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1.
Am Heart J ; 199: 13-21, 2018 05.
Article in English | MEDLINE | ID: mdl-29754650

ABSTRACT

BACKGROUND: Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. METHODS: We hypothesized that a shared decision-making interaction facilitated by an Atrial Fibrillation Shared Decision Making Tool (AFSDM) would improve patient knowledge about atrial fibrillation, and the risks and benefits of various treatment options for stroke prevention; increase satisfaction with the decision-making process; improve the therapeutic alliance between patient and the clinical care team; and increase medication adherence. Using a pre- and post-visit study design, we enrolled 76 patients and completed 2 office visits and 1-month telephone follow-up for 65 patients being seen in our Arrhythmia Clinic over the 1-year period (July 2016 through June 2017). Our primary outcome measure was change in decisional conflict between the first and second clinical visit. RESULTS: Decisional conflict decreased from an average of 31 to 9. Mean change was 22.3 (95% CI, 25.7 - 37.1), corresponding to an effect size of 0.94 standard deviations. Satisfaction with decision increased from 4.0 to 4.5, measures of therapeutic alliance with the care team (Kim Alliance scale) increased from 100.1 to 103.1, and satisfaction with provider increased from 4.2 to 4.5 (P < .0001 for all measures). AF knowledge assessment scores increased from 8.4 to 9.1, and knowledge about personal stroke and bleeding risk increased from 1 to 1.5 (P < .0001). Finally, medication adherence improved as reflected by an increase in the Morisky Medication Adherence scale from 5.9 to 6.4 (P < .0001). CONCLUSIONS: A shared decision-making interaction, facilitated by an AFSDM can significantly improve multiple measures of decision-making quality, leading to improved medication adherence and patient satisfaction.


Subject(s)
Anticoagulants/therapeutic use , Atrial Fibrillation/drug therapy , Decision Making , Medication Adherence , Thrombosis/prevention & control , Aged , Atrial Fibrillation/complications , Feasibility Studies , Female , Follow-Up Studies , Humans , Male , Patient Participation , Patient Satisfaction , Risk Factors , Thrombosis/etiology
2.
Am Heart J ; 194: 49-60, 2017 Dec.
Article in English | MEDLINE | ID: mdl-29223435

ABSTRACT

BACKGROUND: Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. The recent availability of direct oral anticoagulants (DOACs) with comparable efficacy and improved safety compared with warfarin alters the balance between risk factors for stroke and benefit of anticoagulation. Our objective was to examine the impact of DOACs as an alternative to warfarin on the net benefit of oral anticoagulant therapy (OAT) in a real-world population of AF patients. METHODS: This is a retrospective cohort study of patients with paroxysmal or persistent nonvalvular AF. We updated an Atrial Fibrillation Decision Support Tool (AFDST) to include DOACs as treatment options. The tool generates patient-specific recommendations based upon individual patient risk factor profiles for stroke and major bleeding using quality-adjusted life-years (QALYs) calculated for each treatment strategy by a decision analytic model. The setting included inpatient and ambulatory sites in an academic health center in the midwestern United States. The study involved 5,121 adults with nonvalvular AF seen for any ambulatory visit or inpatient hospitalization over the 1-year period (January through December 2016). Outcome measure was net clinical benefit in QALYs. RESULTS: When DOACs are a therapeutic option, the AFDST recommends OAT for 4,134 (81%) patients and no antithrombotic therapy or aspirin for 489 (9%). A strong recommendation for OAT could not be made in 498 (10%) patients. When warfarin is the only option, OAT is recommended for 3,228 (63%) patients and no antithrombotic therapy or aspirin for 973 (19%). A strong recommendation for OAT could not be made in 920 (18%) patients. In total, 1,508 QALYs could be gained if treatment were changed to that recommended by the AFDST. CONCLUSIONS: Availability of DOACs increases the proportion of patients for whom oral anticoagulation therapy is recommended in a real-world cohort of AF patients and increased projected QALYs by more than 1,500 when all patients are receiving thromboprophylaxis as recommended by the AFDST compared with current treatment.


Subject(s)
Anticoagulants/administration & dosage , Atrial Fibrillation/drug therapy , Decision Support Techniques , Hemorrhage/epidemiology , Population Surveillance , Tachycardia, Paroxysmal/drug therapy , Thromboembolism/prevention & control , Administration, Oral , Aged , Aged, 80 and over , Atrial Fibrillation/complications , Atrial Fibrillation/mortality , Female , Follow-Up Studies , Hemorrhage/chemically induced , Humans , Incidence , Male , Middle Aged , Ohio/epidemiology , Retrospective Studies , Survival Rate/trends , Tachycardia, Paroxysmal/complications , Tachycardia, Paroxysmal/mortality , Thromboembolism/epidemiology , Thromboembolism/etiology
3.
Am Heart J ; 176: 17-27, 2016 Jun.
Article in English | MEDLINE | ID: mdl-27264216

