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Holbrook A, Perri D, Levine M, Mbuagbaw L, Jarmain S, Thabane L, Tarride JE, Dolovich L, Hyland S, Telford V, Silva J, Nieuwstraten C. Improving medication prescribing-related outcomes for vulnerable elderly in transitions on high-risk medications (IMPROVE-IT HRM): a pilot randomized trial protocol. Pilot Feasibility Stud 2024; 10:60. [PMID: 38600599 PMCID: PMC11005201 DOI: 10.1186/s40814-024-01484-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 03/25/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Seniors with recurrent hospitalizations who are taking multiple medications including high-risk medications are at particular risk for serious adverse medication events. We will assess whether an expert Clinical Pharmacology and Toxicology (CPT) medication management intervention during hospitalization with follow-up post-discharge and communication with circle of care is feasible and can decrease drug therapy problems amongst this group. METHODS The design is a pragmatic pilot randomized trial with 1:1 patient-level concealed randomization with blinded outcome assessment and data analysis. Participants will be adults 65 years and older admitted to internal medicine services for more than 2 days, who have had at least one other hospitalization in the prior year, taking five or more chronic medications including at least one high-risk medication. The CPT intervention identifies medication targets; completes consult, including priorities for improving prescribing negotiated with the patient; starts the care plan; ensures a detailed discharge medication reconciliation and circle-of-care communication; and sees the patient at least twice after hospital discharge via virtual visits to consolidate the care plan in the community. Control group receives usual care. Primary outcomes are feasibility - recruitment, retention, costs, and clinical - number of drug therapy problems improved, with secondary outcomes examining coordination of transitions in care, quality of life, and healthcare utilization and costs. Follow-up is to 3-month posthospital discharge. DISCUSSION If results support feasibility of ramp-up and promising clinical outcomes, a follow-up definitive trial will be organized using a developing national platform and medication appropriateness network. Since the intervention allows a very scarce medical specialty expertise to be offered via virtual care, there is potential to improve the safety, outcomes, and cost of care widely. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT04077281.
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Affiliation(s)
- Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada.
| | - Dan Perri
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Digital Solutions, St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Mitch Levine
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Biotatistics Unit, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Sarah Jarmain
- Medical and Academic Affairs, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Biotatistics Unit, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Center for Health Economic and Policy Analysis, McMaster University, Hamilton, ON, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
| | - Lisa Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, North York, ON, Canada
| | - Victoria Telford
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
| | - Jessyca Silva
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
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Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, Pacheco-Brousseau L, Finderup J, Gunderson J, Barry MJ, Bennett CL, Bravo P, Steffensen K, Gogovor A, Graham ID, Kelly SE, Légaré F, Sondergaard H, Thomson R, Trenaman L, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2024; 1:CD001431. [PMID: 38284415 PMCID: PMC10823577 DOI: 10.1002/14651858.cd001431.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Meg Carley
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robert Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisa E Douglas
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J Barry
- Informed Medical Decisions Program, Massachusetts General Hospital, Boston, MA, USA
| | - Carol L Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paulina Bravo
- Education and Cancer Prevention, Fundación Arturo López Pérez, Santiago, Chile
| | - Karina Steffensen
- Center for Shared Decision Making, IRS - Lillebælt Hospital, Vejle, Denmark
| | - Amédé Gogovor
- VITAM - Centre de recherche en santé durable, Université Laval, Quebec, Canada
| | - Ian D Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | | | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Logan Trenaman
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Pan MM, Zhang C, Shen L, Sha JJ, Shen H, Yan YD, Wang J, Wang X, Lin HW, Gu ZC. A novel shared decision-making (SDM) tool for anticoagulation management in atrial fibrillation: protocol for a prospective, cluster randomized controlled trial. Trials 2023; 24:623. [PMID: 37779187 PMCID: PMC10544439 DOI: 10.1186/s13063-023-07667-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common arrhythmia that requires anticoagulation therapy to prevent stroke. However, there is still a significant under-/over-treatment in stroke prevention for patients with AF. The adherence and the risk of bleeding associated with oral anticoagulation therapy (OACs) are major concerns. Shared decision-making (SDM) is an approach that involves patients and healthcare providers in making decisions about treatment options. This study aims to assess the effectiveness of a novel SDM tool for anticoagulation management in AF. METHODS The study will be a prospective, cluster randomized controlled trial involving 440 patients with AF in 8 community health service centers (clusters) in Shanghai, China. The SDM group will receive anticoagulation management through the novel SDM tool, while the control group will receive standard care. The follow-up period will be at least 2 years. The primary outcome will be any bleeding event, while secondary outcomes include the accordance of stroke prophylaxis for AF according to the current guidelines, time in therapeutic range (TTR), the occurrences of major bleeding and thrombosis events, and patient knowledge, adherence, and satisfaction. DISCUSSION This study will provide evidence of the effectiveness of shared decision-making in improving the appropriateness of OAC use in Chinese AF patients. The findings may inform the development of guidelines and policies for the management of AF and anticoagulation therapy in China and other countries. TRIAL REGISTRATION ChiCTR ChiCTR2200062123. Registered on 23 July 2022.
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Affiliation(s)
- Mang-Mang Pan
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Chi Zhang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
- School of Medicine, Tongji University, Shanghai, 200092, China
| | - Long Shen
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Jing-Jing Sha
- Shanghai Pudong New Area, Jinyang Community Health Service Center, Shanghai, 200136, China
| | - Hui Shen
- Shanghai Pudong New Area, Huamu Community Health Service Center, Shanghai, 201204, China
| | - Yi-Dan Yan
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Jia Wang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Xin Wang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Hou-Wen Lin
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.
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Flynn KE, McDonnell SM, Brazauskas R, Ahamed SI, McIntosh JJ, Pitt MB, Pizur-Barnekow K, Kim UO, Kruper A, Leuthner SR, Basir MA. Smartphone-Based Video Antenatal Preterm Birth Education: The Preemie Prep for Parents Randomized Clinical Trial. JAMA Pediatr 2023; 177:2807911. [PMID: 37523163 PMCID: PMC10481234 DOI: 10.1001/jamapediatrics.2023.1586] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/09/2023] [Indexed: 08/01/2023]
Abstract
Importance Preterm birth is a leading cause of infant mortality and child morbidity. Preterm birth is not always unexpected, yet standard prenatal care does not offer anticipatory education to parents at risk of delivering preterm, which leaves parents unprepared to make health care choices during the pregnancy that can improve survival and decrease morbidity in case of preterm birth. Objective To evaluate the effect of the Preemie Prep for Parents (P3) program on maternal knowledge of preterm birth, preparation for decision-making, and anxiety. Design, Setting, and Participants Recruitment for this randomized clinical trial conducted at a US academic medical center took place from February 3, 2020, to April 12, 2021. A total of 120 pregnant persons with a risk factor for preterm birth were enrolled between 16 and 21 weeks' gestational age and followed up through pregnancy completion. Intervention Starting at 18 weeks' gestational age, P3 program participants received links delivered via text message to 51 gestational age-specific short animated videos. Control participants received links to patient education webpages from the American College of Obstetricians and Gynecologists. Main Outcomes and Measures At 25 weeks' gestation, scores on the Parent Prematurity Knowledge Questionnaire (scored as percent correct), Preparation for Decision Making Scale (scored 0-100), and Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety computerized adaptive test. Analysis was based on an intention to treat. Results A total of 120 pregnant participants (mean [SD] age, 32.5 [4.9] years) were included in the study; 60 participants were randomized to each group. Participants in the P3 group scored higher than those in the control group on knowledge of long-term outcomes at 25 weeks (88.5% vs 73.2%; estimated difference, 15.3 percentage points; 95% CI, 8.3-22.5 percentage points; P < .001). Participants in the P3 group reported being significantly more prepared than did participants in the control group for neonatal resuscitation decision-making at 25 weeks (Preparation for Decision Making Scale score, 76.0 vs 52.3; difference, 23.7; 95% CI, 14.1-33.2). There was no difference between the P3 group and the control group in anxiety at 25 weeks (mean [SE] PROMIS Anxiety scores, 53.8 [1.1] vs 54.0 [1.1]; difference, -0.1; 95% CI, -3.2 to 2.9). Conclusions and Relevance In this randomized clinical trial, pregnant persons randomly assigned to the P3 program had more knowledge of core competencies and were more prepared to make decisions that affect maternal and infant health, without experiencing worse anxiety. Mobile antenatal preterm birth education may provide a unique benefit to parents with preterm birth risk factors. Trial Registration ClinicalTrials.gov Identifier: NCT04093492.
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Affiliation(s)
| | | | - Ruta Brazauskas
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - S. Iqbal Ahamed
- Department of Computer Science, Marquette University, Milwaukee, Wisconsin
| | | | - Michael B. Pitt
- Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis
| | | | - U. Olivia Kim
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, Illinois
| | - Abbey Kruper
- Department of Obstetrics & Gynecology, Medical College of Wisconsin, Milwaukee
| | | | - Mir A. Basir
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee
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Wang PJ, Lu Y, Mahaffey KW, Lin A, Morin DP, Sears SF, Chung MK, Russo AM, Lin B, Piccini J, Hills MT, Berube C, Pundi K, Baykaner T, Garay G, Lhamo K, Rice E, Pourshams IA, Shah R, Newswanger P, DeSutter K, Nunes JC, Albert MA, Schulman KA, Heidenreich PA, Bunch TJ, Sanders LM, Turakhia M, Verghese A, Stafford RS. Randomized Clinical Trial to Evaluate an Atrial Fibrillation Stroke Prevention Shared Decision-Making Pathway. J Am Heart Assoc 2023; 12:e028562. [PMID: 36342828 PMCID: PMC9973612 DOI: 10.1161/jaha.122.028562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Background Oral anticoagulation reduces stroke and disability in atrial fibrillation (AF) but is underused. We evaluated the effects of a novel patient-clinician shared decision-making (SDM) tool in reducing oral anticoagulation patient's decisional conflict as compared with usual care. Methods and Results We designed and evaluated a new digital decision aid in a multicenter, randomized, comparative effectiveness trial, ENHANCE-AF (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention). The digital AF shared decision-making toolkit was developed using patient-centered design with clear health communication principles (eg, meaningful images, limited text). Available in English and Spanish, the toolkit included the following: (1) a brief animated video; (2) interactive questions with answers; (3) a quiz to check on understanding; (4) a worksheet to be used by the patient during the encounter; and (5) an online guide for clinicians. The study population included English or Spanish speakers with nonvalvular AF and a CHA2DS2-VASc stroke score ≥1 for men or ≥2 for women. Participants were randomized in a 1:1 ratio to either usual care or the shared decision-making toolkit. The primary end point was the validated 16-item Decision Conflict Scale at 1 month. Secondary outcomes included Decision Conflict Scale at 6 months and the 10-item Decision Regret Scale at 1 and 6 months as well as a weighted average of Mann-Whitney U-statistics for both the Decision Conflict Scale and the Decision Regret Scale. A total of 1001 participants were enrolled and followed at 5 different sites in the United States between December 18, 2019, and August 17, 2022. The mean patient age was 69±10 years (40% women, 16.9% Black, 4.5% Hispanic, 3.6% Asian), and 50% of participants had CHA2DS2-VASc scores ≥3 (men) or ≥4 (women). The primary end point at 1 month showed a clinically meaningful reduction in decisional conflict: a 7-point difference in median scores between the 2 arms (16.4 versus 9.4; Mann-Whitney U-statistics=0.550; P=0.007). For the secondary end point of 1-month Decision Regret Scale, the difference in median scores between arms was 5 points in the direction of less decisional regret (P=0.078). The treatment effects lessened over time: at 6 months the difference in medians was 4.7 points for Decision Conflict Scale (P=0.060) and 0 points for Decision Regret Scale (P=0.35). Conclusions Implementation of a novel shared decision-making toolkit (afibguide.com; afibguide.com/clinician) achieved significantly lower decisional conflict compared with usual care in patients with AF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096781.
