The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based decision analysis  Commentary: patients, preferences, and evidence

doi:10.1136/bmj.320.7246.1380

BMJ 2000;320:1380-1384 ( 20 May )

General Practice

The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based decision analysis

Joanne Protheroe, Wellcome entry level training fellow, ^a Tom Fahey, senior lecturer, ^a Alan A Montgomery, MRC health services research training fellow, ^a Tim J Peters, reader in medical statistics. ^b

^a Division of Primary Health Care, Department of Social Medicine, University of Bristol, Bristol BS8 2PR, ^b Department of Social Medicine, University of Bristol

Correspondence to: T Fahey tom.fahey{at}bristol.ac.uk

Objective: To investigate the impact of patients' preferencesfor the treatment of atrial fibrillation, by using individualiseddecision analysis combining probability and utility assessmentsinto a decisiontree.
Design: Observational study based on interviews withpatients.
Setting: Eight general practices inAvon.
Participants: 260 randomly selected patients aged 70-85years with atrialfibrillation.
Main outcome measures: Patients' treatment preferences regardinganticoagulation treatment (warfarin) after individualised decisionanalysis; comparison of these preferences with treatment guidelineson the basis of comorbidity and absolute risk and compared withcurrentprescription.
Results: Of 195 eligible patients, 97 participatedin decision making using decision analysis. Among these 97, thedecision analysis indicated that 59 (61%; 95% confidence interval50% to 71%) would prefer anticoagulation treatment $---$ considerablyfewer than those who would be recommended treatment accordingto guidelines. There was marked disagreement between the decisionanalysis and guideline recommendations ( $kappa$ =0.25 or less). Of 38patients whose decision analysis indicated a preference for anticoagulation,17 (45%) were being prescribed warfarin; on the other hand, 28(47%) of 59 patients were not being prescribed warfarin althoughthe results of their decision analysis suggested they wanted tobe.
Conclusions: In the context of shared decision making,individualised decision analysis is valuable in a sizeable proportionof elderly patients with atrial fibrillation. Taking account ofpatients' preferences would lead to fewer prescriptions for warfarinthan under published guideline recommendations. Decision analysisas a shared decision making tool should be evaluated in a randomisedcontrolledtrial.

