Assessment of Shared Decision-making for Stroke Prevention in Patients With Atrial Fibrillation: A Randomized Clinical Trial

Randomized evaluation of decision support interventions for atrial fibrillation: Rationale and design of the RED-AF study

BACKGROUND

Shared decision making (SDM) improves the likelihood that patients will receive care in a manner consistent with their priorities. To facilitate SDM, decision aids (DA) are commonly used, both to prepare a patient before their clinician visit, as well as to facilitate discussion during the visit. However, the relative efficacy of patient-focused or encounter-based DAs on SDM and patient outcomes remains largely unknown. We aim to directly estimate the comparative effectiveness of two DA's on SDM observed in encounters to discuss stroke prevention strategies in patients with atrial fibrillation (AF).

METHODS

The study aims to recruit 1200 adult patients with non-valvular AF who qualify for anticoagulation therapy, and their clinicians who manage stroke prevention strategies, in a 2x2 cluster randomized multi-center trial at six sites. Two DA's were developed as interactive, online, non-linear tools: a patient decision aid (PDA) to be used by patients before the encounter, and an encounter decision aid (EDA) to be used by clinicians with their patients during the encounter. Patients will be randomized to PDA or usual care; clinicians will be randomized to EDA or usual care.

RESULTS

Primary outcomes are quality of SDM, patient decision making, and patient knowledge. Secondary outcomes include anticoagulation choice, adherence, and clinical events.

CONCLUSION

This trial is the first randomized, head-to-head comparison of the effects of an EDA versus a PDA on SDM. Our results will help to inform future SDM interventions to improve patients' AF outcomes and experiences with stroke prevention strategies.

The ENHANCE-AF clinical trial to evaluate an atrial fibrillation shared decision-making pathway: Rationale and study design

INTRODUCTION

Shared decision making (SDM) may result in treatment plans that best reflect the goals and wishes of patients, increasing patient satisfaction with the decision-making process. There is a knowledge gap to support the use of decision aids in SDM for anticoagulation therapy in patients with atrial fibrillation (AF). We describe the development and testing of a new decision aid, including a multicenter, randomized, controlled, 2-arm, open-label ENHANCE-AF clinical trial (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention) to evaluate its effectiveness in 1,200 participants.

METHODS

Participants will be randomized to either usual care or to a SDM pathway incorporating a digital tool designed to simplify the complex concepts surrounding AF in conjunction with a clinician tool and a non-clinician navigator to guide the participants through each step of the tool. The participant-determined primary outcome for this study is the Decisional Conflict Scale, measured at 1 month after the index visit during which a decision was made regarding anticoagulation use. Secondary outcomes at both 1 and 6 months will include other decision making related scales as well as participant and clinician satisfaction, oral anticoagulation adherence, and a composite rate of major bleeding, death, stroke, or transient ischemic attack. The study will be conducted at four sites selected for their ability to enroll participants of varying racial and ethnic backgrounds, health literacy, and language skills. Participants will be followed in the study for 6 months.

CONCLUSIONS

The results of the ENHANCE-AF trial will determine whether a decision aid facilitates high quality shared decision making in anticoagulation discussions for stroke reduction in AF. An improved shared decision-making experience may allow patients to make decisions better aligned with their personal values and preferences, while improving overall AF care.

Surgeon Use of Shared Decision-making for Older Adults Considering Major Surgery: A Secondary Analysis of a Randomized Clinical Trial

Importance

Because major surgery carries significant risks for older adults with comorbid conditions, shared decision-making is recommended to ensure patients receive care consistent with their goals. However, it is unknown how often shared decision-making is used for these patients.

Objective

To describe the use of shared decision-making during discussions about major surgery with older adults.

Design, Setting, and Participants

This study is a secondary analysis of conversations audio recorded during a randomized clinical trial of a question prompt list. Data were collected from June 1, 2016, to November 31, 2018, from 43 surgeons and 446 patients 60 years or older with at least 1 comorbidity at outpatient surgical clinics at 5 academic centers.

Interventions

Patients received a question prompt list brochure that contained questions they could ask a surgeon.