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Affiliation(s)
- Paul J. Wang
- Stanford University Department of MedicinePalo AltoCA
| | - Ying Lu
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Amy Lin
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | | | - Samuel F. Sears
- East Carolina University Department of PsychologyGreenvilleNC
| | - Mina K. Chung
- Cleveland Clinic Foundation Department of MedicineClevelandOH
| | | | - Bryant Lin
- Stanford University Department of MedicinePalo AltoCA
| | | | | | | | - Krishna Pundi
- Stanford University Department of MedicinePalo AltoCA
| | - Tina Baykaner
- Stanford University Department of MedicinePalo AltoCA
| | - Gotzone Garay
- Stanford University Department of MedicinePalo AltoCA
| | - Karma Lhamo
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Eli Rice
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | - Rushil Shah
- Stanford University Department of MedicinePalo AltoCA
| | - Paul Newswanger
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | | | - Michelle A. Albert
- University of California San Francisco Department of MedicineSan FranciscoCA
| | | | - Paul A. Heidenreich
- Stanford University Department of MedicinePalo AltoCA
- Palo Alto Veterans Administration Health Care Department of MedicinePalo AltoCA
| | - T. Jared Bunch
- University of Utah Department of MedicineSalt Lake CityUT
| | | | - Mintu Turakhia
- Stanford University Department of MedicinePalo AltoCA
- iRhythm TechnologiesSan FranciscoCA
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Peters LJ, Torres-Castaño A, van Etten-Jamaludin FS, Perestelo Perez L, Ubbink DT. What helps the successful implementation of digital decision aids supporting shared decision-making in cardiovascular diseases? A systematic review. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2023; 4:53-62. [PMID: 36743877 PMCID: PMC9890083 DOI: 10.1093/ehjdh/ztac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/31/2022] [Indexed: 11/12/2022]
Abstract
Aims Although digital decision aids (DAs) have been developed to improve shared decision-making (SDM), also in the cardiovascular realm, its implementation seems challenging. This study aims to systematically review the predictors of successful implementation of digital DAs for cardiovascular diseases. Methods and results Searches were conducted in MEDLINE, Embase, PsycInfo, CINAHL, and the Cochrane Library from inception to November 2021. Two reviewers independently assessed study eligibility and risk of bias. Data were extracted by using a predefined list of variables. Five good-quality studies were included, involving data of 215 patients and 235 clinicians. Studies focused on DAs for coronary artery disease, atrial fibrillation, and end-stage heart failure patients. Clinicians reported DA content, its effectivity, and a lack of knowledge on SDM and DA use as implementation barriers. Patients reported preference for another format, the way clinicians used the DA and anxiety for the upcoming intervention as barriers. In addition, barriers were related to the timing and Information and Communication Technology (ICT) integration of the DA, the limited duration of a consultation, a lack of communication among the team members, and maintaining the hospital's number of treatments. Clinicians' positive attitude towards preference elicitation and implementation of DAs in existing structures were reported as facilitators. Conclusion To improve digital DA use in cardiovascular diseases, the optimum timing of the DA, training healthcare professionals in SDM and DA usage, and integrating DAs into existing ICT structures need special effort. Current evidence, albeit limited, already offers advice on how to improve DA implementation in cardiovascular medicine.
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Affiliation(s)
- Loes J Peters
- Department of Surgery, Location Academic Medical Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Faridi S van Etten-Jamaludin
- Research Support Medical Library, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, The Netherlands
| | | | - Dirk T Ubbink
- Department of Surgery, Location Academic Medical Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Mitropoulou P, Grüner-Hegge N, Reinhold J, Papadopoulou C. Shared decision making in cardiology: a systematic review and meta-analysis. Heart 2022; 109:34-39. [PMID: 36007938 DOI: 10.1136/heartjnl-2022-321050] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/30/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To evaluate the effectiveness of interventions to improve shared decision making (SDM) in cardiology with particular focus on patient-centred outcomes such as decisional conflict. METHODS We searched Embase (OVID), the Cochrane library, PubMed and Web of Science electronic databases from inception to January 2021 for randomised controlled trials that investigated the effects of interventions to increase SDM in cardiology. The primary outcomes were decisional conflict, decisional anxiety, decisional satisfaction or decisional regret; a secondary outcome was knowledge gained by the patients. RESULTS Eighteen studies which reported on at least one outcome measure were identified, including a total of 4419 patients. Interventions to increase SDM had a significant effect on reducing decisional conflict (standardised mean difference (SMD) -0.211, 95% CI -0.316 to -0.107) and increasing patient knowledge (SMD 0.476, 95% CI 0.351 to 0.600) compared with standard care. CONCLUSIONS Interventions to increase SDM are effective in reducing decisional conflict and increasing patient knowledge in the field of cardiology. Such interventions are helpful in supporting patient-centred healthcare and should be implemented in wider cardiology practice.
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Affiliation(s)
- Panagiota Mitropoulou
- Cardiology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Johannes Reinhold
- Norwich Medical School, University of East Anglia, Norwich, UK .,Department of Cardiology, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Charikleia Papadopoulou
- Department of Cardiology, Royal Papworth Hospital, Cambridge, UK .,Department of Medicine, University of Cambridge, Cambridge, UK
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Baykaner T, Pundi K, Lin B, Lu Y, DeSutter K, Lhamo K, Garay G, Nunes JC, Morin DP, Sears SF, Chung MK, Paasche-Orlow MK, Sanders LM, Bunch TJ, Hills MT, Mahaffey KW, Stafford RS, Wang PJ. The ENHANCE-AF clinical trial to evaluate an atrial fibrillation shared decision-making pathway: Rationale and study design. Am Heart J 2022; 247:68-75. [PMID: 35092723 DOI: 10.1016/j.ahj.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 11/01/2022]
Abstract
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.
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Zang Y, Liu S, Chen Y. Qualitative study of willingness and demand for participation in decision-making regarding anticoagulation therapy in patient undergoing heart valve replacement. BMC Med Inform Decis Mak 2022; 22:45. [PMID: 35180869 PMCID: PMC8857803 DOI: 10.1186/s12911-022-01780-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 02/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background Promoting patient participation in decision-making aims to maintain the partnership between doctors and patients, reflect the patients’ goals, values, and preferences, and achieve patient-centered care. Realizing patient-centered care, shared collaboration between doctors and patients, and the decision-making process that considers the patients’ priorities and goals are the keys to high-quality health care. Therefore, it is indispensable to analyze the patients’ willingness to participate in the decision-making process and related participation needs regarding anticoagulation treatment for patients undergoing valve replacement. Purpose To analyze the patients’ willingness to participate in the decision-making process and the participation needs of patients undergoing mechanical cardiac valve replacement in the process of anticoagulation therapy to provide a basis for promoting patients' participation in decision-making. Methods Using phenomenological research methods, data were collected through semistructured interviews. Patients were interviewed after mechanical valve replacement from June to August 2021 in a Grade A hospital in Nanjing. Data were analyzed according to the Colaizzi phenomenology method. Results Three major themes were identified from the data: strong willingness to participate but low actual participation, supportive needs, and family members’ participation. Conclusions This study guided interventions to encourage patients who underwent heart valve replacement to participate in the decision-making process. From the patient's perspective, obtaining support in the decision-making process and caregiver enthusiasm is important. This study prompted thoughts about the use of auxiliary tools and provided a reliable basis for constructing decision-making auxiliary programs to guide clinical practice.
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Affiliation(s)
- YaNing Zang
- The Third School of Clinical Medicine, Nanjing Medical University, Qinhuai District, Nanjing City, Jiangsu Province, China
| | - ShanShan Liu
- Department of Cardiothoracic Surgery, Nanjing First Hospital, Nanjing Medical University, Qinhuai District, Nanjing City, Jiangsu Province, China
| | - YuHong Chen
- Department of Nursing, Nanjing First Hospital, Nanjing Medical University, Qinhuai District, Nanjing City, Jiangsu Province, China.
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Examining Adherence to Medication in Patients With Atrial Fibrillation: The Role of Medication Beliefs, Attitudes, and Depression. J Cardiovasc Nurs 2021; 35:337-346. [PMID: 32084080 DOI: 10.1097/jcn.0000000000000650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVES This study examined whether beliefs about medicines, drug attitudes, and depression independently predicted anticoagulant and antiarrhythmic adherence (focusing on the implementation phase of nonadherence) in patients with atrial fibrillation (AF). METHODS This cross-sectional study was part of a larger longitudinal study. Patients with AF (N = 118) completed the Patient Health Questionnaire-8. The Beliefs about Medicines Questionnaire, Drug Attitude Inventory, and Morisky-Green-Levine Medication Adherence Scale (self-report adherence measure), related to anticoagulants and antiarrhythmics, were also completed. Correlation and multiple logistic regression analyses were conducted. RESULTS There were no significant differences in nonadherence to anticoagulants or antiarrhythmics. Greater concerns (r = 0.23, P = .01) were significantly, positively associated with anticoagulant nonadherence only. Depression and drug attitudes were not significantly associated with anticoagulant/antiarrhythmic adherence. Predictors reliably distinguished adherers and nonadherers to anticoagulant medication in the regression model, explaining 14% of the variance, but only concern beliefs (odds ratio, 1.20) made a significant independent contribution to prediction (χ = 11.40, P = .02, with df = 4). When entered independently into a regression model, concerns (odds ratio, 1.24) significantly explained 10.3% of the variance (χ = 7.97, P = .01, with df = 1). Regressions were not significant for antiarrhythmic medication (P = .30). CONCLUSIONS Specifying medication type is important when examining nonadherence in chronic conditions. Concerns about anticoagulants, rather than depression, were significantly associated with nonadherence to anticoagulants but not antiarrhythmics. Anticoagulant concerns should be targeted at AF clinics, with an aim to reduce nonadherence and potentially modifiable adverse outcomes such as stroke.
