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

Noseworthy, Peter A.; Branda, Megan E.; Kunneman, Marleen; Burnett, Bruce; Gionfriddo, Michael R.; McLeod, Christopher J.; Gorr, Haeshik; Brito, Juan P.; Montori, Víctor M.; Spencer‐Bonilla, Gabriela; Sivly, Angela; Fleming, Kirsten; Linzer, Mark; Muegge, Jule; Poplau, Sara; Simpson, Benjamin; Vang, Miamoua; Wambua, Mike; Anderson, Joel; Behnken, Emma; Bellolio, M. Fernanda; Cabalka, Renee; Ferrara, Michael; Giblon, Rachel; Hargraves, Ian; Inselman, Jonathan; LeBlanc, Annie; Olive, Marc; Organick, Paige; Shah, Nilay D.; Thota, Anjali; Ting, Henry H.; Vanmeter, Derek; Zeballos-Palacios, Claudia; Harvey, Lisa; Keune, Shelly; Guyatt, Gordon; Haynes, Brian; Tomlinson, George; Daniels, Paul; Gersh, Bernard J.; Hess, Erik P.; Jaeger, Thomas M.; McBane, Robert D.

doi:10.1016/j.mayocp.2018.08.030

Cited by 43 publications

(51 citation statements)

References 59 publications

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“…To address these limitations and support at-risk patients with AF and their clinicians in making decisions about anticoagulant treatment, we developed the Anticoagulation Choice Shared Decision Making tool. 17 , 18 The aim of the current study was to assess the extent to which the use of the Anticoagulation Choice Shared Decision Making tool affects the quality of SDM and anticoagulant treatment decisions in patients with AF who are at risk of experiencing stroke.…”

Section: Introductionmentioning

confidence: 99%

Assessment of Shared Decision-making for Stroke Prevention in Patients With Atrial Fibrillation

et al. 2020

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; for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators IMPORTANCE Shared decision-making (SDM) about anticoagulant treatment in patients with atrial fibrillation (AF) is widely recommended but its effectiveness is unclear. OBJECTIVE To assess the extent to which the use of an SDM tool affects the quality of SDM and anticoagulant treatment decisions in at-risk patients with AF. DESIGN, SETTING, AND PARTICIPANTS This encounter-randomized trial recruited patients with nonvalvular AF who were considering starting or reviewing anticoagulant treatment and their clinicians at academic, community, and safety-net medical centers between January 30, 2017 and June 27, 2019. Encounters were randomized to either the standard care arm or care that included the use of an SDM tool (intervention arm). Data were analyzed from August 1 to November 30, 2019. INTERVENTIONS Standard care or care using the Anticoagulation Choice Shared Decision Making tool (which presents individualized risk estimates and compares anticoagulant treatment options across issues of importance to patients) during the clinical encounter. MAIN OUTCOMES AND MEASURES Quality of SDM (which included quality of communication, patient knowledge about AF and anticoagulant treatment, accuracy of patient estimates of their own stroke risk [within 30% of their estimate], decisional conflict, and satisfaction), decisions made during the encounter, duration of the encounter, and clinician involvement of patients in the SDM process. RESULTS The clinical trial enrolled 922 patients (559 men [60.6%]; mean [SD] age, 71 [11] years) and 244 clinicians. A total of 463 patients were randomized to the intervention arm and 459 patients to the standard care arm. Participants in both arms reported high communication quality, high knowledge, and low decisional conflict, demonstrated low accuracy in their risk perception, and would similarly recommend the approach used in their encounter. Clinicians were significantly more satisfied after intervention encounters (400 of 453 encounters [88.3%] vs 277 of 448 encounters [61.8%]; adjusted relative risk, 1.49; 95% CI, 1.42-1.53). A total of 747 of 873 patients (85.6%) chose to start or continue receiving an anticoagulant medication. Patient involvement in decision-making (as assessed through video recordings of the encounters using the Observing Patient Involvement in Decision Making 12-item scale) scores were significantly higher in the intervention arm (mean [SD] score, 33.0 [10.8] points vs 29.1 [13.1] points, respectively; adjusted mean difference, 4.2 points; 95% CI, 2.8-5.6 points). No significant between-arm difference was found in encounter duration (mean [SD] duration, 32 [16] minutes in the intervention arm vs 31 [17] minutes in the standard care arm; adjusted mean between-arm difference, 1.1; 95% CI, −0.3 to 2.5 minutes). CONCLUSION AND RELEVANCE The use of an SDM encounter tool improved several measures of SDM quality and clinician satisfaction, with no significant effect on treatment decisions...

