Developing an Atrial Fibrillation Guideline Support Tool (AFGuST) for shared decision making

Mark H. Eckman, Ruth E. Wise, Katherine Naylor, Lora Arduser, Gregory Y.H. Lip, Brett Kissela, Matthew Flaherty, Dawn Kleindorfer, Faisal Khan, Daniel P. Schauer, John Kues, Alexandru Costea
2015 Current Medical Research and Opinion  
Objective-Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients' preferences into this decision. Materials and Methods-CHA 2 DS 2 VASc and
more » ... AS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational "engine" to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy. Results-Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patientspecific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video were developed through an iterative process with clinicians and patient focus groups. Key Limitations-Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy. Conclusions-We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient's stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management. Background and Significance Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder and is also the most powerful common risk factor for stroke: about 15% of all strokes in the U.S. are attributable to AF. Its frequency increases strikingly with age, reaching a prevalence of 10% in those over age 80. 1 With the aging of the U.S. population, the prevalence of AF will increase substantially from over 2.2 million currently to more than 3 million Americans by the year 2020. 1 Over the past decade, numerous randomized trials have established that anticoagulation can reduce significantly the stroke risk posed by AF. However, studies in community settings have demonstrated that inappropriate treatment is common and that there is wide variation in adherence to practice guidelines. 2 Surveys exploring this gap have identified the pivotal physician-related factor to be an "insufficiently balanced evaluation of the risk versus benefit" of oral anticoagulant therapy. 34 Eckman et al. Over the past 2 years, several novel anticoagulants have come on the scene. Four, dabigatran, rivaroxaban, apixaban and edoxaban have received approval for use in patients with AF. At this time, knowledge regarding the efficacy and safety of these novel agents is Eckman et al.
doi:10.1185/03007995.2015.1019608 pmid:25690491 pmcid:PMC4708062 fatcat:sf3k5t73xfb5zox5moiqq6cu5m