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Zhao J, Wang H, Li X, Hu Y, Yan VKC, Wong CKH, Guo Y, Cheung MKH, Lip GYH, Siu CW, Tse HF, Chan EW. Importance of attributes and willingness to pay for oral anticoagulant therapy in patients with atrial fibrillation in China: A discrete choice experiment. PLoS Med 2021; 18:e1003730. [PMID: 34437553 PMCID: PMC8432810 DOI: 10.1371/journal.pmed.1003730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 09/10/2021] [Accepted: 07/12/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Adherence to oral anticoagulant therapy in patients with atrial fibrillation (AF) in China is low. Patient preference, one of the main reasons for discontinuation of oral anticoagulant therapy, is an unfamiliar concept in China. METHODS AND FINDINGS A discrete choice experiment (DCE) was conducted to quantify patient preference on 7 attributes of oral anticoagulant therapy: antidote (yes/no), food-drug interaction (yes/no), frequency of blood monitoring (no need, every 6/3/1 month[s]), risk of nonfatal major bleeding (0.7/3.1/5.5/7.8[%]), risk of nonfatal stroke (ischemic/hemorrhagic) or systemic embolism (0.6/3.2/5.8/8.4[%]), risk of nonfatal acute myocardial infarction (AMI) (0.2/1.0/1.8/2.5[%]), and monthly out-of-pocket cost (0/120/240/360 RMB) (0 to 56 USD). A total of 16 scenarios were generated by using D-Efficient design and were randomly divided into 2 blocks. Eligible patients were recruited and interviewed from outpatient and inpatient settings of 2 public hospitals in Beijing and Shenzhen, respectively. Patients were presented with 8 scenarios and asked to select 1 of 3 options: 2 unlabeled hypothetical treatments and 1 opt-out option. Mixed logit regression model was used for estimating patients' preferences of attributes of oral anticoagulants and willingness to pay (WTP) with adjustments for age, sex, education level, income level, city, self-evaluated health score, histories of cardiovascular disease/other vascular disease/any stroke/any bleeding, and use of anticoagulant/antiplatelet therapy. A total of 506 patients were recruited between May 2018 and December 2019 (mean age 70.3 years, 42.1% women). Patients were mainly concerned about the risks of AMI (β: -1.03; 95% CI: -1.31, -0.75; p < 0.001), stroke or systemic embolism (β: -0.81; 95% CI: -0.90, -0.73; p < 0.001), and major bleeding (β: -0.69; 95% CI: -0.78, -0.60; p < 0.001) and were willing to pay more, from up to 798 RMB to 536 RMB (124 to 83 USD) monthly. The least concerning attribute was frequency of blood monitoring (β: -0.31; 95% CI: -0.39, -0.24; p < 0.001). Patients had more concerns about food-drug interactions even exceeding preferences on the 3 risks, if they had a history of stroke or bleeding (β: -2.47; 95% CI: -3.92, -1.02; p < 0.001), recruited from Beijing (β: -1.82; 95% CI: -2.56, -1.07; p < 0.001), or men (β: -0.96; 95% CI: -1.36, -0.56; p < 0.001). Patients with lower educational attainment or lower income weighted all attributes lower, and their WTP for incremental efficacy and safety was minimal. Since the patients were recruited from 2 major hospitals from developed cities in China, further studies with better representative samples would be needed. CONCLUSIONS Patients with AF in China were mainly concerned about the safety and effectiveness of oral anticoagulant therapy. The preference weighting on food-drug interaction varied widely. Patients with lower educational attainment or income levels and less experience of bleeding or stroke had more reservations about paying for oral anticoagulant therapies with superior efficacy, safety, and convenience of use.
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Affiliation(s)
- Jiaxi Zhao
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, China
| | - Hao Wang
- Department of Cardiology, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xue Li
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, New Territories, Hong Kong SAR, China
| | - Yang Hu
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Vincent K. C. Yan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Carlos K. H. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yutao Guo
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Marco K. H. Cheung
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Hong Kong-Guangdong Stem Cell and Regenerative Medicine Research Centre, The University of Hong Kong and Guangzhou Institutes of Biomedicine and Health, Hong Kong SAR, China
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Esther W. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, New Territories, Hong Kong SAR, China
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Kaiser L, Hübscher M, Rissling O, Schulz S, Langer G, Meerpohl J, Schwingshackl L. [GRADE Guidelines: 19. Assessing the certainty of evidence in the importance of outcomes or values and preferences: Risk of bias and indirectness]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2021; 160:78-88. [PMID: 33461905 DOI: 10.1016/j.zefq.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/11/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group defines patient values and preferences as the relative importance patients place on the main health outcomes. We provide GRADE guidance for assessing the risk of bias and indirectness domains for certainty of evidence about the relative importance of outcomes. STUDY DESIGN AND SETTING We applied the GRADE domains to rate the certainty of evidence in the importance of outcomes to several systematic reviews, iteratively reviewed draft guidance and consulted GRADE members and other stakeholders for feedback. RESULTS This is the first of two articles. A body of evidence addressing the importance of outcomes starts at "high certainty"; concerns with risk of bias, indirectness, inconsistency, imprecision, and publication bias lead to downgrading to moderate, low, or very low certainty. We propose the following subdomains of risk of bias: selection of the study population, missing data, the type of measurement instrument, and confounding; we have developed items for each subdomain. The population, intervention, comparison, and outcome elements associated with the evidence determine the degree of indirectness. CONCLUSION This article provides guidance and examples for rating the risk of bias and indirectness for a body of evidence summarizing the importance of outcomes.
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Affiliation(s)
- Laura Kaiser
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland; Universität Witten/Herdecke, Deutschland.
| | - Markus Hübscher
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Olesja Rissling
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Sandra Schulz
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Gero Langer
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Jörg Meerpohl
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland; Cochrane Deutschland, Cochrane Deutschland Stiftung, Freiburg, Deutschland
| | - Lukas Schwingshackl
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland
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Khalil V, Blackley S, Subramaniam A. Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients' satisfaction-a before and after pilot study. Ir J Med Sci 2020; 190:819-824. [PMID: 32808181 DOI: 10.1007/s11845-020-02343-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic complex diseases like atrial fibrillation have potential long-term economical and personal consequences. Shared decision-making principles may promote therapeutic compliance, satisfaction and outcomes. Pharmacists, as patient-advocates, play a key role in guiding them through complex clinical decisions about their chronic disease management and anticoagulation choices. AIM To evaluate the impact of pharmacist-led shared decision making on patients' satisfaction and appropriateness of their anticoagulation therapy in newly diagnosed atrial fibrillation patients. METHODS A prospective 2-phase before and after single-centre study was conducted in an Australian hospital. Phase 1 provided usual care, and patients' satisfaction and appropriateness of their anticoagulation therapy were evaluated. Phase-2 assessed the impact on satisfaction and appropriateness of anticoagulant therapy following pharmacist-led interventions of shared decision making to promote patients' involvement. RESULTS Patients with pharmacist-led shared decision making reported higher degree of appropriateness of anticoagulation therapy and satisfaction (36% vs 92%, P < 0.001; 25% vs 68, P < 0.001), respectively. Additionally, patients who had a pharmacist input during their hospital stay received guideline-recommended anticoagulant therapy and reported satisfaction with their management was also higher in stage 2 (21% vs 65%, p < 0.001). CONCLUSION The study highlights pharmacist-led shared decision making in atrial fibrillation that contributes to patient satisfaction and appropriateness of therapy.
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Affiliation(s)
- Viviane Khalil
- Peninsula Health, Frankston, Victoria, 3199, Australia. .,Monash University, Clayton , Vic 3800, Australia.
| | | | - Ashwin Subramaniam
- Peninsula Health, Frankston, Victoria, 3199, Australia.,Monash University, Clayton , Vic 3800, Australia.,The Bays Hospital, Vale St, Mornington, 3931, Australia
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Eidam A, Roth A, Lacroix A, Goisser S, Seidling HM, Haefeli WE, Bauer JM. Methods to Assess Patient Preferences in Old Age Pharmacotherapy - A Systematic Review. Patient Prefer Adherence 2020; 14:467-497. [PMID: 32184575 PMCID: PMC7061412 DOI: 10.2147/ppa.s236964] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/14/2020] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The aim of this systematic review was to identify methods used to assess medication preferences in older adults and evaluate their advantages and disadvantages with respect to their applicability to the context of multimorbidity and polypharmacy. MATERIAL AND METHODS Three electronic databases (PubMed, Web of Science, PsycINFO) were searched. Eligible studies elicited individual treatment or outcome preferences in a context that involved long-term pharmacological treatment options. We included studies with a study population aged ≥ 65 years and/or with a mean or median age of ≥ 75 years. Qualitative studies, studies assessing preferences for only two different treatments, and studies targeting preferences for life-sustaining treatments were excluded. The identified preference measurement methods were evaluated based on four criteria (time budget, cognitive demand, variety of pharmacological aspects, and link with treatment strategies) judged to be relevant for the elicitation of patient preferences in polypharmacy. RESULTS Sixty articles met the eligibility criteria and were included in the narrative synthesis. Fifty-five different instruments to assess patient preferences, based on 24 different elicitation methods, were identified. The most commonly applied preference measurement techniques were "medication willingness" (description of a specific medication with inquiry of the participant's willingness to take it), discrete choice experiments, Likert scale-based questionnaires, and rank prioritization. The majority of the instruments were created for disease-specific or context-specific settings. Only three instruments (Outcome Prioritization Tool, a complex intervention, "MediMol" questionnaire) dealt with the broader issue of geriatric multimorbidity. Only seven of the identified tools showed somewhat favorable characteristics for a potential use of the respective method in the context of polypharmacy. CONCLUSION Up to now, few instruments have been specifically designed for the assessment of medication preferences in older patients with multimorbidity. To facilitate valid preference elicitation in the context of geriatric polypharmacy, future research should focus on suitable characteristics of existing techniques to develop new measurement approaches for this increasingly relevant population.
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Affiliation(s)
- Annette Eidam
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
| | - Anja Roth
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
| | - André Lacroix
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
| | - Sabine Goisser
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg69115, Germany
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg69120, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg69120, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg69120, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg69120, Germany
| | - Jürgen M Bauer
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg69115, Germany
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Zhang Y, Alonso-Coello P, Guyatt GH, Yepes-Nuñez JJ, Akl EA, Hazlewood G, Pardo-Hernandez H, Etxeandia-Ikobaltzeta I, Qaseem A, Williams JW, Tugwell P, Flottorp S, Chang Y, Zhang Y, Mustafa RA, Rojas MX, Schünemann HJ. GRADE Guidelines: 19. Assessing the certainty of evidence in the importance of outcomes or values and preferences—Risk of bias and indirectness. J Clin Epidemiol 2019; 111:94-104. [DOI: 10.1016/j.jclinepi.2018.01.013] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/14/2017] [Accepted: 01/11/2018] [Indexed: 12/23/2022]
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Yiu A, Bajorek B. Patient-focused interventions to support vulnerable people using oral anticoagulants: a narrative review. Ther Adv Drug Saf 2019; 10:2042098619847423. [PMID: 31205676 PMCID: PMC6535713 DOI: 10.1177/2042098619847423] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 04/01/2019] [Indexed: 12/18/2022] Open
Abstract
The aim of this review was to identify patient-focused interventions that have been trialed to support vulnerable patient populations taking oral anticoagulants (warfarin and the direct-acting oral anticoagulants (DOACs)) such as older persons (65 years and over), those with limited health literacy, and those from culturally and linguistically diverse (CALD) backgrounds. This review also aimed to report on the effects of these interventions on outcomes relevant to the use of anticoagulant therapy. Original articles published between 1 January 1995 and 30 June 2017 were identified using several electronic databases such as Medline, Ovid, Embase, Scopus, Cochrane, and Google Scholar. The following terms were used for the three-tiered search: Tier 1, elderly, aged, older adult, geriatrics; Tier 2, health literacy, literacy, low health literacy, low English proficiency, patient literacy; and Tier 3, ethnicity, ethnic, ethnic groups, CALD, culturally and linguistically diverse, NESB, non-English speaking background, race, racial groups, religion, religious groups, and minority groups. The terms for each tier were combined with the following terms: anticoagulants, anticoagulation, warfarin, apixaban, dabigatran, rivaroxaban, DOACS, new oral anticoagulants, novel oral anticoagulants, patient care, patient knowledge, comprehension, patient education, patient participation, and communication. A total of 41 studies were identified. Most of the interventions identified included older persons taking warfarin who were monitored using the international normalized ratio (INR) and who received patient education. Many interventions reported a significant positive impact on patients' knowledge, reduction in the number of adverse events caused by hemorrhage, and better INR control. More research on patient-focused interventions is needed that includes patients with limited health literacy, those from CALD backgrounds, and family members and caregivers of patients taking oral anticoagulants.
