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

Abstract

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 CHA2DS2VASc and HAS-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 patient-specific 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.

Oral Anticoagulation in Atrial Fibrillation: Development and Evaluation of a Mobile Health Application to Support Shared Decision-Making

“…A strength of our study was the development of the app based on evidence, taking into account many factors mentioned in guidelines of shared decision making and care of anticoagulated patients. 25 , 35 The level of patients’ previous knowledge was analyzed, and the learning style was adequate to their preferences of terminology and navigability. The amount and detail of information was adjusted, and could be increased or reduced, according to each individual’s understanding.…”

National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018

“…Overall, the results from initial and pilot studies are encouraging in terms of increasing the detection of AF cases through mobile ECG devices [63,[382][383][384][385]; optimising the use of antithrombotic therapy for stroke prevention in AF via computerised decision support [386][387][388]; improving the time in therapeutic range for patients using warfarin via point-of-care monitoring of anticoagulation; increasing adherence to cardiovascular pharmacotherapy via smartphone text messaging [389][390][391]; and increasing access to information for patients and their carers [392][393][394][395].…”

Developing a Conversation Aid to Support Shared Decision Making: Reflections on Designing Anticoagulation Choice

“…13 In addition, most fail to directly support the discussion of practical ways in which anticoagulation affects matters important to patients, such as leisure activities, diet, travel, and out-of-pocket costs. [14][15][16][17] To address these limitations and support SDM conversations between clinicians and their at-risk patients with AF considering anticoagulation therapy, we developed a new conversation aid, Anticoagulation Choice.…”