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Section: Introductionmentioning

confidence: 99%

Assessment of Shared Decision-making for Stroke Prevention in Patients With Atrial Fibrillation

et al. 2020

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“…CV P revention C hoice was iteratively refined and field tested within actual clinical encounters, using procedures we have employed in other studies [ 31 , 32 ]. CV preventive care encounters were video-recorded and reviewed by members of the study team with expertise in CV prevention and human-centered design.…”

Section: Methodsmentioning

confidence: 99%

Increasing risk-concordant cardiovascular care in diverse health systems: a mixed methods pragmatic stepped wedge cluster randomized implementation trial of shared decision making (SDM4IP)

Ridgeway

Branda

Gravholt

et al. 2021

Implement Sci Commun

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Background The primary prevention of cardiovascular (CV) events is often less intense in persons at higher CV risk and vice versa. Clinical practice guidelines recommend that clinicians and patients use shared decision making (SDM) to arrive at an effective and feasible prevention plan that is congruent with each person’s CV risk and informed preferences. However, SDM does not routinely happen in practice. This study aims to integrate into routine care an SDM decision tool (CV Prevention Choice) at three diverse healthcare systems in the USA and study strategies that foster its adoption and routine use. Methods This is a mixed method, hybrid type III stepped wedge cluster randomized study to estimate (a) the effectiveness of implementation strategies on SDM uptake and utilization and (b) the extent to which SDM results in prevention plans that are risk-congruent. Formative evaluation methods, including clinician and stakeholder interviews and surveys, will identify factors likely to impact feasibility, acceptability, and adoption of CV Prevention Choice as well as normalization of CV Prevention Choice in routine care. Implementation facilitation will be used to tailor implementation strategies to local needs, and implementation strategies will be systematically adjusted and tracked for assessment and refinement. Electronic health record data will be used to assess implementation and effectiveness outcomes, including CV Prevention Choice reach, adoption, implementation, maintenance, and effectiveness (measured as risk-concordant care plans). A sample of video-recorded clinical encounters and patient surveys will be used to assess fidelity. The study employs three theoretical approaches: a determinant framework that calls attention to categories of factors that may foster or inhibit implementation outcomes (the Consolidated Framework for Implementation Research), an implementation theory that guides explanation or understanding of causal influences on implementation outcomes (Normalization Process Theory), and an evaluation framework (RE-AIM). Discussion By the project’s end, we expect to have (a) identified the most effective implementation strategies to embed SDM in routine practice and (b) estimated the effectiveness of SDM to achieve feasible and risk-concordant CV prevention in primary care. Trial registration ClinicalTrials.gov, NCT04450914. Posted June 30, 2020 Trial status This study received ethics approval on April 17, 2020. The current trial protocol is version 2 (approved February 17, 2021). The first subject had not yet been enrolled at the time of submission.

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“…Patient centered care should promote shared decision making in difficult clinical scenarios 171. Patient centered care can be defined as “care that is respectful of and responsive to individual patient needs, values, and preferences” and that ensures “the patient’s values guide all clinical decisions.”172173 Discussions about anticoagulation, especially in older patients with increased risk of bleeding, can be complicated and time consuming.…”

Section: Shared Decision Making With Patientsmentioning

confidence: 99%

Screening and management of atrial fibrillation in primary care

Ponamgi

Siontis

Rushlow

et al. 2021

BMJ

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Atrial fibrillation is a common chronic disease seen in primary care offices, emergency departments, inpatient hospital services, and many subspecialty practices. Atrial fibrillation care is complicated and multifaceted, and, at various points, clinicians may see it as a consequence and cause of multi-morbidity, as a silent driver of stroke risk, as a bellwether of an acute medical illness, or as a primary rhythm disturbance that requires targeted treatment. Primary care physicians in particular must navigate these priorities, perspectives, and resources to meet the needs of individual patients. This includes judicious use of diagnostic testing, thoughtful use of novel therapeutic agents and procedures, and providing access to subspecialty expertise. This review explores the epidemiology, screening, and risk assessment of atrial fibrillation, as well as management of its symptoms (rate and various rhythm control options) and stroke risk (anticoagulation and other treatments), and offers a model for the integration of the components of atrial fibrillation care.

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

Cited by 43 publications

References 59 publications

Assessment of Shared Decision-making for Stroke Prevention in Patients With Atrial Fibrillation

Assessment of Shared Decision-making for Stroke Prevention in Patients With Atrial Fibrillation

Increasing risk-concordant cardiovascular care in diverse health systems: a mixed methods pragmatic stepped wedge cluster randomized implementation trial of shared decision making (SDM4IP)

Screening and management of atrial fibrillation in primary care

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