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Affiliation(s)
- Angela Yiu
- Graduate School of Health – Pharmacy, University Technology of Sydney, Level 4, Building 7, 67 Thomas Street, Ultimo, NSW 2007, Australia
| | - Beata Bajorek
- Graduate School of Health – Pharmacy, University of Technology Sydney and Pharmacy Department, Royal North Shore Hospital, Australia
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Ethical implications of the use of decision aids for antenatal counseling at the limits of gestational viability. Semin Fetal Neonatal Med 2018; 23:25-29. [PMID: 29066179 DOI: 10.1016/j.siny.2017.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Shared decision-making is a recent priority in neonatology. However, its implementation is at an early stage. Decision aids are tools designed to assist in shared decision-making. They help patients competently participate in making healthcare decisions. There are limited studies in neonatology on the formal use of decision aids as used in adult medicine. Decision aids are relatively new, even in adult medicine where they were pioneered; therefore, there is a lack of systematic oversight to their development and use. Despite evidence reporting a powerful effect on patients' decisions, decision aids are not subject to quality control, leading to potentially enormous ethical implications. These include: (i) possible introduction of developers' biases; (ii) use of outdated or incorrect information; (iii) misuse to steer a patient towards less expensive treatments; (iv) clinician liability if negative patient outcomes occur, since decision aids are currently not standard of care.
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Fauchier L, Hylek E, Knight E, Lane D, Levi M, Marin F, Palareti G, Collet JP, Rubboli A, Poli D, Camm AJ, Lip G, Andreotti F, Huber K, Kirchhof P. Bleeding risk assessment and management in atrial fibrillation patients. Thromb Haemost 2017; 106:997-1011. [PMID: 22048796 DOI: 10.1160/th11-10-0690] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 10/27/2011] [Indexed: 12/13/2022]
Abstract
SummaryIn this executive summary of a Consensus Document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in atrial fibrillation (AF) patients. The main aim of the document was to summarise ‘best practice’ in dealing with bleeding risk in AF patients when approaching antithrombotic therapy, by addressing the epidemiology and size of the problem, and review established bleeding risk factors. We also summarise definitions of bleeding in the published literature. Patient values and preferences balancing the risk of bleeding against thromboembolism as well as the prognostic implications of bleeding are reviewed. We also provide an overview of published bleeding risk stratification and bleeding risk schema. Brief discussion of special situations (e.g. periablation, peri-devices such as implantable cardioverter defibrillators [ICD] or pacemakers, presentation with acute coronary syndromes and/or requiring percutanous coronary interventions/stents and bridging therapy) is made, as well as a discussion of the prevention of bleeds and managing bleeding complications. Finally, this document puts forwards consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Constructing a relevant decision aid for parents of children with bronchopulmonary dysplasia. J Perinatol 2017; 37:1341-1345. [PMID: 29048414 DOI: 10.1038/jp.2017.141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/10/2017] [Accepted: 05/15/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND To develop and test a decision aid for counseling parents of children with bronchopulmonary dysplasia (BPD).Local problem:Parental education about complex conditions is not standardized and communication and understanding may not be adequate. METHODS Semi-structured interviews were conducted with 33 neonatal clinicians and 12 parents of children with BPD using a qualitative research design. The interviews were used to identify education topics that were felt to be important in BPD education. These topics were then used to create a visual decision aid to be used in counseling sessions with parents. The decision aid was then used in mock counseling sessions with 15 'experienced' participants and 7 'naïve' participants to assess its efficacy. The participants completed a pre and post test to assess change in knowledge as well as an 11-question Likert style acceptability survey. INTERVENTION Implementation of a decision aid while educating parents about BPD. RESULTS Topics identified during the interviews were used to create eight educational cards which included pictures, pictographs and statistics. Overall, participants thought the decision aid contained an appropriate amount of information, were easy to understand and improved their knowledge about BPD. Testing demonstrated a significant increase in knowledge in both the 'experienced' (P<0.0001) and 'naïve' group (P=0.0064). CONCLUSION A decision aid for parents of children with BPD may improve understanding of the condition and help facilitate communication between parents and doctors.
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Gerth A, Limbourg T, Lewalter T, Goette A, Wegscheider K, Treszl A, Meinertz T, Oeff M, Ravens U, Breithardt G, Steinbeck G, Kirchhof P, Nabauer M. Impact of the type of centre on management of AF patients: Surprising evidence for differences in antithrombotic therapy decisions. Thromb Haemost 2017; 105:1010-23. [PMID: 21544322 DOI: 10.1160/th11-02-0070] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 03/09/2011] [Indexed: 11/05/2022]
Abstract
SummaryAtrial fibrillation (AF) patients may receive treatment from specialists or from general medicine physicians representing different levels of care within a structured health care system. This “choice” is influenced by patient flow within a health care system, patient preference, and individual access to health care resources. We analysed how the postgraduate training and work environment of treating physicians affects management decisions in AF patients. Patient characteristics and treatment decisions were analysed at the time of enrolment into the registry of the German Atrial Fibrillation NETwork (AFNET). A total of 9,577 patients were enrolled from 2004 to 2006 in 191 German centres that belonged to the following four levels of care: 13 tertiary care centres (TCC) enrolled 3,795 patients (39.6%), 58 district hospitals (DH) enrolled 2,339 patients (24.4%), 62 office-based cardiologists (OC) enrolled 2,640 patients (27.6%), and 58 general practitioners or internists (GP) enrolled 803 patients (8.4%). Patients with new-onset AF were often treated in DH. TCC treated younger patients who more often presented with paroxysmal AF. Older patients and patients in permanent AF more often received outpatient care. Consistent with recommendations, younger patients and patients with non-permanent AF received rhythm control therapy more often. In addition, the type of centre affected the decision for rhythm control. Stroke risk was similar between centre types (mean CHADS2 scores 1.6 –1.9). TCC (68.8%) and OC (73.6%) administered adequate antithrombotic therapy more often than DH (55.1%) or GP (52.0%, p<0.001 between groups). Upon multivariate analysis, enrolment by TCC or OC was associated with a 1.60 (1.20–2.12, p=0.001) fold chance for adequate antithrombotic treatment. This difference between centre types was consistent irrespective of the type of stroke risk estimation (ESC 2001 guidelines, CHADS2 score), and also consistent when the recently suggested CHA2DS2-VASc score was used to estimate stroke risk. In conclusion, management decisions in AF are influenced by the education and clinical background of treating physicians in Germany. Inpatients receive more rhythm control therapy. Adequate antithrombotic therapy is more often administered in specialist (cardiologist) centres.
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Loewen PS, Ji AT, Kapanen A, McClean A. Patient values and preferences for antithrombotic therapy in atrial fibrillation. Thromb Haemost 2017; 117:1007-1022. [DOI: 10.1160/th16-10-0787] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 02/23/2017] [Indexed: 11/05/2022]
Abstract
SummaryGuidelines recommend that patients’ values and preferences should be considered when selecting stroke prevention therapy for atrial fibrillation (SPAF). However, doing so is difficult, and tools to assist clinicians are sparse. We performed a narrative systematic review to provide clinicians with insights into the values and preferences of AF patients for SPAF antithrombotic therapy. Narrative systematic review of published literature from database inception. Research questions: 1) What are patients’ AF and SPAF therapy values and preferences? 2) How are SPAF therapy values and preferences affected by patient factors? 3) How does conveying risk information affect SPAF therapy preferences? and 4) What is known about patient values and preferences regarding novel oral anticoagulants (NOACs) for SPAF? Twenty-five studies were included. Overall study quality was moderate. Severe stroke was associated with the greatest disutility among AF outcomes and most patients value the stroke prevention efficacy of therapy more than other attributes. Utilities, values, and preferences about other outcomes and attributes of therapy are heterogeneous and unpredictable. Patients’ therapy preferences usually align with their values when individualised risk information is presented, although divergence from this is common. Patients value the attributes of NOACs but frequently do not prefer NOACs over warfarin when all therapy-related attributes are considered. In conclusion, patients’ values and preferences for SPAF antithrombotic therapy are heterogeneous and there is no substitute for directly clarifying patients’ individual values and preferences. Research using choice modelling and tools to help clinicians and patients clarify their SPAF therapy values and preferences are needed.Supplementary Material to this article is available online at www.thrombosis-online.com.
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O'Neill ES, Grande SW, Sherman A, Elwyn G, Coylewright M. Availability of patient decision aids for stroke prevention in atrial fibrillation: A systematic review. Am Heart J 2017; 191:1-11. [PMID: 28888264 DOI: 10.1016/j.ahj.2017.05.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 05/28/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Atrial fibrillation is a common irregular heart rhythm that increases patients' risk of stroke. Aspirin, warfarin, direct oral anticoagulants, and an implantable device can reduce this risk. Given the availability of multiple comparable options, this decision depends on patient preferences and is appropriate for the use of decision aids and other efforts to promote shared decision making. The objective of this review was to examine the existence and accessibility of, as well as select outcomes associated with, published, formally evaluated patient decision aids for stroke prevention in atrial fibrillation. METHODS Six databases were searched from inception to March 2016 with a research librarian. Two authors independently reviewed potential articles, selected trials meeting inclusion criteria, and assessed outcome measures. Outcomes included patient knowledge, involvement, choice, and decisional conflict. RESULTS The search resulted in 666 articles; most were excluded for not examining stroke prevention in atrial fibrillation and 7 studies were eventually included. Six decision aids displayed combinations of aspirin, warfarin, or no therapy; 1 included a direct oral anticoagulant. Interventions were associated with increased patient knowledge, increased likelihood of making a choice, and low decisional conflict. Use of decision aids in this review was associated with less selection of warfarin. None of the tested decision aids are currently available. DISCUSSION Published patient decision aids for stroke prevention in atrial fibrillation are not accessible for clinical use. Given the availability of multiple comparable options, there is a need to develop and test new patient decision aids in this context.
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Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, Holmes‐Rovner M, Llewellyn‐Thomas H, Lyddiatt A, Thomson R, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2017; 4:CD001431. [PMID: 28402085 PMCID: PMC6478132 DOI: 10.1002/14651858.cd001431.pub5] [Citation(s) in RCA: 1228] [Impact Index Per Article: 175.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values. OBJECTIVES To assess the effects of decision aids in people facing treatment or screening decisions. SEARCH METHODS Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008. SELECTION CRITERIA We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids. DATA COLLECTION AND ANALYSIS Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence. MAIN RESULTS We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup. AUTHORS' CONCLUSIONS Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.
