Facilitators and Barriers for the use of Direct Anticoagulant: A qualitative study

IntroductionAtrial fibrillation (AF) is the most common arrhythmia globally and a leading cause of stroke, heart failure, and cardiovascular disease. In low- and middle-income countries (LMICs), including Nepal, managing AF is challenging due to limited access to timely diagnosis and traditional treatments like Vitamin K Antagonists (VKAs). Non-Vitamin K antagonist oral anticoagulants (NOACs) have improved stroke prevention in AF patients, but affordability and accessibility remain significant barriers. This study explores barriers and facilitators to NOAC use for stroke prevention among AF patients in Nepal. Materials and MethodsThis qualitative study involved in-depth interviews with 57 stakeholders in cardiovascular disease programs, policies, and management in Bagmati province, Nepal. Interviews were digitally recorded, transcribed verbatim, and analyzed using NVivo software. ResultsBarriers included low awareness among healthcare providers regarding NOACs rural health workers and patients, lack of essential equipment, insufficient human resources, absence of dedicated policies, and limited specialized training. The cost and unavailability of advanced medications like NOACs further hindered access. Challenges in Prothrombin time Internalized Normalized Ration(INR) monitoring for Warfarin users also persisted. Key facilitators were increased awareness among healthcare workers about AF at macro urban levels and the implementation of the Package of Essential Noncommunicable (PEN) disease interventions protocol for managing cardiovascular diseases. ConclusionThis study identifies critical gaps in AF management in Nepal, particularly in rural settings, where limited infrastructure, inadequate training, and low public awareness hinder effective diagnosis and treatment. The high cost and restricted access to NOACs, coupled with challenges in using Warfarin, exacerbate these issues. Addressing these gaps through national guidelines, improved infrastructure, training programs, and cost-effective policies is essential. Embedding an educational program in a broader quality improvement initiative can enhance healthcare workers knowledge and ensure equitable and effective AF management across Nepal.