Abstract Body (Do not enter title and authors here): Introduction: Atrial fibrillation (AF) is a common arrhythmia associated with ischemic stroke. Prior work shows that stroke-reducing oral anticoagulant (OAC) therapy is less commonly prescribed in minoritized racial/ethnic groups, but the drivers of these disparities are unclear.

Hypothesis: We hypothesized that clinicians and patients would provide key themes to inform disparities in OAC prescribing.

Goals/Aims: To identify barriers to and facilitators of equitable OAC prescribing.

Methods: Using data from a cohort of patients with incident AF in the Veterans Health Administration (VA) from 2018-2021, we identified VA medical centers (N=21) with high vs. low rates of OAC prescribing and racial disparities (>10%) in prescribing. From these sites, we recruited 30 clinicians (PCPs, cardiologists, pharmacists) and 33 patients with AF (67% Black or Hispanic). We conducted 1:1 semi-structured interviews from 6/1/23-3/1/24. A primary and secondary analyst co-coded 20% of the interviews using negotiated consensus before coding the remaining interviews independently. Themes related to patient and structural-level barriers to and facilitators of equitable OAC use were identified using thematic analysis.

Results: Clinicians identified patient-level barriers including knowledge of someone who had a negative anticoagulation experience, mistrust of the health system, and concerns about bleeding risk and side effects. Patients raised concerns about the OAC regimen or distrust of medications and a lack of information about OACs. Structural-level barriers identified by clinicians included perceptions that patients’ adverse social circumstances (e.g., homelessness) interfere with medication use, care fragmentation between VA and non-VA clinics, and AF care not being a top VA priority. Patients also identified distance to VA and poor coordination of care as barriers. All clinicians noted comfort prescribing OACs as a facilitator of equitable prescribing. Other facilitators included strong collaboration between clinicians and anticoagulation clinics, patient-clinician trust, and Veterans learning about the benefits of OAC.

Conclusion: Clinicians and diverse patients with AF in VA identified several barriers to equitable prescribing of OAC, including adverse social determinants of health and care fragmentation. Strengthening physician-pharmacist collaboration, building trust with patients, and enhancing AF education are actionable strategies for eliminating disparities in OAC use.