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Durso, S. C. (2006). Using clinical guidelines designed for older adults with diabetes mellitus and complex health status.. JAMA 295: 1935-1940 [Abstract] [Full text]
Thomson, R, Murtagh, M, Khaw, F-M (2005). Tensions in public health policy: patient engagement, evidence-based public health and health inequalities. Qual Saf Health Care 14: 398-400 [Abstract] [Full text]
Man-Son-Hing, M., Gage, B. F., Montgomery, A. A., Howitt, A., Thomson, R., Devereaux, P. J., Protheroe, J., Fahey, T., Armstrong, D., Laupacis, A. (2005). Preference-Based Antithrombotic Therapy in Atrial Fibrillation: Implications for Clinical Decision Making. Med Decis Making 25: 548-559 [Abstract]
Ruiz Ortiz, M, Romo Penas, E, Franco Zapata, M F, Mesa Rubio, D, Anguita Sanchez, M, Lopez Granados, A, Arizon del Prado, J M, Valles Belsue, F (2005). Oral anticoagulation in patients aged 75 years or older with chronic non-valvar atrial fibrillation: effectiveness and safety in daily clinical practice. Heart 91: 1225-1226 [Full text]
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Emmerich, J., Le Heuzey, J.-Y., Bath, P. M.W., Connolly, S. J. (2005). Indication for antithrombotic therapy for atrial fibrillation: reconciling the guidelines with clinical practice. Eur Heart J Suppl 7: C28-C33 [Abstract] [Full text]
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Rutten, F. H, Hak, E., Stalman, W. A., Verheij, T. J., Hoes, A. W (2003). Is treatment of atrial fibrillation in primary care based on thromboembolic risk assessment?. Fam Pract 20: 16-21 [Abstract] [Full text]
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(2001). Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J 22: 1852-1923
Fuster, V., Ryden, L. E., Asinger, R. W., Cannom, D. S., Crijns, H. J., Frye, R. L., Halperin, J. L., Kay, G. N., Klein, W. W., Levy, S., McNamara, R. L., Prystowsky, E. N., Wann, L. S., Wyse, D. G., Gibbons, R. J., Antman, E. M., Alpert, J. S., Faxon, D. P., Fuster, V., Gregoratos, G., Hiratzka, L. F., Jacobs, A. K., Russell, R. O., Smith, S. C. Jr, Klein, W. W., Alonso-Garcia, A., Blomstrom-Lundqvist, C., De Backer, G., Flather, M., Hradec, J., Oto, A., Parkhomenko, A., Silber, S., Torbicki, A. (2001). ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary: A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 38: 1231-1265 [Full text]
Fuster, V., Ryden, L. E., Asinger, R. W., Cannom, D. S., Crijns, H. J., Frye, R. L., Halperin, J. L., Kay, G. N., Klein, W. W., Levy, S., McNamara, R. L., Prystowsky, E. N., Wann, L. S., Wyse, D. G., Gibbons, R. J., Antman, E. M., Alpert, J. S., Faxon, D. P., Fuster, V., Gregoratos, G., Hiratzka, L. F., Jacobs, A. K., Russell, R. O., Smith, S. C. Jr, Klein, W. W., Alonso-Garcia, A., Blomstrom-Lundqvist, C., De Backer, G., Flather, M., Hradec, J., Oto, A., Parkhomenko, A., Silber, S., Torbicki, A. (2001). ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 38: 1266-1266 [Full text]
Bowling, A, Ebrahim, S (2001). Measuring patients' preferences for treatment and perceptions of risk. Qual Saf Health Care 10: i2-8 [Full text]
Edwards, A, Elwyn, G (2001). Understanding risk and lessons for clinical risk communication about treatment preferences. Qual Saf Health Care 10: i9-13 [Abstract] [Full text]
Dudley, N (2001). Importance of risk communication and decision making in cardiovascular conditions in older patients: a discussion paper. Qual Saf Health Care 10: i19-22 [Abstract] [Full text]
Montgomery, A A, Fahey, T (2001). How do patients' treatment preferences compare with those of clinicians?. Qual Saf Health Care 10: i39-43 [Abstract] [Full text]
Cleland, J. G F, Kaye, G. C, Mant, J., Fitzmaurice, D., Murray, E., Lip, G. Y H, Hobbs, F D R., Peterson, G., Jackson, S., Stragliotto, E., Godtfredsen, J., Boysen, G., Petersen, P., Evans, A., Kalra, L., Cates, C., Taylor, F., Cohen, H., Ebrahim, S. (2001). Long term anticoagulation or antiplatelet treatment. BMJ 323: 233-233 [Full text]
Emery, P., Reginster, J.-Y., Appelboom, T., Breedveld, F. C., Edelmann, E., Kekow, J., Malaise, M., Mola, E. M., Montecucco, C., Sanda, M., Sany, J., Scott, D. L., Serni, U., Seydoux, G. (2001). WHO Collaborating Centre consensus meeting on anti-cytokine therapy in rheumatoid arthritis. Rheumatology (Oxford) 40: 699-702 [Abstract] [Full text]
Timmermans, D, van Bockel, H, Kievit, J (2001). Improving the quality of surgeons' treatment decisions: a comparison of clinical decision making with a computerised evidence based decision analytical model. Qual Saf Health Care 10: 4-9 [Abstract] [Full text]
Taylor, F C, Cohen, H, Ebrahim, S (2001). Systematic review of long term anticoagulation or antiplatelet treatment in patients with non-rheumatic atrial fibrillation. BMJ 322: 321-326 [Abstract] [Full text]
Fahey, T., Montgomery, A. A., Peters, T. J., Tsuyuki, R. T., McAlister, F. A., Bungard, T. J., Ghali, W. A., Teo, K. K. (2000). Warfarin Therapy for Atrial Fibrillation: The Patient's Preference Is Important. Arch Intern Med 160: 2403-2403 [Full text]
McAlister, F. A., O'Connor, A. M., Wells, G., Grover, S. A., Laupacis, A. (2000). When should hypertension be treated? The different perspectives of Canadian family physicians and patients. CMAJ 163: 403-408 [Abstract] [Full text]
(2000). Preferences of Atrial Fib Patients: Some Don't Want Anticoagulation. JWatch General 2000: 1-1 [Full text]

Rapid Responses:

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Measuring preferences in primary care: Andrew Thornett
bmj.com, 21 May 2000 [Full text]
Decisions, decisions.: D A Fitzmaurice
bmj.com, 23 May 2000 [Full text]
Re: Decisions, decisions: Andrew Thornett
bmj.com, 24 May 2000 [Full text]
Patients' preferences and "paternalistic approach" in elderly patients with atrial fibrillation: Renzo Rozzini
bmj.com, 6 Jun 2000 [Full text]
response to comments on decision analysis: Tom Fahey
bmj.com, 20 Jun 2000 [Full text]