Main Outcomes and Measures

The 5-domain Observing Patient Involvement in Decision-making (OPTION5) score (range, 0-100, with higher scores indicating greater shared decision-making) was used to measure shared decision-making.

Results

A total of 378 surgical consultations were analyzed (mean [SD] patient age, 71.9 [7.2] years; 206 [55%] male; 312 [83%] White). The mean (SD) OPTION5 score was 34.7 (20.6) and was not affected by the intervention. The mean (SD) score in the group receiving the question prompt list was 36.7 (21.2); in the control group, the mean (SD) score was 32.9 (19.9) (effect estimate, 3.80; 95% CI, -0.30 to 8.00; P = .07). Individual surgeon use of shared decision-making varied greatly, with a lowest median score of 10 (IQR, 10-20) to a high of 65 (IQR, 55-80). Lower-performing surgeons had little variation in OPTION5 scores, whereas high-performing surgeons had wide variation. Use of shared decision-making increased when surgeons appeared reluctant to operate (effect estimate, 7.40; 95% CI, 2.60-12.20; P = .003). Although longer conversations were associated with slightly higher OPTION5 scores (effect estimate, 0.69; 95% CI, 0.52-0.88; P < .001), 57% of high-scoring transcripts were 26 minutes long or less. On multivariable analysis, patient age and gender, patient education, surgeon age, and surgeon gender were not significantly associated with OPTION5 scores.

Conclusions and Relevance

These findings suggest that although shared decision-making is important to support the preferences of older adults considering major surgery, surgeon use of shared decision-making is highly variable. Skillful shared decision-making can be done in less than 30 minutes; however, surgeons who engage in high-scoring shared decision-making are more likely to do so when surgical intervention is less obviously beneficial for the patient.

Trial Registration

ClinicalTrials.gov Identifier: NCT02623335.

Patient values and preferences in pulmonary embolism testing in the emergency department

INTRODUCTION

Patient-centered care is concordant with patient values and preferences. There is a lack of research on patient values and preferences for pulmonary embolism (PE) testing in the emergency department (ED), and a poor physician understanding of patient-specific goals. Our aim was to map patient-specific values, preferences, and expectations regarding PE testing in the ED.

METHOD

This qualitative study used constructivist grounded theory to identify patient values and expectations around PE testing in the ED. We conducted semi-structured interviews with ED patients who were being tested for PE in two EDs. Patients who were waiting for PE imaging or D-dimer results were approached and consented to take part in a 30-minute audio-recorded interview. Each interview was transcribed verbatim and analyzed using constant comparative coding. The interview script was modified to maximize information on emerging themes. Major themes and subthemes were derived, each representing an opportunity, barrier, or value to address with patient-centered PE testing.

RESULTS

From 30 patient interviews, we mapped four major themes: patient satisfaction comes from addressing the patient's primary concern (for example, their pain); patients expect individualized care; patients prefer imaging over clinical examination for PE testing; and patients expect 100% confidence from their emergency physician when given a diagnosis. Subthemes included symptomatic relief, finding a diagnosis, receiving tests, rapid progression through their care, perception of highly accurate CT scans, willingness to seek a second opinion, direct physician communication, and expectation of case-specific testing with cognitive reassurance.

CONCLUSION

Addressing each of these four themes by realigning ED processes could provide patient-centered PE testing.

Effect of Shared Decision-Making for Stroke Prevention on Treatment Adherence and Safety Outcomes in Patients With Atrial Fibrillation: A Randomized Clinical Trial

