. L., ACC/AHA (Practice Guidelines) Task Force Members, , Smith, S. C. Jr, Jacobs, A. K., Adams, C. D., Anderson, J. L., Antman, E. M., Halperin, J. L., Hunt, S. A., Nishimura, R., Ornato, J. P., Page, R. L., Riegel, B. (2006). ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Eur Heart J 27: 1979-2030 [Full text]  
  • DeWilde, S, Carey, I M, Emmas, C, Richards, N, Cook, D G (2006). Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care. Heart 92: 1064-1070 [Abstract] [Full text]  
  • Lip, G Y H, Boos, C J (2006). Antithrombotic treatment in atrial fibrillation. Heart 92: 155-161 [Abstract] [Full text]  
  • Thomson, R, Murtagh, M, Khaw, F-M (2005). Tensions in public health policy: patient engagement, evidence-based public health and health inequalities. Qual Saf Health Care 14: 398-400 [Abstract] [Full text]  
  • Lorenz, K. A., Ryan, G. W., Morton, S. C., Chan, K. S., Wang, S., Shekelle, P. G. (2005). A qualitative examination of primary care providers' and physician managers' uses and views of research evidence. Int J Qual Health Care 17: 409-414 [Abstract] [Full text]  
  • Man-Son-Hing, M., Gage, B. F., Montgomery, A. A., Howitt, A., Thomson, R., Devereaux, P. J., Protheroe, J., Fahey, T., Armstrong, D., Laupacis, A. (2005). Preference-Based Antithrombotic Therapy in Atrial Fibrillation: Implications for Clinical Decision Making. Med Decis Making 25: 548-559 [Abstract]  
  • Emmerich, J., Le Heuzey, J.-Y., Bath, P. M.W., Connolly, S. J. (2005). Indication for antithrombotic therapy for atrial fibrillation: reconciling the guidelines with clinical practice. Eur Heart J Suppl 7: C28-C33 [Abstract] [Full text]  
  • Miller, P. S.J., Drummond, M. F., Langkilde, L. K., McMurray, J. J.V., Ogren, M. (2005). Economic factors associated with antithrombotic treatments for stroke prevention in patients with atrial fibrillation. Eur Heart J Suppl 7: C41-C54 [Abstract] [Full text]  
  • Choudhury, A, Lip, G Y H (2005). How good is anticoagulation control in non-valvar atrial fibrillation? Observations on the elderly, ethnicity, patient perceptions, and understanding of AF thromboprophylaxis. Heart 91: 425-426 [Abstract] [Full text]  
  • Elstein, A. S., Fryback, D. G., Weinstein, M. C., Pauker, S. G., Holmes-Rovner, M., Young, M. J., Barry, M. J., Eckman, M. H., Hunink, M. G. M., Tsevat, J., Wong, J. B. (2004). Presidential Reflections on the 25th Anniversary of the Society for Medical Decision Making. Med Decis Making 24: 408-420  
  • Lipman, T., Murtagh, M. J, Thomson, R. (2004). How research-conscious GPs make decisions about anticoagulation in patients with atrial fibrillation: a qualitative study. Fam Pract 21: 290-298 [Abstract] [Full text]  
  • Stewart, S, Murphy, N, Walker, A, McGuire, A, McMurray, J J V (2004). Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK. Heart 90: 286-292 [Abstract] [Full text]  
  • Rutten, F. H, Hak, E., Stalman, W. A., Verheij, T. J., Hoes, A. W (2003). Is treatment of atrial fibrillation in primary care based on thromboembolic risk assessment?. Fam Pract 20: 16-21 [Abstract] [Full text]  
  • Hart, R. G., Bailey, R. D. (2002). An assessment of guidelines for prevention of ischemic stroke. Neurology 59: 977-982 [Abstract] [Full text]  
  • Bellelli, G., Bianchetti, A., Trabucchi, M., Copland, M., Walker, I. D., Tait, R. C. (2002). Let's Strip the King: Eligibility Not Safety Is the Problem of Anticoagulation for Stroke Prevention in Elderly Patients With Atrial Fibrillation. Arch Intern Med 162: 1067-1067 [Full text]  
  • Grol, R. (2001). Improving the Quality of Medical Care: Building Bridges Among Professional Pride, Payer Profit, and Patient Satisfaction. JAMA 286: 2578-2585 [Abstract] [Full text]  
