Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
BMC Medical Informatics and Decision Making
Published in: BMC Medical Informatics and Decision Making 1/2011

Open Access 01-12-2011 | Technical advance

Development of a tool to improve the quality of decision making in atrial fibrillation

Authors: Liana Fraenkel, Richard L Street Jr, Terri R Fried

Published in: BMC Medical Informatics and Decision Making | Issue 1/2011

Login to get access

Abstract

Background

Decision-making about appropriate therapy to reduce the stroke risk associated with non-valvular atrial fibrillation (NVAF) involves the consideration of trade-offs among the benefits, risks, and inconveniences of different treatment options. The objective of this paper is to describe the development of a decision support tool for NVAF based on the provision of individualized risk estimates for stroke and bleeding and on preparing patients to communicate with their physicians about their values and potential treatment options.

Methods

We developed a tool based on the principles of the International Patient Decision Aids Standards. The tool focuses on the patient-physician dyad as the decision-making unit and emphasizes improving the interaction between the two. It is built on the recognition that the application of patient values to a specific treatment decision is complex and that the final treatment choice is best made through a process of patient-clinician communication.

Results

The tool provides education incorporating patients ' illness perceptions to explain the relationship between NVAF and stroke, and then presents individualized risk estimates, derived using separate risk calculators for stroke and bleeding over a clinically meaningful time period (5 years) associated with no treatment, aspirin, and warfarin. Sequelae of both stroke and bleeding outcomes are also described. Patients are encouraged to verbalize how they value the incremental risks and benefits associated with each option and write down specific concerns to address with their physician. A physician prompt to encourage patients to discuss their opinions is included as part of the decision support tool. In pilot testing with 11 participants (mean age 78 ± 9 years, 64% with ≤ high-school education), 8 (72%) rated ease of completion as "very easy," and 9 (81%) rated amount of information as "just right."

