Atrial fibrillation (AF) is the most potent risk factor for stroke and six randomized trials of anticoagulants have demonstrated a risk reduction of stroke by two-thirds. Unfortunately, anticoagulants are often under-used for stroke prevention in AF. Reasons for this underuse are not entirely known, but include discordance between providers' and patients' preferences and beliefs about the use of anticoagulants for stroke prevention in AF. Efforts to better understand this decision-making could potentially improve patient outcomes. VA Health Services Research & Development funded this project (QUERI RRP 06-153).
This project has the following goals: (1) testing the feasibility of a previously validated clinical decision aid "Making Choices: An Atrial Fibrillation Treatment Decision-Making Aid" in the VA population; and (2) developing an implementation process for using this decision aid in the VA population.
This project address the gaps in decision making by developing an implementation strategy process and testing the feasibility of using a previouosly validated clinica decisin making tool. "Making Choices: An Atrial Fibrillation Treatment Decision-Making Aide" developed by the Atrial Fibrillation Decision Aid Group at the University of Ottawa. The program consists of a physician manual, and for patients, a video, personal worksheet, and education booklets that are specific to four levels of stroke risk (low, medium, high and very high) that detial the risk and benefits of therapy for stroke prevention in atrial fibrillation as described by the current American College of Chest Physicians recommendations. To develop an implementation strategy for using the decision aid in our patients we employed four recruitment strategies. We also tested the feasibility of the using decision aide in our veteran population. Enrolled patients were sent a copy of the decision aide along with either a CD or audiocassette recording and the worksheet. A telephone interview was conducted after they completed the decision aid (approximately 10 days after mailing the interview). We asessed patients' opinion on the usefulness of the information in the decision aide, the knowledge gained, their prefered role in decision-making and their level of decisional conflict using previously validated instruments. One month later, we re-contacted patients to assess if they had talked or made an appointment with theri provider about their treatment, what their role was in the decision-making process and if they had changed their choice of therapy. UF IRB and the VA R&D Committee approved this study.
We employed four recruitment strategies to develop an implementation strategy. These included (1) Directly contacting providers with potentially eligible patients and providing them with study recruitment materials for them to give to eligible patients; (2) Presentations at monthly primary care clinics to inform providers and provide them with study recruitment materials; (3) Provided recruitment packets to service chiefs from community based outpatient clinics for them to distribute to their providers; (4) Partnered with clinical pharmacist in our facility's anticoagulation clinic to help identify potentially eligible patients. The last strategy was the most successful for quickly identifying potentially eligible patients and then contacting their provider to obtain permission to approach the patient for possible study enrollment. We found that relying on busy providers to refer potentially eligible patients was not very effective. Due to our institutional IRB restrictions we were not allowed to approach patients directly for participation in the study.
Overall, 14 veterans contacted us, and 7 completed the decision aid and the first interview; six completed the second interview. All participants were men. Their average score on the decisional conflict scale was 32.4 (0 = no conflict, 100 =high conflict). Each of the scale item scores suggested low decisional conflict. All reported started anti-thrombotic therapy (2 asa, 5 warfarin). On average most subjects were somewhat to very satisified with their decision. The subjects rated the information in the decision aid as very good for atrial fibrillation, good to very good for types of strokes, very good for risks of stroke, very good for benefits of medication, and good for stories about others. The majority (n=6) reported that the amount of information was "just right"; one patient reporteed "too little". All felt that the length of the program was "just right". Only two subjects correctly identified their risk for stroke; most believed that they were at lower risk of stroke than they actually were. When asked about how the decision on treatment was made patients initially reported that they "prefer to make the final decision after seriously considering their doctor's opinion", but when questioned one month after they reported that their "physician made the decision, but storngly considered their opinion. In general, patients who completed the decision aid felt the information was very good. Furthermore, although they wanted greater involvement in the decison-making about their care, they were willing to allow their provider to make the final decision for them. We also found that the decision aid that we used may not be suitable for all levels of health literacy, though it was beyond the scope of this project to further assess and/or test other decision aides.
Our findings suggest that the veterans that we studied want to take an active role in their decision-making for their healthcare, but often defer to their provider for decision-making regarding stroke prevention in atrial fibrillation. Processes that encourage veterans to be more informed about the risks and benefits of treatment for stroke prevention and take a more active role in their health care decision making may be warranted to improve adherence to national guidelines for stroke prevention.
- Matchar D, Beyth RJ. Innovations in Anticoagulation Management: the VA leading the Way. Paper presented at: Anticoagulation Forum on Anticoagulant Therapy Annual Conference; 2007 May 5; Chicago, IL.
- Wilson DL, Beyth RJ, Bautista M, Sberna M, Mueller M, Kwon SY. Improved Clinical Decision Making for Stroke Prevention. Poster session presented at: American Pharmaceutical Association Annual Meeting; 2007 Mar 18; Atlanta, GA.