The complexity of anticoagulant prescribing in advanced kidney disease: a case vignette study

Background Anticoagulants are high-risk medications that require careful consideration of the risks and benefits. In the setting of advanced kidney disease decisions around prescribing anticoagulants is problematic. This relates to a lack of good-quality evidence and the altered renal clearance and protein binding in kidney disease. This leads to prescribing variation and results in patients experiencing different standards of care. The aim of this study was to explore the factors influencing anticoagulant prescribing decisions among nephrology and haematology healthcare professionals in commonly encountered scenarios, in order to better understand variation in prescribing practice. Methods Three case-vignettes were presented to 15 haematology and nephrology professionals as part of a semi-structured interview. Participants were purposively selected based on variable responses to a UK anticoagulant prescribing practice survey. An inductive thematic analysis was undertaken as described by Braun and Clark with an iterative review process to identify final themes. Results There were five main themes that arose from the analysis; evidence, patient factors, knowledge and experience, team influence and systems and they were present across all the three vignettes. The prescribing of anticoagulation in advanced kidney disease is strongly influenced by the knowledge and expertise gleaned by prescribers previous experiences and the incorporation of patient factors. Prescribers commonly seek opinion from senior staff and other members of the multiprofessional team to support their decision making. Decisions are also influenced by organisational factors that are beyond their individual control. Conclusion Development of guidelines, delivery of education and good-quality evidence is needed to improve prescribing variation and ultimately the quality of care provided to patients with advanced kidney disease.