Evaluation of patients' attitudes towards stroke prevention and bleeding risk in atrial fibrillation.

Patient's values and preferences regarding the relative importance of preventing strokes and avoiding bleeding are now recognised to be of great importance in deciding on therapy for the prevention of stroke due to atrial fibrillation (SPAF). We used an iPad questionnaire to determine the minimal clinically important difference (Treatment Threshold) and the maximum number of major bleeding events that a patient would be willing to endure in order to prevent one stroke (Bleeding Ratio) for the initiation of antithrombotic therapy in 172 hospital in-patients with documented non-valvular atrial fibrillation in whom anticoagulant therapy was being considered. Patients expressed strong opinions regarding SPAF. We found that 12% of patients were "medication averse" and were not willing to consider antithrombotic therapy; even if it was 100% effective in preventing strokes. Of those patients who were willing to consider antithrombotic therapy, 42% were identified as "risk averse" and 15% were "risk tolerant". Patients required at least a 0.8% (NNT=125) annual absolute risk reduction and 15% relative risk reduction in the risk of stroke in order to agree to initiate antithrombotic therapy, and patients were willing to endure 4.4 major bleeds in order to prevent one stroke. In conclusion, there was a substantial amount of inter-patient variability, and often extreme differences in opinion regarding tolerance of bleeding risk in the context of stroke prevention in atrial fibrillation. These findings highlight the importance of considering patient preferences when deciding on SPAF therapy.

Evaluation of referral completion after a workplace cholesterol screening program.

We designed a randomized clinical trial to examine effectiveness of a follow-up educational mailing to improve referral completion following a workplace cholesterol screening program. Of 836 employees who participated in a cholesterol screening program at Blue Cross and Blue Shield of Maryland, 313 (37%) had a total cholesterol greater than or equal to 200 mg/dL and were referred to their physician for remeasurement and evaluation. Individuals with elevated cholesterol who agreed to a telephone interview two months after screening (n = 272) were randomized to a control or intervention group. The intervention consisted of a booster mailing two weeks after screening designed to encourage further physician follow-up and to increase knowledge about cholesterol and its dietary control and about risk factors for coronary heart disease (CHD). No statistically significant differences appeared between the control and intervention groups in rate of referral completion. However, a blood cholesterol level of greater than or equal to 240 mg/dL at the time of screening was the most significant predictor of referral completion (P less than .0001). Of those randomized, the association between the number of other additional risk factors for CHD and referral completion was not statistically significant. There was, however, a trend toward reported changes in lifestyle behavior as a result of screening, particularly in diet modification.