The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based decision analysisCommentary: patients, preferences, and evidence
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7246.1380 (Published 20 May 2000) Cite this as: BMJ 2000;320:1380
Abstract
Objective: To investigate the impact of patients' preferences for the treatment of atrial fibrillation, by using individualised decision analysis combining probability and utility assessments into a decision tree.
Design: Observational study based on interviews with patients.
Setting: Eight general practices in Avon.
Participants: 260 randomly selected patients aged 70–85 years with atrial fibrillation.
Main outcome measures: Patients' treatment preferences regarding anticoagulation treatment (warfarin) after individualised decision analysis; comparison of these preferences with treatment guidelines on the basis of comorbidity and absolute risk and compared with current prescription.
Results: Of 195 eligible patients, 97 participated in decision making using decision analysis. Among these 97, the decision analysis indicated that 59 (61%; 95% confidence interval 50% to 71%) would prefer anticoagulation treatment—considerably fewer than those who would be recommended treatment according to guidelines. There was marked disagreement between the decision analysis and guideline recommendations (kappa =0.25 or less). Of 38 patients 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 although the results of their decision analysis suggested they wanted to be.
Conclusions: In the context of shared decision making, individualised decision analysis is valuable in a sizeable proportion of elderly patients with atrial fibrillation. Taking account of patients' preferences would lead to fewer prescriptions for warfarin than under published guideline recommendations. Decision analysis as a shared decision making tool should be evaluated in a randomised controlled trial.
Footnotes
- Accepted 15 March 2000
The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based decision analysis
- Joanne Protheroe, Wellcome entry level training fellowa,
- Tom Fahey, senior lecturer (tom.fahey{at}bristol.ac.uk)a,
- Alan A Montgomery, MRC health services research training fellowa,
- Tim J Peters, reader in medical statisticsb
- a Division of Primary Health Care, Department of Social Medicine, University of Bristol, Bristol BS8 2PR
- b Department of Social Medicine, University of Bristol
- Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT
- Correspondence to: T Fahey
- Accepted 15 March 2000
Abstract
Objective: To investigate the impact of patients' preferences for the treatment of atrial fibrillation, by using individualised decision analysis combining probability and utility assessments into a decision tree.
Design: Observational study based on interviews with patients.
Setting: Eight general practices in Avon.
Participants: 260 randomly selected patients aged 70–85 years with atrial fibrillation.
Main outcome measures: Patients' treatment preferences regarding anticoagulation treatment (warfarin) after individualised decision analysis; comparison of these preferences with treatment guidelines on the basis of comorbidity and absolute risk and compared with current prescription.
Results: Of 195 eligible patients, 97 participated in decision making using decision analysis. Among these 97, the decision analysis indicated that 59 (61%; 95% confidence interval 50% to 71%) would prefer anticoagulation treatment—considerably fewer than those who would be recommended treatment according to guidelines. There was marked disagreement between the decision analysis and guideline recommendations (kappa =0.25 or less). Of 38 patients 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 although the results of their decision analysis suggested they wanted to be.
Conclusions: In the context of shared decision making, individualised decision analysis is valuable in a sizeable proportion of elderly patients with atrial fibrillation. Taking account of patients' preferences would lead to fewer prescriptions for warfarin than under published guideline recommendations. Decision analysis as a shared decision making tool should be evaluated in a randomised controlled trial.
Footnotes
Funding This study was funded as part of a Wellcome entry level training fellowship for JP. TF receives some funding from an NHS R&D primary care career scientist award
Competing interests None declared.
- Accepted 15 March 2000
Commentary: patients, preferences, and evidence
- Liam Smeeth, clinical research fellow (liam.smeeth{at}lshtm.ac.uk)
- a Division of Primary Health Care, Department of Social Medicine, University of Bristol, Bristol BS8 2PR
- b Department of Social Medicine, University of Bristol
- Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT
Footnotes
Competing interests None declared.
A figure showing the study profile appears on the BMJ's website