Barriers to Guideline-Directed Anticoagulation in Patients With Atrial Fibrillation: New Approaches to an Old Problem.

Optimising guideline-directed anticoagulation in atrial fibrillation remains a perennial problem despite strong evidence for improved health outcomes with guideline-directed use of anticoagulation. Efforts to improve uptake have been hampered by barriers found at the level of the physician, patient, disease, and choice of therapy. Clinician judgement is often clouded by factors such as therapeutic inertia, aversion to bleeding risk, and implicit bias. For patients, negative preconceptions of therapy, impact of therapy on day-to-day life, and the nocebo effect pose significant barriers. Both groups are affected by poor education. Utility of a single-pronged approach directed toward clinicians or patients have demonstrated variable success, with the highest impact appreciated in studies using shared-decision models. Further, there is emerging evidence for use of integrated models of care, which have shown efficacy in improving patient outcomes, as well as use of digital platforms such as mobile app-based interventions, which can be of aid to the clinician in improving patient adherence to anticoagulation, with translated improved outcomes in clinical trials. This narrative review aims to investigate the physician and health system, patient, and drug therapy and disease barriers to uptake of guideline-directed anticoagulation in the treatment of nonvalvular atrial fibrillation.

Motivations of assessment item writers in medical programs: a qualitative study.

BACKGROUND: The challenge of generating sufficient quality items for medical student examinations is a common experience for medical program coordinators. Faculty development strategies are commonly used, but there is little research on the factors influencing medical educators to engage in item writing. To assist with designing evidence-based strategies to improve engagement, we conducted an interview study informed by self-determination theory (SDT) to understand educators' motivations to write items. METHODS: We conducted 11 semi-structured interviews with educators in an established medical program. Interviews were transcribed verbatim and underwent open coding and thematic analysis. RESULTS: Major themes included; responsibility for item writing and item writer motivations, barriers and enablers; perceptions of the level of content expertise required to write items; and differences in the writing process between clinicians and non-clinicians. CONCLUSIONS: Our findings suggest that flexible item writing training, strengthening of peer review processes and institutional improvements such as improved communication of expectations, allocation of time for item writing and pairing new writers with experienced writers for mentorship could enhance writer engagement.

Barriers and facilitators to writing quality items for medical school assessments - a scoping review.

BACKGROUND: Producing a sufficient quantity of quality items for use in medical school examinations is a continuing challenge in medical education. We conducted this scoping review to identify barriers and facilitators to writing good quality items and note gaps in the literature that are yet to be addressed. METHODS: We conducted searches of three databases (ERIC, Medline and Scopus) as well as Google Scholar for empirical studies on the barriers and facilitators for writing good quality items for medical school examinations. RESULTS: The initial search yielded 1997 articles. After applying pre-determined criteria, 13 articles were selected for the scoping review. Included studies could be broadly categorised into studies that attempted to directly investigate the barriers and facilitators and studies that provided implicit evidence. Key findings were that faculty development and quality assurance were facilitators of good quality item writing while barriers at both an individual and institutional level include motivation, time constraints and scheduling. CONCLUSIONS: Although studies identified factors that may improve or negatively impact on the quality of items written by faculty and clinicians, there was limited research investigating the barriers and facilitators for individual item writers. Investigating these challenges could lead to more targeted and effective interventions to improve both the quality and quantity of assessment items.