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Affiliation(s)
- Dawn Stacey
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
- Ottawa Hospital Research InstituteCentre for Practice Changing Research501 Smyth RdOttawaONCanadaK1H 8L6
| | - France Légaré
- CHU de Québec Research Center, Université LavalPopulation Health and Optimal Health Practices Research Axis10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Krystina Lewis
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
| | | | - Carol L Bennett
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramAdministrative Services Building, Room 2‐0131053 Carling AvenueOttawaONCanadaK1Y 4E9
| | - Karen B Eden
- Oregon Health Sciences UniversityDepartment of Medical Informatics and Clinical EpidemiologyBICC 5353181 S.W. Sam Jackson Park RoadPortlandOregonUSA97239‐3098
| | - Margaret Holmes‐Rovner
- Michigan State University College of Human MedicineCenter for Ethics and Humanities in the Life SciencesEast Fee Road956 Fee Road Rm C203East LansingMichiganUSA48824‐1316
| | - Hilary Llewellyn‐Thomas
- Dartmouth CollegeThe Dartmouth Center for Health Policy & Clinical Practice, The Geisel School of Medicine at DartmouthHanoverNew HampshireUSA03755
| | - Anne Lyddiatt
- No affiliation28 Greenwood RoadIngersollONCanadaN5C 3N1
| | - Richard Thomson
- Newcastle UniversityInstitute of Health and SocietyBaddiley‐Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Lyndal Trevena
- The University of SydneyRoom 322Edward Ford Building (A27)SydneyNSWAustralia2006
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Clarkesmith DE, Pattison HM, Khaing PH, Lane DA. Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation. Cochrane Database Syst Rev 2017; 4:CD008600. [PMID: 28378924 PMCID: PMC6478129 DOI: 10.1002/14651858.cd008600.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation (AF) with one or more risk factors for stroke; however, anticoagulation control (time in therapeutic range (TTR)) with vitamin K antagonists (VKAs) is dependent on many factors. Educational and behavioural interventions may impact patients' ability to maintain their international normalised ratio (INR) control. This is an updated version of the original review first published in 2013. OBJECTIVES To evaluate the effects of educational and behavioural interventions for oral anticoagulation therapy (OAT) on TTR in patients with AF. SEARCH METHODS We updated searches from the previous review by searching the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (January 2016, Issue 1), MEDLINE Ovid (1949 to February week 1 2016), EMBASE Classic + EMBASE Ovid (1980 to Week 7 2016), PsycINFO Ovid (1806 to Week 1 February 2016) and CINAHL Plus with Full Text EBSCO (1937 to 16/02/2016). We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials evaluating the effect of any educational and behavioural intervention compared with usual care, no intervention, or intervention in combination with other self-management techniques among adults with AF who were eligible for, or currently receiving, OAT. DATA COLLECTION AND ANALYSIS Two of the review authors independently selected studies and extracted data. Risk of bias was assessed using the Cochrane 'Risk of bias' tool. We included outcome data on TTR, decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), beliefs about medication, illness perceptions, and anxiety and depression. We pooled data for three outcomes - TTR, anxiety and depression, and decision conflict - and reported mean differences (MD). Where insufficient data were present to conduct a meta-analysis, we reported effect sizes and confidence intervals (CI) from the included studies. We evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. MAIN RESULTS Eleven trials with a total of 2246 AF patients (ranging from 14 to 712 by study) were included within the review. Studies included education, decision aids, and self-monitoring plus education interventions. The effect of self-monitoring plus education on TTR was uncertain compared with usual care (MD 6.31, 95% CI -5.63 to 18.25, I2 = 0%, 2 trials, 69 participants, very low-quality evidence). We found small but positive effects of education on anxiety (MD -0.62, 95% CI -1.21 to -0.04, I2 = 0%, 2 trials, 587 participants, low-quality evidence) and depression (MD -0.74, 95% CI -1.34 to -0.14, I2 = 0%, 2 trials, 587 participants, low-quality evidence) compared with usual care. The effect of decision aids on decision conflict favoured usual care (MD -0.1, 95% CI -0.17 to -0.02, I2 = 0%, 2 trials, 721 participants, low-quality evidence). AUTHORS' CONCLUSIONS This review demonstrates that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.
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Affiliation(s)
- Danielle E Clarkesmith
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS TrustDudley RoadBirminghamUKB18 7QH
| | - Helen M Pattison
- Aston UniversitySchool of Life and Health SciencesAston TriangleBirminghamUKB4 7ET
| | - Phyo H Khaing
- University of BirminghamCollege of Medical and Dental Sciences8 Minnesota DriveGreat SankeyBirminghamCheshireUKWA5 3SY
| | - Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS TrustDudley RoadBirminghamUKB18 7QH
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Patient preferences regarding atrial fibrillation stroke prophylaxis in patients at potential risk of atrial fibrillation. Int J Clin Pharm 2017; 39:468-472. [DOI: 10.1007/s11096-017-0440-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 02/11/2017] [Indexed: 11/26/2022]
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Clarkesmith DE, Lip GYH, Lane DA. Patients' experiences of atrial fibrillation and non-vitamin K antagonist oral anticoagulants (NOACs), and their educational needs: A qualitative study. Thromb Res 2017; 153:19-27. [PMID: 28314139 DOI: 10.1016/j.thromres.2017.03.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/27/2017] [Accepted: 03/06/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Qualitative research on atrial fibrillation (AF) patient's experiences and perceptions of taking the non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention is limited. This study explores patients' experiences of dabigatran and their recommendations for development of educational materials. PATIENTS AND METHODS Semi-structured individual interviews with 8 warfarin-naive and 8 warfarin-experienced AF patients, using qualitative deductive thematic analysis. RESULTS The four main overarching themes included: understanding the diagnosis; reaching a treatment decision; challenges of living with OAC; and patient perceptions of treatment. Patients discussed their shock of diagnosis, and seeking information and support at that time. Narratives suggest patients preferred to be led by the doctor when making treatment decisions, and would often compare dabigatran to warfarin. Patients reported side-effects and challenges with both treatment options, and discussed their beliefs surrounding medications, including misconceptions. In addition to the original framework, two further themes were added: challenges of living with AF, and patient recommendations. Generally patients found AF symptoms distressing, which impacted their quality of life. Patient recommendations included the content and delivery of educational materials and development of tools to help with their understanding of AF and anticoagulation, as well as treatment adherence and anxiety surrounding symptoms and side effects. CONCLUSION Patient recommendations emphasised the need for interventions to relieve anxiety surrounding the diagnosis and possible treatment side effects. Tailored 'disease-specific' support is essential to ensure efficacious treatment. This qualitative study highlights the need for patient involvement in the development of educational materials and resources for patients commencing treatment with NOACs.
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Affiliation(s)
- Danielle E Clarkesmith
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham B18 7QH, United Kingdom
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham B18 7QH, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham B18 7QH, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Virdee MS, Stewart D. Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention. Int J Clin Pharm 2017; 39:173-180. [DOI: 10.1007/s11096-016-0419-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 12/21/2016] [Indexed: 12/30/2022]
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Li G, Thabane L, Delate T, Witt DM, Levine MAH, Cheng J, Holbrook A. Can We Predict Individual Combined Benefit and Harm of Therapy? Warfarin Therapy for Atrial Fibrillation as a Test Case. PLoS One 2016; 11:e0160713. [PMID: 27513986 PMCID: PMC4981352 DOI: 10.1371/journal.pone.0160713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/22/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To construct and validate a prediction model for individual combined benefit and harm outcomes (stroke with no major bleeding, major bleeding with no stroke, neither event, or both) in patients with atrial fibrillation (AF) with and without warfarin therapy. METHODS Using the Kaiser Permanente Colorado databases, we included patients newly diagnosed with AF between January 1, 2005 and December 31, 2012 for model construction and validation. The primary outcome was a prediction model of composite of stroke or major bleeding using polytomous logistic regression (PLR) modelling. The secondary outcome was a prediction model of all-cause mortality using the Cox regression modelling. RESULTS We included 9074 patients with 4537 and 4537 warfarin users and non-users, respectively. In the derivation cohort (n = 4632), there were 136 strokes (2.94%), 280 major bleedings (6.04%) and 1194 deaths (25.78%) occurred. In the prediction models, warfarin use was not significantly associated with risk of stroke, but increased the risk of major bleeding and decreased the risk of death. Both the PLR and Cox models were robust, internally and externally validated, and with acceptable model performances. CONCLUSIONS In this study, we introduce a new methodology for predicting individual combined benefit and harm outcomes associated with warfarin therapy for patients with AF. Should this approach be validated in other patient populations, it has potential advantages over existing risk stratification approaches as a patient-physician aid for shared decision-making.
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Affiliation(s)
- Guowei Li
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- St. Joseph's Hospital, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- St. Joseph's Hospital, McMaster University, Hamilton, ON, Canada
- * E-mail: (AH); (LT)
| | - Thomas Delate
- Kaiser Permanente Colorado Clinical Pharmacy Research Team, Aurora, CO, United States of America
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Denver, CO, United States of America
| | - Daniel M. Witt
- Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah, United States of America
| | - Mitchell A. H. Levine
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- St. Joseph's Hospital, McMaster University, Hamilton, ON, Canada
- Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ji Cheng
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- St. Joseph's Hospital, McMaster University, Hamilton, ON, Canada
| | - Anne Holbrook
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- St. Joseph's Hospital, McMaster University, Hamilton, ON, Canada
- Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- * E-mail: (AH); (LT)
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Patient preference and evidence based decisions on anticoagulant therapy for atrial fibrillation. Thromb Res 2016; 145:149-50. [PMID: 27503747 DOI: 10.1016/j.thromres.2016.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022]
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Zeng-Treitler Q, Gibson B, Hill B, Butler J, Christensen C, Redd D, Shao Y, Bray B. The effect of simulated narratives that leverage EMR data on shared decision-making: a pilot study. BMC Res Notes 2016; 9:359. [PMID: 27448407 PMCID: PMC4957847 DOI: 10.1186/s13104-016-2152-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 07/04/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Shared decision-making can improve patient satisfaction and outcomes. To participate in shared decision-making, patients need information about the potential risks and benefits of treatment options. Our team has developed a novel prototype tool for shared decision-making called hearts like mine (HLM) that leverages EHR data to provide personalized information to patients regarding potential outcomes of different treatments. These potential outcomes are presented through an Icon array and/or simulated narratives for each "person" in the display. In this pilot project we sought to determine whether the inclusion of simulated narratives in the display affects individuals' decision-making. Thirty subjects participated in this block-randomized study in which they used a version of HLM with simulated narratives and a version without (or in the opposite order) to make a hypothetical therapeutic decision. After each decision, participants completed a questionnaire that measured decisional confidence. We used Chi square tests to compare decisions across conditions and Mann-Whitney U tests to examine the effects of narratives on decisional confidence. Finally, we calculated the mean of subjects' post-experiment rating of whether narratives were helpful in their decision-making. RESULTS In this study, there was no effect of simulated narratives on treatment decisions (decision 1: Chi squared = 0, p = 1.0; decision 2: Chi squared = 0.574, p = 0.44) or Decisional confidence (decision 1, w = 105.5, p = 0.78; decision 2, w = 86.5, p = 0.28). Post-experiment, participants reported that narratives helped them to make decisions (mean = 3.3/4). CONCLUSIONS We found that simulated narratives had no measurable effect on decisional confidence or decisions and most participants felt that the narratives were helpful to them in making therapeutic decisions. The use of simulated stories holds promise for promoting shared decision-making while minimizing their potential biasing effect.
