Original Investigation
Pulmonary Medicine
January 3, 2025
Factors in Initial Anticoagulation Choice in Hospitalized Patients With Pulmonary Embolism
William B. Stubblefield, Ron Helderman, Natalie Strokes, et al
JAMA Netw Open. 2025;8(1):e2452877. doi:10.1001/jamanetworkopen.2024.52877
Question What are factors associated with initial anticoagulation choice in hospitalized patients with acute pulmonary embolism (PE)?
Findings In this qualitative study of 46 physicians, major barriers and facilitators of using unfractionated heparin or low-molecular-weight heparin included agnosticism to choice of anticoagulant, inertia of learned practice, therapeutic momentum after anticoagulation was initiated, and institutional culture and support.
Meaning Findings of this study identify potential targets for implementation strategies for guideline-concordant anticoagulation in patients with acute PE.
Abstract
Importance Despite guideline recommendations to use low-molecular-weight heparins (LMWHs) or direct oral anticoagulants in the treatment of most patients with acute pulmonary embolism (PE), US-based studies have found increasing use of unfractionated heparin (UFH) in hospitalized patients.
Objective To identify barriers and facilitators of guideline-concordant anticoagulation in patients hospitalized with acute PE.
Design, Setting, and Participants This qualitative study conducted semistructured interviews from February 1 to June 3, 2024, that were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis. Interview participants were physicians in emergency medicine, hospital medicine (hospitalist), interventional cardiology, and interventional radiology. Participants were recruited using maximum variation sampling targeting UFH-dominant vs LMWH-dominant approaches in hospitalized patients with acute PE. We triangulated results with a group of interventional cardiologists and radiologists (interventionalists).
Main Outcomes and Measures Common themes and factors associated with anticoagulant selection for hospitalized patients with acute PE. Reflexive thematic analysis was used to identify these themes and factors.
Results Of the 46 interviewees (median [IQR] age, 43 [36-50] years; 33 who identified as men [71.7%]), 25 (54.3%) were emergency physicians, 17 (37.0%) were hospitalists, and 4 (8.7%) were interventionalists. Each interview lasted a median (IQR) of 29 (25-32) minutes. Prominent themes associated with anticoagulant selection included agnosticism regarding choice of anticoagulant, the inertia of learned practice, and therapeutic momentum after anticoagulation initiation. Institutional culture and support were factors associated with choice of the dominant anticoagulation strategy. Additionally, factors associated with UFH use were fear of decompensation and misperceptions regarding the pharmacology of anticoagulants and catheter-directed treatments.
Conclusions and Relevance In this qualitative study, physicians across a spectrum of specialties and geographical settings reported common barriers and facilitators to the use of guideline-concordant anticoagulation in patients hospitalized with acute PE, particularly agnosticism regarding choice of anticoagulant, inertia of learned practice, therapeutic momentum after anticoagulation initiation, and institutional culture and support. Future implementation efforts may consider targeting these domains.