Conclusions

The risks and benefits of different treatment options for reduction of stroke in NVAF vary widely according to patients' comorbidities. This tool facilitates the provision of individualized outcome data and encourages patients to communicate with their physicians about these risks and benefits. Future studies will examine whether use of the tool is associated with improved quality of decision making.
Appendix
Available only for authorised users
Literature
1.
Hart RG, Pearce LA, Aguilar MI: Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007, 146: 857-867.CrossRefPubMed
2.
Albers GW, Dalen JE, Laupacis A, Manning WJ, Petersen P, Singer DE: Antithrombotic therapy in atrial fibrillation. Chest. 2001, 119: 194S-206S. 10.1378/chest.119.1_suppl.194S.CrossRefPubMed
3.
Fuster V, Ryden LE, Asinger RW: ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences: developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol. 2001, 38: 1231-1266. 10.1016/S0735-1097(01)01587-X.CrossRefPubMed
4.
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ: Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001, 285: 2864-2870. 10.1001/jama.285.22.2864.CrossRefPubMed
5.
Gage BF, Yan Y, Milligan PE: Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006, 151: 713-719. 10.1016/j.ahj.2005.04.017.CrossRefPubMed
6.
Fraenkel L, Fried TR: Individualized medical decision making: necessary, achievable, but not yet attainable. Arch Intern Med. 2010, 170: 566-569. 10.1001/archinternmed.2010.8.CrossRefPubMedPubMedCentral
7.
Man-Son-Hing M, Gage BF, Montgomery AA, Howitt A, Thomson R, Devereaux PJ, Protheroe J, Fahey T, Armstrong D, Laupacis A: Preference-based antithrombotic therapy in atrial fibrillation: implications for clinical decision making. Med Decis Making. 2005, 25: 548-559. 10.1177/0272989X05280558.CrossRefPubMed
8.
Holbrook A, Labiris R, Goldsmith CH, Ota K, Harb S, Sebaldt RJ: Influence of decision aids on patient preferences for anticoagulant therapy: a randomized trial. CMAJ. 2007, 176: 1597-1598. 10.1503/cmaj.070490.CrossRef
9.
Man-Son-Hing M, Laupacis A, O'Connor AM: Development of a decision aid for atrial fibrillation who are considering antithrombotic therapy. J Gen Intern Med. 2000, 15: 723-730. 10.1046/j.1525-1497.2000.90909.x.CrossRefPubMedPubMedCentral
10.
Thomson RG, Eccles MP, Steen IN, Greenaway J, Stobbart L, Murtagh MJ, May CR: A patient decision aid to support shared decision-making on anti-thrombotic treatment of patients with atrial fibrillation: randomised controlled trial. Qual Safety Health Care. 2007, 16: 216-223. 10.1136/qshc.2006.018481.CrossRef
11.
Street RL: Aiding medical decision making: a communication perspective. Med Decis Making. 2007, 27: 550-553. 10.1177/0272989X07307581.CrossRefPubMed
12.
Elwyn G, O'Connor A, Stacey D, Volk R, Edwards A, Coulter A, Thomson R, Barratt A, Barry M, Bernstein S: Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. BMJ. 2006, 333: 417-10.1136/bmj.38926.629329.AE.CrossRefPubMedPubMedCentral
13.
Petrie KJ, Weinman JA: Perceptions of health and illness: Current research and applications. 1997, Amsterdam: Harwood Academic Publishers
14.
15.
Hernandez-Diaz S, Rodriguez LAG: Cardioprotective aspirin users and their excess risk of upper gastrointestinal complications. BMC Med. 2006, 4: 22-10.1186/1741-7015-4-22.CrossRefPubMedPubMedCentral
16.
Wang TJ, Massaro JM, Levy D: A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study. JAMA. 2003, 290: 1049-1056. 10.1001/jama.290.8.1049.CrossRefPubMed
17.
Beyth RJ, Quinn LM, Landefeld CS: Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin. Am J Med. 1998, 105: 91-99. 10.1016/S0002-9343(98)00198-3.CrossRefPubMed
18.
Shireman TI, Mahnken JD, Howard PA, Kresowik TF, Hou Q, Ellerbeck EF: Development of a contemporary bleeding risk model for elderly warfarin recipients. Chest. 2006, 130: 1390-1396. 10.1378/chest.130.5.1390.CrossRefPubMed
19.
Garcia Rodriguez LA, Hernandez-Diaz S, de Abajo FJ: Association between aspirin and upper gastrointestinal complications: systematic review of epidemiologic studies. Br J Clin Pharmacol. 2001, 52: 563-571. 10.1046/j.0306-5251.2001.01476.x.CrossRefPubMed
20.
Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002, 324: 71-86. 10.1136/bmj.324.7329.71.
21.
22.
Beck JR, Pauker SG, Gottlieb JE, Klein K, Kassirer JP: A convenient approximation of life expectancy (the "DEALE"): II. Use in medical decision-making. Am J Med. 1982, 73: 889-897. 10.1016/0002-9343(82)90787-2.CrossRefPubMed
23.