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Affiliation(s)
- Qing Zeng-Treitler
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Bryan Gibson
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Brent Hill
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA. .,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA.
| | - Jorie Butler
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Carrie Christensen
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Douglas Redd
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Yijun Shao
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Bruce Bray
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
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Fatima S, Holbrook A, Schulman S, Park S, Troyan S, Curnew G. Development and validation of a decision aid for choosing among antithrombotic agents for atrial fibrillation. Thromb Res 2016; 145:143-8. [PMID: 27388221 DOI: 10.1016/j.thromres.2016.06.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 06/06/2016] [Accepted: 06/14/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Multiple antithrombotic agents are available for stroke prevention in atrial fibrillation (AF). A decision aid can assist patients in making informed decisions that best serves their needs. OBJECTIVE To validate a decision aid to assist patients in choosing between antithrombotic agents (antiplatelets, warfarin, direct-acting oral anticoagulants (DOACs)) for AF. METHODS Patients (60years or older) were recruited for this prospective study. The decision aid presented descriptions related to AF, then charts portraying important outcomes for comparisons between 1) no treatment, aspirin and anticoagulants, 2) warfarin versus DOACs, and 3) DOAC versus DOAC. The primary outcome was confidence in making treatment decisions. The secondary outcomes included change in knowledge scores, ratings of clarity, helpfulness and comprehensiveness. RESULTS Eighty-one patients (mean age 75.2 [SD 7.5], 77% taking an anticoagulant) participated. After using the decision aid, mean decisional conflict score was low at 7.2 [SD 10.8] on a scale from 1 to 100. Mean knowledge score (total possible 10) improved from 7.4 [SD 1.7] to 9.3 [SD 1.0] (p<0.001). The mean helpfulness score in making a treatment choice was high at 6.2 [SD 0.9] on a scale from 1 to 7. No participant found the decision aid difficult to understand. Information in the decision aid was rated as good or excellent in terms of clarity and comprehensiveness. CONCLUSIONS Our decision aid addresses a key medication safety gap - assisting patients to participate in shared decisions about anticoagulation. Future research is required to evaluate how decision aids influence actual choices and clinical outcomes.
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Affiliation(s)
- Safoora Fatima
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Anne Holbrook
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, ON, Canada; Clinical Pharmacology, St Joseph's Healthcare Hamilton, Canada.
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Steve Park
- Clinical Pharmacology, St Joseph's Healthcare Hamilton, Canada
| | - Sue Troyan
- Clinical Pharmacology, St Joseph's Healthcare Hamilton, Canada
| | - Greg Curnew
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Barnes GD, Izzo B, Conte ML, Chopra V, Holbrook A, Fagerlin A. Use of decision aids for shared decision making in venous thromboembolism: A systematic review. Thromb Res 2016; 143:71-5. [PMID: 27203185 DOI: 10.1016/j.thromres.2016.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/29/2016] [Accepted: 05/10/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Optimal care of patients with venous thromboembolism requires the input of patient preferences into clinical decision-making. However, the availability and impact of decision aids to facilitate shared decision making in care of venous thromboembolism is not well known. OBJECTIVES To assess the availability, clinical impact and outcomes associated with the use of decision aids in patients with or at risk for venous thromboembolism. PATIENTS/METHODS A systematic review of the literature was performed exploring the use of decision aids in patients with venous thromboembolism. Criteria for primary inclusion required use of patient values clarification in the decision aid. A secondary review without the requirement of a patient values clarification was performed to be more inclusive. The data was summarized such that knowledge gaps and opportunities for enquiry were identified. RESULTS The primary review identified one study that explored the decision to extend anticoagulation in patients with a recent venous thromboembolism beyond the stipulated 3-month duration. The secondary review identified an additional study exploring the decision to undergo computer tomography testing in patients at low risk for pulmonary embolism in an emergency department setting. Both studies were of modest quality given a lack of control group for comparison analysis. CONCLUSIONS Despite numerous calls to increase use of shared decision-making, a paucity of data exists to help patients engage in the treatment decisions for venous thromboembolism. Future studies of additional VTE clinical decisions with longer-term clinical outcomes appear necessary.
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Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan Medical Center, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan Medical Center, Ann Arbor, MI, USA.
| | - Brett Izzo
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Marisa L Conte
- Taubman Health Science Library, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Vineet Chopra
- Institute for Healthcare Policy and Innovation, University of Michigan Medical Center, Ann Arbor, MI, USA; Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA; VA Salt Lake City, Salt Lake City, UT, USA
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Alonso‐Coello P, Montori VM, Díaz MG, Devereaux PJ, Mas G, Diez AI, Solà I, Roura M, Souto JC, Oliver S, Ruiz R, Coll‐Vinent B, Gich I, Schünemann HJ, Guyatt G. Values and preferences for oral antithrombotic therapy in patients with atrial fibrillation: physician and patient perspectives. Health Expect 2015; 18:2318-27. [PMID: 24813058 PMCID: PMC5810657 DOI: 10.1111/hex.12201] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Exploration of values and preferences in the context of anticoagulation therapy for atrial fibrillation (AF) remains limited. To better characterize the distribution of patient and physician values and preferences relevant to decisions regarding anticoagulation in patients with AF, we conducted interviews with patients at risk of developing AF and physicians who manage patients with AF. METHODS We interviewed 96 outpatients and 96 physicians in a multicenter study and elicited the maximal increased risk of bleeding (threshold risk) that respondents would tolerate with warfarin vs. aspirin to achieve a reduction in three strokes in 100 patients over a 2-year period. We used the probabilistic version of the threshold technique. RESULTS The median threshold risk for both patients and physicians was 10 additional bleeds (10 P = 0.7). In both groups, we observed large variability in the threshold number of bleeds, with wider variability in patients than clinicians [patient range: 0-100, physician range: 0-50]. We observed one cluster of patients and physicians who would tolerate <10 bleeds and another cluster of patients, but not physicians, who would accept more than 35. CONCLUSIONS Our findings suggest wide variability in patient and physician values and preferences regarding the trade-off between strokes and bleeds. Results suggest that in individual decision making, physician and patient values and preferences will often be discordant; this mandates tailoring treatment to the individual patient's preferences.
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Affiliation(s)
- Pablo Alonso‐Coello
- Iberoamerican Cochrane CentreBiomedical Research Institute Sant Pau‐CIBER of Epidemiology and Public Health (CIBERESP‐ IIB Sant Pau)BarcelonaSpain
| | | | - M. Gloria Díaz
- Unidad Docente de Medicina Familiar y ComunitariaHospital DonostiaDonostiaSpain
| | - Philip J. Devereaux
- Department of Clinical Epidemiology & BiostatisticsCLARITY Research GroupMcMaster University Medical Centre 2C9HamiltonONCanada
| | - Gemma Mas
- Iberoamerican Cochrane CentreBiomedical Research Institute Sant Pau‐CIBER of Epidemiology and Public Health (CIBERESP‐ IIB Sant Pau)BarcelonaSpain
| | - Ana I. Diez
- Centro de Salud de BeraunErrenteriaSan SebastiánSpain
| | - Ivan Solà
- Iberoamerican Cochrane CentreBiomedical Research Institute Sant Pau‐CIBER of Epidemiology and Public Health (CIBERESP‐ IIB Sant Pau)BarcelonaSpain
| | | | - Juan C. Souto
- Unitat d'Hemostàsia i TrombosiHospital de la Santa Creu i Sant PauBarcelonaSpain
| | - Sven Oliver
- Unidad Formadora de Medicina Familiar y Comunitaria de A CoruñaCoruñaSpain
| | | | | | - Ignasi Gich
- Iberoamerican Cochrane CentreBiomedical Research Institute Sant Pau‐CIBER of Epidemiology and Public Health (CIBERESP‐ IIB Sant Pau)BarcelonaSpain
| | - Holger J. Schünemann
- Department of Clinical Epidemiology & BiostatisticsCLARITY Research GroupMcMaster University Medical Centre 2C9HamiltonONCanada
| | - Gordon Guyatt
- Department of Clinical Epidemiology & BiostatisticsCLARITY Research GroupMcMaster University Medical Centre 2C9HamiltonONCanada
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Li G, Holbrook A, Delate T, Witt DM, Levine MAH, Thabane L. Prediction of individual combined benefit and harm for patients with atrial fibrillation considering warfarin therapy: a study protocol. BMJ Open 2015; 5:e009518. [PMID: 26546146 PMCID: PMC4636617 DOI: 10.1136/bmjopen-2015-009518] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Clinical prediction rules have been validated and widely used in patients with atrial fibrillation (AF) to predict stroke and major bleeding. However, these prediction rules were not developed in the same population, and do not provide the key information that patients and prescribers need at the time anticoagulants are being considered-what is the individual patient-specific risk of both benefit (decreased stroke) and harm (increased major bleeding). In this study, our primary objective is to develop and validate a prediction model for patients' individual combined benefit and harm outcomes (stroke, major bleeding and neither event) with and without warfarin therapy. Our secondary outcome is all-cause mortality. METHODS AND ANALYSIS We will use data from the Kaiser Permanente Colorado (KPCO) anticoagulation management databases and electronic medical records. Patients with a primary or secondary diagnosis during an ambulatory KPCO medical office visit, emergency department visit, or inpatient stay between 1 January 2005 and 31 December 2012 with no AF diagnosis in the previous 180 days will be included. Patients' demographic characteristics, laboratory data, comorbidities, warfarin medication data and concurrent use of medication will be used to construct the prediction model. For primary outcomes (stroke with no major bleeding, and major bleeding with no stroke), we will perform polytomous logistic regression to develop a prediction model for patients' individual combined benefit and harm outcomes, taking neither event group as the reference group. As regards death, we will use Cox proportional hazards regression analysis to build a prediction model for all-cause mortality. ETHICS AND DISSEMINATION This study has been approved by the KPCO Institutional Review Board and the Hamilton Integrated Research Ethics Board. Results from this study will be published in a peer-reviewed journal electronically and in print. The prediction models may aid in patient-physician shared decision-making when they are considering warfarin therapy.
