Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study  Commentary: Varied preferences reflect the reality of clinical practice

doi:10.1136/bmj.323.7323.1218

BMJ 2001;323:1218 ( 24 November )

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Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study

P J Devereaux, cardiology resident, ^a David R Anderson, associate professor, ^a Martin J Gardner, professor, ^a Wayne Putnam, associate professor, ^b Gordon J Flowerdew, associate professor, ^c Brenda F Brownell, project coordinator, ^a Seema Nagpal, research associate, ^d Jafna L Cox, associate professor. ^a

^a Department of Medicine, Dalhousie University, Halifax, Nova Scotia, B3K 6A3, Canada, ^b Department of Family Medicine, Dalhousie University, Halifax, ^c Department of Community Health and Epidemiology, Dalhousie University, Halifax, ^d College of Pharmacy, Dalhousie University, Halifax

Correspondence to: P J Devereaux philipj{at}mcmaster.ca

Objective: To determine and compare physicians' and patients'thresholds for how much reduction in risk of stroke is necessaryand how much risk of excess bleeding is acceptable with antithrombotictreatment in people with atrialfibrillation.
Design: Prospective observationalstudy.
Setting: Tertiary and peripheral referral centres inNova Scotia,Canada.
Participants: 63 physicians who were treating patients withatrial fibrillation and 61 patients at high risk for atrialfibrillation.
Main outcome measures: Participants underwent a face to face interviewwith a probability trade-off tool. Thresholds were determinedfor the minimum reduction in risk of stroke necessary and themaximum increase in risk of excess bleeding acceptable for treatmentwith aspirin and warfarin in people with atrialfibrillation.
Results: The minimum number of strokes that neededto be prevented in 100 patients over two years for warfarin tobe justified was significantly lower for patients than for physicians(1.8 (SD 1.9) v 2.5 (1.6), P=0.009), whereas for aspirin therewas no difference between patients and physicians (1.3 (1.3) v1.6 (1.5), P=0.29). The maximum number of excess bleeds acceptablein 100 patients over two years for use of warfarin and aspirinwas significantly higher for patients than for physicians (warfarin17.4 (7.1) v 10.3 (6.1); aspirin 14.7 (8.5) v 6.7 (6.2); P<0.001for bothcomparisons).
Conclusions: Patients at high risk for atrial fibrillationplaced more value on the avoidance of stroke and less value onthe avoidance of bleeding than did physicians who treat patientswith atrial fibrillation. The views of the individual patientshould be considered when decisions are being made about antithrombotictreatment for people with atrialfibrillation.

What is already known on this topic
Several observational studies have shown an apparent underuse of antithrombotic drugs in patients with atrial fibrillation, despite evidence of efficacy

What this study adds
There is considerable variability between physicians and patients in their weighing up of the potential outcomes associated with atrial fibrillation and its treatment

For anticoagulation treatment to be acceptable patients required less reduction in risk of stroke and were more tolerant of an increase in risk of bleeding than physicians

Physicians varied considerably in how much risk of bleeding they thought was acceptable for a given reduction in risk of stroke associated with antithrombotic drugs

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Going from evidence to recommendations: Gordon H Guyatt, Andrew D Oxman, Regina Kunz, Yngve Falck-Ytter, Gunn E Vist, Alessandro Liberati, Holger J Schünemann for the GRADE Working Group
BMJ 2008 336: 1049-1051. [Extract] [Full Text] [PDF]

What is "quality of evidence" and why is it important to clinicians?: Gordon H Guyatt, Andrew D Oxman, Regina Kunz, Gunn E Vist, Yngve Falck-Ytter, Holger J Schünemann for the GRADE Working Group
BMJ 2008 336: 995-998. [Extract] [Full Text] [PDF]

Delusions and dupes
BMJ 2001 323: 0. [Full Text] [PDF]

Doctors and patients have different priorities regarding anticoagulation
BMJ 2001 323: 0. [Full Text]

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