Encounter tool improves shared decision-making in stroke prevention for AF
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A shared decision-making encounter tool improved measures of quality including communication and knowledge in patients with nonvalvular atrial fibrillation considering anticoagulant treatment for stroke prevention, researchers reported.
The randomized SDM4AFib trial, published in JAMA Internal Medicine, also showed that clinicians were more satisfied with the encounter tool in addition to standard care compared with standard care alone.
“Our findings calibrate expectations about the impact of using [shared decision-making] tools in practice,” Marleen Kunneman, PhD, assistant professor of medicine at Mayo Clinic in Rochester, Minnesota, told Healio. “Clinicians interested in improving their own care of patients with atrial fibrillation may be interested in using this tool in their practice without concern that it will lengthen the visits or discourage patients from starting or continuing to use anticoagulation.”
Researchers analyzed data from 922 patients (mean age, 71 years; 60.6% men) with nonvalvular AF and 244 clinicians with whom patients had conversations about potentially starting anticoagulation therapy for stroke prevention. Patients were assigned care with a shared decision-making tool (n = 463; mean age, 71 years; 63% men) or standard care alone (n = 459; mean age, 71 years; 58% men).
“Guidelines recommended shared decision-making when it comes to determine whether and how to anticoagulate patients with atrial fibrillation to prevent strokes,” Kunneman said in an interview. “They have done so without direct evidence that this approach would improve care or patient outcomes. Our trial is the largest randomized trial to directly test this recommendation by comparing care as usual with and without a shared decision-making tool used during the clinical encounter between patients and clinicians.”
The clinicians’ usual approach was used in patients assigned standard care. For those assigned the intervention, clinicians used the Anticoagulation Choice Shared Decision-Making tool for encounters. This tool calculated a patient’s stroke risk with the CHA2DS2-VASc score and provided their individual risk at 1 year or 5 years with and without anticoagulant treatment. It also compared available anticoagulant treatment options across issues important to the patient including use, need for monitoring and costs.
“The tool was designed to fit well within typical clinical encounters between patients with atrial fibrillation and their clinicians,” Kunneman told Healio. “Furthermore, we video recorded the encounters and noticed that clinicians, with minimal training, could really use the tool as intended, and consistently over a longer period of time.”
The primary outcome was the quality of shared decision-making, including effective knowledge transfer to the patient, high-quality communication, satisfaction with the decision-making process and agreement between the patient and the clinicians on the course of action that was decided upon during the encounter.
Patients in both groups reported high knowledge, high communication quality and low decisional conflict. They also demonstrated low accuracy in risk perception and said they would recommend the approach used in their encounter. Compared with standard care, clinicians were more satisfied after intervention encounters (88.3% vs. 61.8%; adjusted RR = 1.49; 95% CI, 1.42-1.53).
In addition, 85.6% of patients decided to start or continue anticoagulation medication.
Scores to assess a patient’s involvement during the decision-making process were significantly higher in the intervention group compared with the standard care group (33 vs. 29.1; adjusted mean difference, 4.2; 95% CI, 2.8-5.6).
Encounter duration did not significantly differ between the intervention and standard care groups (32 minutes vs. 31 minutes, respectively; adjusted mean between-arm difference, 1.1; 95% CI, 0.3 to 2.5).
“There is an ongoing trial testing whether the [shared decision-making] tool needs to be used during the clinical encounter vs. simply be used with patients in preparation for the encounter,” Kunneman said in an interview. “Also, the results of follow-up to determine adherence to therapy will be important in clarifying the value of this intervention.”
For more information:
Marleen Kunneman, PhD, can be reached at kerunit@mayo.edu; Twitter: @kerunit.
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