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Affiliation(s)
- Guowei Li
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Anne Holbrook
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Delate
- Kaiser Permanente Colorado Clinical Pharmacy Research Team, Aurora, Colorado, USA
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Denver, Colorado, USA
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah, USA
| | - Mitchell AH Levine
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
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Lane DA, Aguinaga L, Blomström-Lundqvist C, Boriani G, Dan GA, Hills MT, Hylek EM, LaHaye SA, Lip GYH, Lobban T, Mandrola J, McCabe PJ, Pedersen SS, Pisters R, Stewart S, Wood K, Potpara TS, Gorenek B, Conti JB, Keegan R, Power S, Hendriks J, Ritter P, Calkins H, Violi F, Hurwitz J. Cardiac tachyarrhythmias and patient values and preferences for their management: the European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2015; 17:1747-69. [PMID: 26108807 DOI: 10.1093/europace/euv233] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ghijben P, Lancsar E, Zavarsek S. Preferences for oral anticoagulants in atrial fibrillation: a best-best discrete choice experiment. PHARMACOECONOMICS 2014; 32:1115-27. [PMID: 25027944 DOI: 10.1007/s40273-014-0188-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is recognised as a growing clinical and public health problem in many countries, owing to disability and death from stroke associated with the condition, high hospitalisation costs and an increasing prevalence with ageing populations. Under-treatment with oral anticoagulants has been a significant challenge of treatment, historically related to patient concerns over the safety and convenience of warfarin, which until recently was the only oral anticoagulant available. OBJECTIVES The aim of this study is to examine: (1) patient preferences for attributes of warfarin and the new oral anticoagulants (dabigatran, rivaroxaban, apixaban) in AF; (2) which attributes are most important; and (3) whether current under-treatment is likely to improve with the new oral anticoagulants. METHODS This study was conducted in Melbourne, Australia, with members of the general public with or without AF aged ≥40 years, where those without AF proxy for newly-diagnosed patients. Participants completed a computerised best-best discrete choice experiment (and follow-up interview) as if they had AF with a moderate-to-high risk of stroke. Choice data were modelled using mixed rank-ordered logit. Relative value was explored via estimation of marginal rates of substitution with predicted probability analysis used to simulate potential uptake of oral anticoagulants. RESULTS Seventy-six participants were recruited and completed the study. Efficacy (stroke risk) was more important than safety (bleed risk, antidote), which were both considerably more important than convenience factors (blood tests, dose frequency, drug or food interactions). Cost was also important. Predicted use of the new oral anticoagulants (and under-treatment of AF) using simulation, given moderate-to-high risk of stroke, is 25 % (52 %), 54 % (29 %) and 70 % (21 %) assuming a market price of AUD$120/month, AUD$30/month (subsidised price) and AUD$30/month with an antidote, respectively. CONCLUSIONS Based on the study sample and the modelled attributes, the overall profiles of the new oral anticoagulants were preferred to warfarin as their cost decreased. Public subsidisation and the development of antidotes (such as vitamin K for warfarin) for the new oral anticoagulants may have a positive effect on the under-treatment of AF.
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Affiliation(s)
- Peter Ghijben
- Centre for Health Economics, Monash University, Clayton, VIC, 3800, Australia,
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Myles PS, Thompson G, Fedorow C, Farrington C, Sheridan N. Evaluation of differences in patient and physician perception of benefit and risks of aspirin and antifibrinolytic therapy in cardiac surgery. Anaesth Intensive Care 2014; 42:592-8. [PMID: 25233172 DOI: 10.1177/0310057x1404200508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
It is unclear whether physicians and patients have similar concerns and preferences when considering benefit and risks of aspirin and antifibrinolytic therapy for cardiac surgery. We surveyed both groups to ascertain their perceptions and preferences for treatment in this setting. Both preoperative and postoperative cardiac surgical patients and the physician craft groups caring for them (cardiology, surgery, anaesthesia/critical care), were provided with estimates of benefits and risks of aspirin and antifibrinolytic therapy. All study participants were asked to stipulate the minimal absolute risk reduction required for them to agree to such therapy. When compared with the cardiac surgical patients they treat, physicians required a smaller thrombotic risk reduction with aspirin whilst accepting its known increased risk of bleeding. This was significantly different in a high-risk stroke setting (incidence 5%) where the required relative risk reduction with aspirin use for physicians was 20% versus patients 40% (P <0.001); and for myocardial infarction, physicians 20% versus patients 36% (P=0.051). For antifibrinolytic therapy, the tolerated increased relative risk of stroke for physicians was 20% versus patients 10% (P=0.004), and for myocardial infarction, physicians 16.7% versus patients 4.2% (P <0.001). The three physician craft groups had comparable tolerances of thrombotic risk. Patient and physician preferences for perioperative aspirin and antifibrinolytic therapy sometimes differ based on risk benefit analysis.
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Affiliation(s)
- P S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria
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Hess EP, Coylewright M, Frosch DL, Shah ND. Implementation of shared decision making in cardiovascular care: past, present, and future. Circ Cardiovasc Qual Outcomes 2014; 7:797-803. [PMID: 25052074 DOI: 10.1161/circoutcomes.113.000351] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Erik P Hess
- From the Department of Emergency Medicine, Division of Emergency Medicine Research (E.P.H.), Knowledge and Evaluation Research Unit (E.P.H., M.C., N.D.S.), Department of Health Sciences Research, Division of Health Care Policy and Research (E.P.H., N.D.S.), and Division of Cardiovascular Diseases (M.C.), Mayo Clinic, Rochester, MN; Gordon and Betty Moore Foundation, Palo Alto, CA (D.L.F.); Palo Alto Medical Foundation Research Institute, Palo Alto, CA (D.L.F.); and Department of Medicine, University of California, Los Angeles (D.L.F.).
| | - Megan Coylewright
- From the Department of Emergency Medicine, Division of Emergency Medicine Research (E.P.H.), Knowledge and Evaluation Research Unit (E.P.H., M.C., N.D.S.), Department of Health Sciences Research, Division of Health Care Policy and Research (E.P.H., N.D.S.), and Division of Cardiovascular Diseases (M.C.), Mayo Clinic, Rochester, MN; Gordon and Betty Moore Foundation, Palo Alto, CA (D.L.F.); Palo Alto Medical Foundation Research Institute, Palo Alto, CA (D.L.F.); and Department of Medicine, University of California, Los Angeles (D.L.F.)
| | - Dominick L Frosch
- From the Department of Emergency Medicine, Division of Emergency Medicine Research (E.P.H.), Knowledge and Evaluation Research Unit (E.P.H., M.C., N.D.S.), Department of Health Sciences Research, Division of Health Care Policy and Research (E.P.H., N.D.S.), and Division of Cardiovascular Diseases (M.C.), Mayo Clinic, Rochester, MN; Gordon and Betty Moore Foundation, Palo Alto, CA (D.L.F.); Palo Alto Medical Foundation Research Institute, Palo Alto, CA (D.L.F.); and Department of Medicine, University of California, Los Angeles (D.L.F.)
| | - Nilay D Shah
- From the Department of Emergency Medicine, Division of Emergency Medicine Research (E.P.H.), Knowledge and Evaluation Research Unit (E.P.H., M.C., N.D.S.), Department of Health Sciences Research, Division of Health Care Policy and Research (E.P.H., N.D.S.), and Division of Cardiovascular Diseases (M.C.), Mayo Clinic, Rochester, MN; Gordon and Betty Moore Foundation, Palo Alto, CA (D.L.F.); Palo Alto Medical Foundation Research Institute, Palo Alto, CA (D.L.F.); and Department of Medicine, University of California, Los Angeles (D.L.F.)
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Myat A, Ahmad Y, Haldar S, Tantry US, Redwood SR, Gurbel PA, Lip GY. Is bleeding a necessary evil? The inherent risk of antithrombotic pharmacotherapy used for stroke prevention in atrial fibrillation. Expert Rev Cardiovasc Ther 2014; 11:1029-49. [PMID: 23984927 DOI: 10.1586/14779072.2013.815423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Current European atrial fibrillation (AF) guidelines have assigned a strong recommendation for the initiation of antithrombotic therapy to prevent thromboembolism in all but those AF patients at low risk (or with contraindications). Furthermore, the selection of antithrombotic therapy is based on the absolute risks of thromboembolism and bleeding, and the relative risk and benefit for a given patient. By their very mechanism of action, antithrombotic agents used for stroke prevention in AF will potentially increase the risk of bleeding events. Moreover, the introduction of novel oral anticoagulation agents have introduced new, hitherto ill-defined, deficiencies in the authors' knowledge with respect to anticoagulation monitoring, availability of direct antidotes, drug-drug interactions and the ability to appropriately control and reverse their actions if bleeding events occur. The authors present a comprehensive review on all aspects of bleeding related to currently licensed antithrombotic agents used for stroke prevention in patients with AF.
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Affiliation(s)
- Aung Myat
- King's College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas' Hospital, London SE1 7EH, UK.
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Seaburg L, Hess EP, Coylewright M, Ting HH, McLeod CJ, Montori VM. Shared decision making in atrial fibrillation: where we are and where we should be going. Circulation 2014; 129:704-10. [PMID: 24515956 DOI: 10.1161/circulationaha.113.004498] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Luke Seaburg
- Department of Medicine (L.S.), Department of Emergency Medicine, Division of Emergency Medicine Research (E.P.H.), Division of Health Care and Policy Research, Department of Health Sciences Research (E.P.H., V.M.M.), Division of Cardiology, Department of Medicine (M.C., H.H.T., C.J.M.), and Division of Endocrinology, Department of Medicine (V.M.M.), Mayo Clinic, Rochester, MN; and Knowledge and Evaluation Research Unit, Rochester, MN (E.P.H., M.C., H.H.T., V.M.M.)
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Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R, Trevena L, Wu JHC. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014:CD001431. [PMID: 24470076 DOI: 10.1002/14651858.cd001431.pub4] [Citation(s) in RCA: 838] [Impact Index Per Article: 83.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty. OBJECTIVES To assess the effects of decision aids for people facing treatment or screening decisions. SEARCH METHODS For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008). SELECTION CRITERIA We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions. DATA COLLECTION AND ANALYSIS Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:A) 'choice made' attributes;B) 'decision-making process' attributes.Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model. MAIN RESULTS This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).A) Criteria involving 'choice made' attributes:Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).B) Criteria involving 'decision-making process' attributes:Decision aids compared to usual care interventions resulted in:a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); andc) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.C) Secondary outcomes Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable.The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive. AUTHORS' CONCLUSIONS There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada
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Clarkesmith DE, Pattison HM, Lip GYH, Lane DA. Educational intervention improves anticoagulation control in atrial fibrillation patients: the TREAT randomised trial. PLoS One 2013; 8:e74037. [PMID: 24040156 PMCID: PMC3767671 DOI: 10.1371/journal.pone.0074037] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 07/25/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Stroke prevention in atrial fibrillation (AF), most commonly with warfarin, requires maintenance of a narrow therapeutic target (INR 2.0 to 3.0) and is often poorly controlled in practice. Poor patient-understanding surrounding AF and its treatment may contribute to the patient's willingness to adhere to recommendations. METHOD A theory-driven intervention, developed using patient interviews and focus groups, consisting of a one-off group session (1-6 patients) utilising an "expert-patient" focussed DVD, educational booklet, self-monitoring diary and worksheet, was compared in a randomised controlled trial (ISRCTN93952605) against usual care, with patient postal follow-ups at 1, 2, 6, and 12-months. Ninety-seven warfarin-naïve AF patients were randomised to intervention (n=46, mean age (SD) 72.0 (8.2), 67.4% men), or usual care (n=51, mean age (SD) 73.7 (8.1), 62.7% men), stratified by age, sex, and recruitment centre. Primary endpoint was time within therapeutic range (TTR); secondary endpoints included knowledge, quality of life, anxiety/depression, beliefs about medication, and illness perceptions. MAIN FINDINGS Intervention patients had significantly higher TTR than usual care at 6-months (76.2% vs. 71.3%; p=0.035); at 12-months these differences were not significant (76.0% vs. 70.0%; p=0.44). Knowledge increased significantly across time (F (3, 47) = 6.4; p<0.01), but there were no differences between groups (F (1, 47) = 3.3; p = 0.07). At 6-months, knowledge scores predicted TTR (r=0.245; p=0.04). Patients' scores on subscales representing their perception of the general harm and overuse of medication, as well as the perceived necessity of their AF specific medications predicted TTR at 6- and 12-months. CONCLUSIONS A theory-driven educational intervention significantly improves TTR in AF patients initiating warfarin during the first 6-months. Adverse clinical outcomes may potentially be reduced by improving patients' understanding of the necessity of warfarin and reducing their perception of treatment harm. Improving education provision for AF patients is essential to ensure efficacious and safe treatment. The trial is registered with Current Controlled Trials, ISRCTN93952605, and details are available at www.controlled-trials.com/ISRCTN93952605.