Background Guidelines promote shared decision-making (SDM) for anticoagulation in patients with atrial fibrillation. We recently showed that adding a within-encounter SDM tool to usual care (UC) increases patient involvement in decision-making and clinician satisfaction, without affecting encounter length. We aimed to estimate the extent to which use of an SDM tool changed adherence to the decided care plan and clinical safety end points. Methods and Results We conducted a multicenter, encounter-level, randomized trial assessing the efficacy of UC with versus without an SDM conversation tool for use during the clinical encounter (Anticoagulation Choice) in patients with nonvalvular atrial fibrillation considering starting or reviewing anticoagulation treatment. We conducted a chart and pharmacy review, blinded to randomization status, at 10 months after enrollment to assess primary adherence (proportion of patients who were prescribed an anticoagulant who filled their first prescription) and secondary adherence (estimated using the proportion of days for which treatment was supplied and filled for direct oral anticoagulant, and as time in therapeutic range for warfarin). We also noted any strokes, transient ischemic attacks, major bleeding, or deaths as safety end points. We enrolled 922 evaluable patient encounters (Anticoagulation Choice=463, and UC=459), of which 814 (88%) had pharmacy and clinical follow-up. We found no differences between arms in either primary adherence (78% of patients in the SDM arm filled their first prescription versus 81% in UC arm) or secondary adherence to anticoagulation (percentage days covered of the direct oral anticoagulant was 74.1% in SDM versus 71.6% in UC; time in therapeutic range for warfarin was 66.6% in SDM versus 64.4% in UC). Safety outcomes, mostly bleeds, occurred in 13% of participants in the SDM arm and 14% in the UC arm. Conclusions In this large, randomized trial comparing UC with a tool to promote SDM against UC alone, we found no significant differences between arms in primary or secondary adherence to anticoagulation or in clinical safety outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: clinicaltrials.gov. Identifier: NCT02905032.

Assessment of Patients' Views on Drug Benefits and Risks: An Interview Study with Cardiovascular Patients

Better and balanced information strategies supporting cardiovascular patients' adherence are required. Cardiovascular drugs have outstanding morbidity and mortality benefits. This can be counteracted by patients' perceptions of risks. Drug information should help the patient but not fuel unwarranted fears. We performed a cross-sectional survey of patients admitted to a cardiology ward. We evaluated (i) the patients' general benefit-risk estimation of their pharmacotherapy; (ii) views on benefits; (iii) views on risks; and (iv) information sources. Additionally, we assessed aspects of anxiety and depression with the Patient Health Questionnaire-4 (PHQ-4). (i) 67 patients (66%) rated expected drug benefits higher than potential risks. (ii) 72% of benefits motivated the patients to take their medication as prescribed. Patients more frequently mentioned surrogate markers as benefits than clinical benefits (p < 0.001). (iii) 56% of risks mentioned were perceived as bothersome and 35% as concerning. Risks were more often perceived as bothersome and concerning by patients with higher PHQ-4 scores (p=0.016). (iv) Physicians were the most frequent information source of benefits (92% of patients) and risks (45%), and pharmacy staff for 27% and 14%, respectively. Laymen or media served as sources of information on benefits in 39%, for risks in 40%, and package leaflets in 26% and 36%. 42% of the patients would like to receive more information on benefits versus 27% on risks. Our results suggest that knowledge of benefits motivates patients to take their drugs as prescribed. There is already good information on surrogate markers for process control with active patient involvement. However, a lack of knowledge still exists in relation to clinical benefits. Regarding risks, it has been shown that patients with higher PHQ-4 scores are more likely to be bothered or concerned. Both emphases on clinical benefits and individualization depending on PHQ-4 scores may be valuable resources for patient counseling to support adherence.

Biomarkers of Metabolic Syndrome: Role in Pathogenesis and Pathophysiology Of Atrial Fibrillation

The relationship between Metabolic syndrome and Atrial Fibrillation is confirmed by many studies. The components of Metabolic syndrome cause remodeling of the atrial. Metabolic syndrome and metabolic derangements of the syndrome could be the cause of the pathogenesis of AF. This review article discusses the major biomarkers of Metabolic syndrome and their role in the pathogenesis of AF. The biomarkers are adiponectin, leptin, Leptin/ Adiponectin ratio, TNF-α, Interleukin-6, Interleukin-10, PTX3, ghrelin, uric acid, and OxLDL.The elevated plasma levels of adiponectin were linked to the presence of persistent AF. Leptin signaling contributes to angiotensin-II evoked AF and atrial fibrosis. Tumor necrosis factor-alpha involvement has been shown in the pathogenesis of chronic AF. Similarly, Valvular AF patients showed high levels of TNF-α. Increased left atrial size was associated with the interleukin-6 because it is a well-known risk factor for AF. Interleukin-10 as well as TNF-α were linked to AF recurrence after catheter ablation. PTX3 could be superior to other inflammatory markers that were reported to be elevated in AF. The serum ghrelin concentration in AF patients was reduced and significantly increased after treatment. Elevated levels of uric acid could be related to the burden of AF. Increased OxLDL was found in AF as compared to sinus rhythm control.