  • Devereaux, P J, Anderson, D. R, Gardner, M. J, Putnam, W., Flowerdew, G. J, Brownell, B. F, Nagpal, S., Cox, J. L, Fahey, T. (2001). Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study Commentary: Varied preferences reflect the reality of clinical practice. BMJ 323: 1218-1218 [Abstract] [Full text]  
  • Freeman, A C, Sweeney, K (2001). Why general practitioners do not implement evidence: qualitative study. BMJ 323: 1100-1100 [Abstract] [Full text]  
  • (2001). Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J 22: 1852-1923  
  • Fuster, V., Ryden, L. E., Asinger, R. W., Cannom, D. S., Crijns, H. J., Frye, R. L., Halperin, J. L., Kay, G. N., Klein, W. W., Levy, S., McNamara, R. L., Prystowsky, E. N., Wann, L. S., Wyse, D. G., Gibbons, R. J., Antman, E. M., Alpert, J. S., Faxon, D. P., Fuster, V., Gregoratos, G., Hiratzka, L. F., Jacobs, A. K., Russell, R. O., Smith, S. C. Jr, Klein, W. W., Alonso-Garcia, A., Blomstrom-Lundqvist, C., De Backer, G., Flather, M., Hradec, J., Oto, A., Parkhomenko, A., Silber, S., Torbicki, A. (2001). ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 38: 1266-1266 [Full text]  
  • Dudley, N (2001). Importance of risk communication and decision making in cardiovascular conditions in older patients: a discussion paper. Qual Saf Health Care 10: i19-22 [Abstract] [Full text]  
  • Gage, B. F., Waterman, A. D., Shannon, W., Boechler, M., Rich, M. W., Radford, M. J. (2001). Validation of Clinical Classification Schemes for Predicting Stroke: Results From the National Registry of Atrial Fibrillation. JAMA 285: 2864-2870 [Abstract] [Full text]  
  • Evans, A., Kalra, L. (2001). Are the Results of Randomized Controlled Trials on Anticoagulation in Patients With Atrial Fibrillation Generalizable to Clinical Practice?. Arch Intern Med 161: 1443-1447 [Abstract] [Full text]  
  • Hart, R. G., Halperin, J. L. (2001). Atrial Fibrillation and Stroke : Concepts and Controversies. Stroke 32: 803-808 [Full text]  
  • Fitzmaurice, D A, Mant, J, Murray, E T, Hobbs, F D R, Oswald, N., Oliver, M D, Ono, A., Bellelli, G., Bianchetti, A., Trabucchi, M. (2000). Anticoagulation to prevent stroke in atrial fibrillation. BMJ 321: 1156-1156 [Full text]  
  • Hart, R. G. (2000). Anticoagulation therapy for patients with atrial fibrillation. CMAJ 163: 956-957 [Full text]  
  • Dudley, N., Berry, C., McMurray, J. (2000). Anticoagulation for patients with atrial fibrillation. BMJ 321: 638-638 [Full text]  
  • Redfern, J., McKevitt, C., Dundas, R., Rudd, A. G., Wolfe, C. D.A. (2000). Behavioral Risk Factor Prevalence and Lifestyle Change After Stroke : A Prospective Study. Stroke 31: 1877-1881 [Abstract] [Full text]  
  • Protheroe, J., Fahey, T., Montgomery, A. A, Peters, T. J, Smeeth, L. (2000). The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based decision analysis Commentary: patients, preferences, and evidence. BMJ 320: 1380-1384 [Abstract] [Full text]  
  • Connolly, S. J (2000). Anticoagulation for patients with atrial fibrillation and risk factors for stroke. BMJ 320: 1219-1220 [Full text]  
  • Lodwick, A. (1999). State-of-the-Art Review: Warfarin Therapy: A Review of the Literature Since the Fifth American College of Chest Physicians' Consensus Conference on Antithrombotic Therapy. CLIN APPL THROMB HEMOST 5: 208-215  
  • Peterson, G., Howitt, A., Armstrong, D. (1999). Antithrombotic treatment for atrial fibrillation. BMJ 319: 708-708 [Full text]  

Rapid Responses:

Read all Rapid Responses

Let the patient decide
D A Fitzmaurice
bmj.com, 15 May 1999 [Full text]
Evidence Based Medicine in East Kent General Practices
Derek Mitchell
bmj.com, 17 May 1999 [Full text]
Smiley faces
Philip M Peverley
bmj.com, 21 May 1999 [Full text]
How were risks presented?
Gregory Peterson
bmj.com, 24 May 1999 [Full text]
Access jobs at BMJ Careers
Whats new online at Student BMJ