Hurlen M, Abdelnoor M, Smith P, Erikssen J, Arnesen H: Warfarin, aspirin, or both after myocardial infarction. N Engl J Med. 2002, 347: 969-974. 10.1056/NEJMoa020496.CrossRefPubMed
24.
Fried TR, Bradley EH, Towle VR, Allore H: Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002, 346: 1061-1066. 10.1056/NEJMsa012528.CrossRefPubMed
25.
Fried TR, McGraw S, Agostini JV, Tinetti ME: Views of older persons with multiple morbidities on competing outcomes and clinical decision-making. J Am Geriatr Soc. 2008, 56: 1839-1844. 10.1111/j.1532-5415.2008.01923.x.CrossRefPubMedPubMedCentral
26.
Fang MC, Go AS, Chang Y, Hylek EM, Henault LE, Jensvold NG, Singer DE: Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med. 2007, 120: 700-705. 10.1016/j.amjmed.2006.07.034.CrossRefPubMedPubMedCentral
27.
Thom T, Haase N, Rosamond W: Heart Disease and Stroke Statistics--2006 Update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006, 6: e85-e151.CrossRef
28.
Levinson W, Kao A, Kuby A, Thisted RA: Not all patients want to participate in decision-making. JGIM. 2005, 20: 531-535. 10.1111/j.1525-1497.2005.04101.x.CrossRefPubMedPubMedCentral
29.
Say R, Murtagh M, Thomson R: Patients' preference for involvement in medical decision making: a narrative review. Patient Educ Couns. 2006, 60: 102-114. 10.1016/j.pec.2005.02.003.CrossRefPubMed
30.
Fraenkel L, McGraw S: What are the essential elements to enable patient participation in medical decision making?. J Gen Intern Med. 2007, 22: 614-619. 10.1007/s11606-007-0149-9.CrossRefPubMedPubMedCentral
31.
32.
McAlister FA, Man-Son-Hing M, Straus SE, Ghali WA, Anderson D, Majumdar SR, Gibson P, Cox JL, Fradette M: Impact of a patient decision aid on care among patients with nonvalvular atrial fibrillation: a cluster randomized trial. CMAJ. 2005, 173: 496-501. 10.1503/cmaj.050091.CrossRefPubMedPubMedCentral
33.
Say R, Murtagh M, Thomson R: Patients' preference for involvement in medical decision making: a narrative review. Patient Educ Counsel. 2006, 60: 102-114. 10.1016/j.pec.2005.02.003.CrossRef
34.
Street RL: Information-giving in medical consultations: The influence of patients' communicative styles and personal characteristics. Soc Sci Med. 1991, 32: 541-10.1016/0277-9536(91)90288-N.CrossRefPubMed
35.
Cegala DJ, Post DM, McClure L: The effects of patient communication skills training on the discourse of older patients during a primary care interview. J Am Geriatr Soc. 2001, 49: 1505-1511. 10.1046/j.1532-5415.2001.4911244.x.CrossRefPubMed
36.
Davey HM, Barratt AL, Davey E, Butow PN, Redman S, Houssami N, Salkeld GP: Medical tests: women's reported and preferred decision-making roles and preferences for information on benefits, side-effects and false results. Health Expectations. 2002, 5: 330-340. 10.1046/j.1369-6513.2002.00194.x.CrossRefPubMed
37.
Ford S, Schofield T, Hope T: Are patients' decision-making preferences being met?. Health Expectations. 2003, 6: 72-80. 10.1046/j.1369-6513.2003.00211.x.CrossRefPubMed
38.
Hylek EM, Evans-Molina C, Shea C, Henault LE, Regan S: Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007, 115: 2689-2696. 10.1161/CIRCULATIONAHA.106.653048.CrossRefPubMed
39.
O'Connor AM, Bennett CL, Stacey D, Barry M, Col NF, Eden KB, Entwistle VA, Fiset V, Holmes-Rovner M, Khangura S: Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2009, CD001431-
Metadata
Title
Development of a tool to improve the quality of decision making in atrial fibrillation
Authors
Liana Fraenkel
Richard L Street Jr
Terri R Fried
Publication date
01-12-2011
Publisher
BioMed Central
Published in
BMC Medical Informatics and Decision Making / Issue 1/2011
Electronic ISSN: 1472-6947
DOI
https://doi.org/10.1186/1472-6947-11-59

Other articles of this Issue 1/2011

BMC Medical Informatics and Decision Making 1/2011 Go to the issue

Correspondence

How are the different specialties represented in the major journals in general medicine?

Research article

The Chronic Kidney Disease Model: A General Purpose Model of Disease Progression and Treatment

Research article

Does electronic clinical microbiology results reporting influence medical decision making: a pre- and post-interview study of medical specialists

Technical advance

Architecture of a consent management suite and integration into IHE-based regional health information networks

Research article

The re-identification risk of Canadians from longitudinal demographics

Research article

Redesign of a computerized clinical reminder for colorectal cancer screening: a human-computer interaction evaluation