ABSTRACT

BACKGROUND: Appropriate thromboprophylaxis for patients with atrial fibrillation (AF) remains a national challenge. METHODS: We hypothesized that provision of decision support in the form of an Atrial Fibrillation Decision Support Tool (AFDST) would improve thromboprophylaxis for AF patients. We conducted a cluster randomized trial involving 15 primary care practices and 1,493 adults with nonvalvular AF in an integrated health care system between April 2014 and February 2015. Physicians in the intervention group received patient-level treatment recommendations made by the AFDST. Our primary outcome was the proportion of patients with antithrombotic therapy that was discordant from AFDST recommendation. RESULTS: Treatment was discordant in 42% of 801 patients in the intervention group. Physicians reviewed reports for 240 patients. Among these patients, thromboprophylaxis was discordant in 63%, decreasing to 59% 1 year later (P = .02). In nonstratified analyses, changes in discordant care were not significantly different between the intervention group and control groups. In multivariate regression models, assignment to the intervention group resulted in a nonsignificant trend toward decreased discordance (P = .29), and being a patient of a resident physician (P = .02) and a higher HAS-BLED score predicted decreased discordance (P = .03), whereas female gender (P = .01) and a higher CHADSVASc score (P = .10) predicted increased discordance. CONCLUSIONS: Among patients whose physicians reviewed recommendations of the decision support tool discordant therapy decreased significantly over 1 year. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy.


Subject(s)
Anticoagulants , Atrial Fibrillation/drug therapy , Chemoprevention , Hemorrhage , Platelet Aggregation Inhibitors , Thromboembolism/prevention & control , Aged , Anticoagulants/administration & dosage , Anticoagulants/adverse effects , Atrial Fibrillation/complications , Chemoprevention/methods , Chemoprevention/statistics & numerical data , Decision Support Systems, Management/organization & administration , Decision Support Systems, Management/statistics & numerical data , Female , Hemorrhage/chemically induced , Hemorrhage/prevention & control , Humans , Male , Outcome and Process Assessment, Health Care , Platelet Aggregation Inhibitors/administration & dosage , Platelet Aggregation Inhibitors/adverse effects , Risk Assessment/methods , Thromboembolism/etiology
4.
J Am Geriatr Soc ; 64(5): 1054-60, 2016 05.
Article in English | MEDLINE | ID: mdl-27225358

ABSTRACT

OBJECTIVES: To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. DESIGN: Retrospective cohort study. SETTING: Primary care practices of an academic healthcare system. PARTICIPANTS: Adults (aged 28-93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). MEASUREMENTS: Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. RESULTS: Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. CONCLUSION: Physicians should understand that female sex is a significant risk factor for AF-related stroke and incorporate this into decision-making about thromboprophylaxis. Treating older adults with aspirin instead of OAT exposes them to significant risk of bleeding with little to no reduction in AF-related stroke risk.


Subject(s)
Anticoagulants/therapeutic use , Atrial Fibrillation/drug therapy , Decision Support Techniques , Stroke/prevention & control , Thromboembolism/prevention & control , Aged , Aged, 80 and over , Chemoprevention/methods , Female , Hemorrhage/chemically induced , Humans , Male , Primary Health Care , Quality-Adjusted Life Years , Retrospective Studies , Risk Factors , Sex Factors , Unnecessary Procedures
5.
Circ Cardiovasc Qual Outcomes ; 7(5): 680-6, 2014 Sep.
Article in English | MEDLINE | ID: mdl-25205788

ABSTRACT

BACKGROUND: Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS2 or the CHA2DS2VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy. METHODS AND RESULTS: This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatment and treatment recommended by an Atrial Fibrillation Decision Support Tool. Current treatment was discordant from treatment recommended by the Atrial Fibrillation Decision Support Tool in 931 patients. A clinically significant gain in quality-adjusted life expectancy (defined as ≥0.1 quality-adjusted life-years) was projected in 832 patients. Subgroups were examined. For example, oral anticoagulant therapy was recommended for 188 who currently were receiving no antithrombotic therapy. For the entire cohort, a total of 736 quality-adjusted life-years could be gained were treatment changed to that recommended by the Atrial Fibrillation Decision Support Tool. CONCLUSIONS: Use of a decision support tool that integrates patient-specific stroke and bleeding risk could result in significant gains in quality-adjusted life expectancy for a primary care population of patients with atrial fibrillation.


Subject(s)
Atrial Fibrillation/epidemiology , Computer Simulation , Decision Making, Computer-Assisted , Anticoagulants/therapeutic use , Atrial Fibrillation/drug therapy , Cohort Studies , Fibrinolytic Agents/therapeutic use , Guidelines as Topic , Health Information Management , Humans , Outcome and Process Assessment, Health Care , Quality Improvement , Quality-Adjusted Life Years , Retrospective Studies , United States
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