Shared Decision Making in Cardiac Electrophysiology Procedures and Arrhythmia Management

Shared decision making (SDM) has been advocated to improve patient care, patient decision acceptance, patient-provider communication, patient motivation, adherence, and patient reported outcomes. Documentation of SDM is endorsed in several society guidelines and is a condition of reimbursement for selected cardiovascular and cardiac arrhythmia procedures. However, many clinicians argue that SDM already occurs with clinical encounter discussions or the process of obtaining informed consent and note the additional imposed workload of using and documenting decision aids without validated tools or evidence that they improve clinical outcomes. In reality, SDM is a process and can be done without decision tools, although the process may be variable. Also, SDM advocates counter that the low-risk process of SDM need not be held to the high bar of demonstrating clinical benefit and that increasing the quality of decision making should be sufficient. Our review leverages a multidisciplinary group of experts in cardiology, cardiac electrophysiology, epidemiology, and SDM, as well as a patient advocate. Our goal is to examine and assess SDM methodology, tools, and available evidence on outcomes in patients with heart rhythm disorders to help determine the value of SDM, assess its possible impact on electrophysiological procedures and cardiac arrhythmia management, better inform regulatory requirements, and identify gaps in knowledge and future needs.

Usability and Perceived Usefulness of the AFib 2gether Mobile App in a Clinical Setting: Single-Arm Intervention Study

Background

Although the American Heart Association and other professional societies have recommended shared decision-making as a way for patients with atrial fibrillation (AF) or atrial flutter to make informed decisions about using anticoagulation (AC), the best method for facilitating shared decision-making remains uncertain.

Objective

The aim of this study is to assess the AFib 2gether mobile app for usability, perceived usefulness, and the extent and nature of shared decision-making that occurred for clinical encounters between patients with AF and their cardiology providers in which the app was used.

Methods

We identified patients visiting a cardiology provider between October 2019 and May 2020. We measured usability from patients and providers using the Mobile App Rating Scale. From the 8 items of the Mobile App Rating Scale, we reported the average score (out of 5) for domains of functionality, esthetics, and overall quality. We administered a 3-item questionnaire to patients relating to their perceived usefulness of the app and a separate 3-item questionnaire to providers to measure their perceived usefulness of the app. We performed a chart review to track the occurrence of AC within 6 months of the index visit. We also audio recorded a subset of the encounters to identify evidence of shared decision-making.

Results

We facilitated shared decision-making visits for 37 patients visiting 13 providers. In terms of usability, patients’ average ratings of functionality, esthetics, and overall quality were 4.51 (SD 0.61), 4.26 (SD 0.51), and 4.24 (SD 0.89), respectively. In terms of usefulness, 41% (15/37) of patients agreed that the app improved their knowledge regarding AC, and 62% (23/37) agreed that the app helped clarify to their provider their preferences regarding AC. Among providers, 79% (27/34) agreed that the app helped clarify their patients’ preferences, 82% (28/34) agreed that the app saved them time, and 59% (20/34) agreed that the app helped their patients make decisions about AC. In addition, 32% (12/37) of patients started AC after their shared decision-making visits. We audio recorded 25 encounters. Of these, 84% (21/25) included the mention of AC for AF, 44% (11/25) included the discussion of multiple options for AC, 72% (18/25) included a provider recommendation for AC, and 48% (12/25) included the evidence of patient involvement in the discussion.

Conclusions

Patients and providers rated the app with high usability and perceived usefulness. Moreover, one-third of the patients began AC, and approximately 50% (12/25) of the encounters showed evidence of patient involvement in decision-making. In the future, we plan to study the effect of the app on a larger sample and with a controlled study design.

Trial Registration

ClinicalTrials.gov NCT04118270; https://clinicaltrials.gov/ct2/show/NCT04118270

International Registered Report Identifier (IRRID)

RR2-21986

Feasibility and usability of a mobile health tool on anticoagulation management for patients with atrial fibrillation: a pilot study

PURPOSE

Appropriate prescription of oral anticoagulants (OACs) and good patient adherence are essential to ensure optimal anticoagulation in patients with atrial fibrillation (AF). The aim of this study is to develop a mobile health tool to aid both clinicians and patients with AF in anticoagulation therapy.