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Affiliation(s)
- Danielle E. Clarkesmith
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
- School of Health and Life Sciences, Aston University, Birmingham, United Kingdom
| | - Helen M. Pattison
- School of Health and Life Sciences, Aston University, Birmingham, United Kingdom
| | - Gregory Y. H. Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
- School of Health and Life Sciences, Aston University, Birmingham, United Kingdom
| | - Deirdre A. Lane
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
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Wess ML, Saleem JJ, Tsevat J, Luckhaupt SE, Johnston JA, Wise RE, Kopke JE, Eckman MH. Usability of an atrial fibrillation anticoagulation decision-support tool. J Prim Care Community Health 2013; 2:100-6. [PMID: 23804743 DOI: 10.1177/2150131910387608] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In individuals with nonvalvular atrial fibrillation, anticoagulant therapy with warfarin reduces the rate of thromboembolic events but increases the risk of bleeding. Treatment decisions frequently are inconsistent with guidelines. A new web-based atrial fibrillation decision-support tool (AF-DST) provides patient-specific information on the risk-benefit tradeoff of anticoagulation. METHODS The authors performed a pilot usability testing study of the AF-DST with 4 medical house officers and 4 attending physicians by simulating 9 outpatient clinical encounters involving tradeoffs between risks and benefits of anticoagulation. They recorded positive and negative critical incidents in the simulations and assessed satisfaction with use of the AF-DST by the Computer System Usability Questionnaire (CSUQ; score range on each item: 1 = strongly disagree to 7 = strongly agree). RESULTS Users found the AF-DST to be helpful and had high CSUQ scores (mean item score, 6.3). Usability testing identified 6 positive and 14 negative critical incidents. Participants felt that the AF-DST guided them toward the correct decision. Nevertheless, they desired more information on the "black box" calculations and ignored alerts. Training level appeared to affect how the AF-DST was used, in particular, how users interacted with the AF-DST. CONCLUSIONS Overall satisfaction with the AF-DST was high and the tool effectively communicated recommendations and uncertainty. Usability testing identified design issues and potential errors caused by decision-support tool use; these gaps should be addressed prior to clinical implementation.
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Affiliation(s)
- Mark L Wess
- Division of General Internal Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Clarkesmith DE, Pattison HM, Lane DA. Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation. Cochrane Database Syst Rev 2013:CD008600. [PMID: 23736948 DOI: 10.1002/14651858.cd008600.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation who are at moderate-to-high risk of stroke, however anticoagulation control (time in therapeutic range (TTR)) is dependent on many factors. Educational and behavioural interventions may impact on patients' ability to maintain their International Normalised Ratio (INR) control. OBJECTIVES To evaluate the effects on TTR of educational and behavioural interventions for oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (2012, Issue 7 of 12), MEDLINE Ovid (1950 to week 4 July 2012), EMBASE Classic + EMBASE Ovid (1947 to Week 31 2012), PsycINFO Ovid (1806 to 2012 week 5 July) on 8 August 2012 and CINAHL Plus with Full Text EBSCO (to August 2012) on 9 August 2012. We applied no language restrictions. SELECTION CRITERIA The primary outcome analysed was TTR. Secondary outcomes included decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), and anxiety. DATA COLLECTION AND ANALYSIS The two review authors independently extracted data. Where insufficient data were present to conduct a meta-analysis, effect sizes and confidence intervals (CIs) of the included studies were reported. Data were pooled for two outcomes, TTR and decision conflict. MAIN RESULTS Eight trials with a total of 1215 AF patients (number of AF participants included in the individual trials ranging from 14 to 434) were included within the review. Studies included education, decision aids, and self-monitoring plus education.For the primary outcome of TTR, data for the AF participants in two self-monitoring plus education trials were pooled and did not favour self-monitoring plus education or usual care in improving TTR, with a mean difference of 6.31 (95% CI -5.63 to 18.25). For the secondary outcome of decision conflict, data from two decision aid trials favoured usual care over the decision aid in terms of reducing decision conflict, with a mean difference of -0.1 (95% CI -0.2 to -0.02). AUTHORS' CONCLUSIONS This review demonstrated that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.
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Affiliation(s)
- Danielle E Clarkesmith
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK. 2School of Life and Health Sciences,Aston University, Birmingham, UK
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Impact of the Ottawa Influenza Decision Aid on healthcare personnel's influenza immunization decision: a randomized trial. J Hosp Infect 2012; 82:194-202. [DOI: 10.1016/j.jhin.2012.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 08/04/2012] [Indexed: 11/18/2022]
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Fox-Wilson G, Cruickshank S. Stroke prevention in primary care: optimising management of AF through nurse specialist support. ACTA ACUST UNITED AC 2012. [DOI: 10.12968/bjca.2012.7.9.432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Gillian Fox-Wilson
- South London Cardiovascular and Stroke Network, 84 Kennington Road, London, SE11 6NL
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Development and pretesting of a decision-aid to use when counseling parents facing imminent extreme premature delivery. J Pediatr 2012; 160:382-7. [PMID: 22048056 DOI: 10.1016/j.jpeds.2011.08.070] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 08/01/2011] [Accepted: 08/31/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To develop and pretest a decision-aid to help parents facing extreme premature delivery during antenatal counseling regarding delivery room resuscitation. STUDY DESIGN Semistructured interviews with 31 clinicians and with 30 parents of children born <26 weeks' gestation were conducted following standard methods of qualitative research. These characterized perceptions of prenatal counseling to identify information that parents value when making decisions regarding delivery room resuscitation. These parental needs were formatted into a decision-aid. We assessed the primary outcome of how effectively the decision-aid improved knowledge during a simulated counseling session. Two groups of women were studied: parents with a history of prematurity ("experienced") and healthy women without prior knowledge of prematurity ("naïve"). RESULTS Interviewees thought that visual formats to present survival and short- and long-term outcome information facilitated their own preparation, recall, and understanding. Accordingly, we designed a decision-aid as a set of cards with pictures and pictographs to show survival rates and complications. There was significant improvement in knowledge in 13 "experienced" parents (P = .04) and 11 "naïve" women (P < .0001). Participants found the cards useful and easy to understand. CONCLUSIONS A decision-aid for parents facing extreme premature delivery may improve their understanding of complicated information during antenatal counseling.
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Abstract
Atrial fibrillation is the commonest arrhythmia worldwide and is a growing problem. AF is responsible for 25% of all strokes, and these patients suffer greater mortality and disability. Warfarin has traditionally been the only successful therapy for stroke prevention, but its limitations have resulted in underutilisation. Major progress has been made in AF research, leading to improved management strategies. Better risk stratification permits identification of truly low-risk patients who do not require anticoagulation and we are able to simplify ourevaluation of a patient's bleeding risk.The advent of novel anticoagulants means warfarin is no longer the only choice for stroke prophylaxis. These drugs circumvent many of warfarin's inconveniences, but onlylong-term study and use will conclusively demonstrate how they compare to warfarin. The landscape of stroke prevention in AF has changed with effective alternatives to warfarin available for the first time in 60 years-but each new option brings new considerations.
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Affiliation(s)
- Yousif Ahmad
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Gregory Y.H. Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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Abstract
The management of atrial fibrillation has evolved greatly in the past few years, and many areas have had substantial advances or developments. Recognition of the limitations of aspirin and the availability of new oral anticoagulant drugs that overcome the inherent drawbacks associated with warfarin will enable widespread application of effective thromboprophylaxis with oral anticoagulants. The emphasis on stroke risk stratification has shifted towards identification of so-called truly low-risk patients with atrial fibrillation who do not need antithrombotic therapy, whereas oral anticoagulation therapy should be considered in patients with one or more risk factors for stroke. New antiarrhythmic drugs, such as dronedarone and vernakalant, have provided some additional opportunities for rhythm control in atrial fibrillation. However, the management of the disorder is increasingly driven by symptoms. The availability of non-pharmacological approaches, such as ablation, has allowed additional options for the management of atrial fibrillation in patients who are unsuitable for or intolerant of drug approaches.
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Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK.
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MacLean S, Mulla S, Akl EA, Jankowski M, Vandvik PO, Ebrahim S, McLeod S, Bhatnagar N, Guyatt GH. Patient values and preferences in decision making for antithrombotic therapy: a systematic review: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e1S-e23S. [PMID: 22315262 PMCID: PMC3278050 DOI: 10.1378/chest.11-2290] [Citation(s) in RCA: 189] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Development of clinical practice guidelines involves making trade-offs between desirable and undesirable consequences of alternative management strategies. Although the relative value of health states to patients should provide the basis for these trade-offs, few guidelines have systematically summarized the relevant evidence. We conducted a systematic review relating to values and preferences of patients considering antithrombotic therapy. METHODS We included studies examining patient preferences for alternative approaches to antithrombotic prophylaxis and studies that examined, in the context of antithrombotic prophylaxis or treatment, how patients value alternative health states and experiences with treatment. We conducted a systematic search and compiled structured summaries of the results. Steps in the process that involved judgment were conducted in duplicate. RESULTS We identified 48 eligible studies. Sixteen dealt with atrial fibrillation, five with VTE, four with stroke or myocardial infarction prophylaxis, six with thrombolysis in acute stroke or myocardial infarction, and 17 with burden of antithrombotic treatment. CONCLUSION Patient values and preferences regarding thromboprophylaxis treatment appear to be highly variable. Participant responses may depend on their prior experience with the treatments or health outcomes considered as well as on the methods used for preference elicitation. It should be standard for clinical practice guidelines to conduct systematic reviews of patient values and preferences in the specific content area.
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Affiliation(s)
- Samantha MacLean
- Department of Biostatistics and Clinical Epidemiology, McMaster University, Hamilton, ON, Canada.
| | - Sohail Mulla
- Department of Biostatistics and Clinical Epidemiology, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Biostatistics and Clinical Epidemiology, McMaster University, Hamilton, ON, Canada; Department of Medicine, State University of New York at Buffalo, Buffalo, NY
| | - Milosz Jankowski
- Department of Internal Medicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Per Olav Vandvik
- Norwegian Knowledge Centre for the Health Services and Department of Medicine Gjøvik, Innlandet Hospital Trust, Gjøvik, Norway
| | - Shanil Ebrahim
- Department of Biostatistics and Clinical Epidemiology, McMaster University, Hamilton, ON, Canada
| | - Shelley McLeod
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada
| | - Neera Bhatnagar
- Department of Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Biostatistics and Clinical Epidemiology, McMaster University, Hamilton, ON, Canada
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