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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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]