METHODS

In this study, a novel anticoagulation management model integrating decision support and patient follow-up, the I-Anticoagulation, was developed based on a WeChat Mini Program. With this tool, the risks of stroke and bleeding in AF patients can automatically be calculated according to their characteristics. Anticoagulation regimens were recommended based on a trade-off analysis that balances stroke and bleeding risks according to recent clinical guidelines. A shared decision can be made with full communication between medical professionals and patients. Moreover, follow-up was also conducted using I-Anticoagulation.

RESULTS

A total of 120 AF patients receiving anticoagulants (40 received warfarin and 80 received non-vitamin K antagonist oral anticoagulants [NOACs]) were included in the pilot study. The incidence of thromboembolic events was 2.5% and 1.3%, and the rates of bleeding events were 22.5% and 13.8% in the warfarin and NOAC groups, respectively. Generally, self-reported adherence was high, and the satisfaction with anticoagulation was good in all patients with AF.

CONCLUSION

Overall, the anticoagulation management model developed in this study could be involved in the full process of anticoagulation therapy in AF patients to improve rationality, adherence, and satisfaction in both medical professionals and patients. However, the usability, feasibility, and acceptability of the I-Anticoagulant-based anticoagulation management model need to be further assessed through well-designed random clinical trials.

Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown.

OBJECTIVE

To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of recorded encounters and participant surveys at 5 US medical centers (including academic, community, and safety-net centers) from the SDM4AFib randomized trial compared standard AF care with and without use of a shared decision-making (SDM) tool. Included patients were considering anticoagulation treatment and were recruited by their clinicians between January 30, 2017, and June 27, 2019. Data were analyzed between August and November 2019.

MAIN OUTCOMES AND MEASURES

The incidence of and factors associated with cost conversations, and the association of cost conversations with patients' consideration of treatment cost burden and their choice of anticoagulation.

RESULTS

A total of 830 encounters (out of 922 enrolled participants) were recorded. Patients' mean (SD) age was 71.0 (10.4) years; 511 patients (61.6%) were men, 704 (86.0%) were White, 303 (40.9%) earned between $40 000 and $99 999 in annual income, and 657 (79.2%) were receiving anticoagulants. Clinicians' mean (SD) age was 44.8 (13.2) years; 75 clinicians (53.2%) were men, and 111 (76%) practiced as physicians, with approximately half (69 [48.9%]) specializing in either internal medicine or cardiology. Cost conversations occurred in 639 encounters (77.0%) and were more likely in the SDM arm (378 [90%] vs 261 [64%]; OR, 9.69; 95% CI, 5.77-16.29). In multivariable analysis, cost conversations were more likely to occur with female clinicians (66 [47%]; OR, 2.85; 95% CI, 1.21-6.71); consultants vs in-training clinicians (113 [75%]; OR, 4.0; 95% CI, 1.4-11.1); clinicians practicing family medicine (24 [16%]; OR, 12.12; 95% CI, 2.75-53.38]), internal medicine (35 [23%]; OR, 3.82; 95% CI, 1.25-11.70), or other clinicians (21 [14%]; OR, 4.90; 95% CI, 1.32-18.16) when compared with cardiologists; and for patients with an annual household income between $40 000 and $99 999 (249 [82.2%]; OR, 1.86; 95% CI, 1.05-3.29) compared with income below $40 000 or above $99 999. More patients who had cost conversations reported cost as a factor in their decision (244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent.

CONCLUSIONS AND RELEVANCE

Cost conversations were common, particularly for middle-income patients and with female and consultant-level primary care clinicians, as well as in encounters using an SDM tool; they were associated with patients' consideration of treatment cost burden but not final treatment choice. With increasing costs of care passed on to patients, these findings can inform efforts to promote cost conversations in practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02905032.

The Need for Brevity During Shared Decision Making (SDM) for Cancer Screening: Veterans' Perspectives on an "Everyday SDM" Compromise

Introduction. Detailed or "full" shared decision making (SDM) about cancer screening is difficult in the primary care setting. Time spent discussing cancer screening is time not spent on other important issues. Given time constraints, brief SDM that is incomplete but addresses key elements may be feasible and acceptable. However, little is known about how patients feel about abbreviated SDM. This study assessed patient perspectives on a compromise solution ("everyday SDM"): 1) primary care provided makes a tailored recommendation, 2) briefly presents qualitative information on key tradeoffs, and 3) conveys full support for decisional autonomy and desires for more information. Methods. We recruited a stratified random sample of Veterans from an academic Veterans Affairs medical center who were eligible for lung cancer screening, oversampling women and minority patients, to attend a 6-hour deliberative focus group. Experts informed participants about cancer screening, factors that influence screening benefits, and the role of patient preferences. Then, facilitator-led small groups elicited patient questions and informed opinions about the everyday SDM proposal, its acceptability, and their recommendations for improvement. Results. Thirty-six Veterans with a heavy smoking history participated (50% male, 83% white). There was a strong consensus that everyday SDM was acceptable if patients were the final deciders and could get more information on request. Participants broadly recommended that clinicians only mention downsides directly related to screening and avoid discussion of potential downstream harms (such as biopsies). Discussion. Although further testing in more diverse populations and different conditions is needed, these patients found the everyday SDM approach to be acceptable for routine lung cancer screening discussions, despite its use of an explicit recommendation and presentation of only qualitative information.

Personalized, Electronic Health Record-Integrated Decision Aid for Stroke Prevention in Atrial Fibrillation: A Small Cluster Randomized Trial and Qualitative Analysis of Efficacy and Acceptability

BACKGROUND

Shared decision-making in cardiology is increasingly recommended to improve patient-centeredness of care. Decision aids can improve patient knowledge and decisional quality but are infrequently used in real-world practice. This mixed-methods study tests the efficacy and acceptability of a decision aid integrated into the electronic health record (Integrated Decision Aid [IDeA]) and delivered by clinicians for patients with atrial fibrillation considering options to reduce stroke risk. We aimed to determine whether the IDeA improves patient knowledge, reduces decisional conflict, and is seen as acceptable by clinicians and patients.

METHODS

A small cluster randomized trial included 6 cardiovascular clinicians and 66 patients randomized either to the IDeA (HealthDecision) or usual care (clinician discretion) during a clinical encounter when stroke prevention treatment options were discussed. The primary outcome was patient knowledge of personalized stroke risk. Exploratory outcomes included decisional conflict, values concordance, trust, the presence of a shared decision-making process, and patient knowledge related to time spent using the IDeA. Additionally, we conducted semistructured interviews with clinicians and patients who used the IDeA were conducted to assess acceptability and predictions of future use.

RESULTS

The IDeA significantly increased patients' knowledge of their stroke risk (odds ratio, 3.88 [95% CI, 1.39-10.78]; P<0.01]). Patients had less uncertainty about their final decision (P=0.04). There were no significant differences in values concordance, trust in clinician or shared decision-making. Despite training, each clinician used the IDeA differently. Qualitative analysis revealed patients prefer using the IDeA earlier in their diagnosis. Clinicians were satisfied with the IDeA, yet varied in the contexts in which they planned to use it in the future.

CONCLUSIONS

Using an Integrated Decision Aid, or IDeA, increases patient knowledge and lessens uncertainty for decision-making around stroke prevention in atrial fibrillation. Qualitative data provide insight into potential implementation strategies in real-world practice.

The year in cardiovascular medicine 2020: arrhythmias

of the progress in arrhythmias in 2020. RACE4 and ALL-IN indicated that integrated nurse-led care improves outcomes in AF patients.3,4 The same was reported for early rhythm control therapy15 and cryoablation as initial AF treatment.25,26 Subcutaneous ICD was non-inferior to classical transvenous ICD therapy in PRAETORIAN.54 One mechanistic study showed that autoantibodies against misexpressed actin, keratin, and connexin-43 proteins create a blood-borne biomarker profile enhancing diagnosis of Brugada syndrome.50 Another mechanistic study indicated that transseptal LV pacing yields similar improvement in contractility as His bundle pacing whilst being more easy to execute.44 In PRE-DETERMINE a simple-to-use ECG risk score improved risk prediction in patients with ischemic heart disease possibly enhancing appropriate ICD therapy in high risk patients.58.

Shared Decision Making Tools for People Facing Stroke Prevention Strategies in Atrial Fibrillation: A Systematic Review and Environmental Scan

OBJECTIVE

Shared decision making (SDM) tools can help implement guideline recommendations for patients with atrial fibrillation (AF) considering stroke prevention strategies. We sought to characterize all available SDM tools for this purpose and examine their quality and clinical impact.

METHODS

We searched through multiple bibliographic databases, social media, and an SDM tool repository from inception to May 2020 and contacted authors of identified SDM tools. Eligible tools had to offer information about warfarin and ≥1 direct oral anticoagulant. We extracted tool characteristics, assessed their adherence to the International Patient Decision Aids Standards, and obtained information about their efficacy in promoting SDM.

RESULTS

We found 14 SDM tools. Most tools provided up-to-date information about the options, but very few included practical considerations (e.g., out-of-pocket cost). Five of these SDM tools, all used by patients prior to the encounter, were tested in trials at high risk of bias and were found to produce small improvements in patient knowledge and reductions in decisional conflict.

CONCLUSION

Several SDM tools for stroke prevention in AF are available, but whether they promote high-quality SDM is yet to be known. The implementation of guidelines for SDM in this context requires user-centered development and evaluation of SDM tools that can effectively promote high-quality SDM and improve stroke prevention in patients with AF.

Usability, Perceived Usefulness, and Shared Decision-Making Features of the AFib 2gether Mobile App: Protocol for a Single-Arm Intervention Study

BACKGROUND

The Centers for Disease Control and Prevention has estimated that atrial fibrillation (AF) affects between 2.7 million and 6.1 million people in the United States. Those who have AF tend to have a much higher stroke risk than others. Although most individuals with AF benefit from anticoagulation (AC) therapy, a significant majority are hesitant to start it. To add, providers often struggle in helping patients negotiate the decision to start AC therapy. To assist in the communication between patients and providers regarding preferences and knowledge about AC therapy, different strategies are being used to try and solve this problem. In this research study, we will have patients and providers utilize the AFib 2gether app with hopes that it will create a platform for shared decision making regarding the prevention of stroke in patients with AF receiving AC therapy.

OBJECTIVE

The aim of our study is to measure several outcomes related to encounters between patients and their cardiology providers where AFib 2gether is used. These outcomes include usability and perceived usefulness of the app from the perspective of patients and providers. In addition, we will assess the extent and nature of shared decision making.

METHODS

Eligible patients and providers will evaluate the AFib 2gether mobile app for usability and perceived usefulness in facilitating shared decision making regarding understanding the patient's risk of stroke and whether or not to start AC therapy. Both patients and providers will review the app and complete multiple questionnaires about the usability and perceived usefulness of the mobile app in a clinical setting. We will also audio-record a subset of encounters to assess for evidence of shared decision making.

RESULTS

Enrollment in the AFib 2gether shared decision-making study is still ongoing for both patients and providers. The first participant enrolled on November 22, 2019. Analysis and publishing of results are expected to be completed in spring 2021.

CONCLUSIONS

The AFib 2gether app emerged from a desire to increase the ability of patients and providers to engage in shared decision making around understanding the risk of stroke and AC therapy. We anticipate that the AFib 2gether mobile app will facilitate patient discussion with their cardiologist and other providers. Additionally, we hope the study will help us identify barriers that providers face when placing patients on AC therapy. We aim to demonstrate the usability and perceived usefulness of the app with a future goal of testing the value of our approach in a larger sample of patients and providers at multiple medical centers across the country.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04118270; https://clinicaltrials.gov/ct2/show/NCT04118270.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21986.

Shared Decision-Making for Implantable Cardioverter-Defibrillators: Policy Goals, Metrics, and Challenges

Shared decision-making has become a new focus of health policy. Though its core elements are largely agreed upon, there is little consensus regarding which outcomes to prioritize for policy-mandated shared decision-making.