Can Shared Decision Making Improve Stroke Prevention in Atrial Fibrillation?
2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 3 Linguagem: Inglês
10.1161/circoutcomes.119.006080
ISSN1941-7705
AutoresSarah McCarthy, Rebecca K. Delaney, Peter A. Noseworthy,
Tópico(s)Acute Ischemic Stroke Management
ResumoHomeCirculation: Cardiovascular Quality and OutcomesVol. 13, No. 3Can Shared Decision Making Improve Stroke Prevention in Atrial Fibrillation? Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBCan Shared Decision Making Improve Stroke Prevention in Atrial Fibrillation?Implications of the Updated Guidelines Sarah R. Brand-McCarthy, PhD, MPH, Rebecca K. Delaney, PhD, Peter A. Noseworthy, MD and on behalf of the STEP-UP AFIB Writing Group Sarah R. Brand-McCarthySarah R. Brand-McCarthy Sarah McCarthy, PhD, MPH, Department of Psychiatry & Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Email E-mail Address: [email protected] Department of Psychiatry & Psychology (S.B.-M.), Mayo Clinic, Rochester, MN. Knowledge and Evaluation Research Unit (S.B.-M., P.A.N.), Mayo Clinic, Rochester, MN. , Rebecca K. DelaneyRebecca K. Delaney Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (R.K.D.). , Peter A. NoseworthyPeter A. Noseworthy Knowledge and Evaluation Research Unit (S.B.-M., P.A.N.), Mayo Clinic, Rochester, MN. Department of Cardiovascular Medicine and Department of Internal Medicine (P.A.N.), Mayo Clinic, Rochester, MN. and on behalf of the STEP-UP AFIB Writing Group Originally published4 Mar 2020https://doi.org/10.1161/CIRCOUTCOMES.119.006080Circulation: Cardiovascular Quality and Outcomes. 2020;13:e006080The American College of Cardiology, American Heart Association, and Heart Rhythm Society Guidelines for the Management of Patients with atrial fibrillation (AF)1 continue to call for the use of shared decision making (SDM). SDM is a process in which clinicians and patients work together to make medical decisions based on the clinical evidence, their experiences, and the patients' preferences and values. Implementing SDM with patients who live with complex disease and variable illness trajectories is challenging. Guidelines about the use of SDM often emphasize its use at the first clinical encounter, such as at the time of initial AF diagnosis when clinicians and patients are discussing whether to initiate an anticoagulant, and if so, which one to prescribe. Therefore, the role for SDM for AF can seem like a one-time intervention. However, in this article, we argue that SDM is most useful when it is conceptualized as an ongoing process that responds to the dynamic nature of the patients' health conditions and to the patient's evolving life circumstances2 as shown in the Figure.Download figureDownload PowerPointFigure. Ongoing process of shared decision making. GI indicates gastrointestinal; OAC, oral anticoagulation; and SDM, shared decision making.The initial conversations regarding treatment of AF often focus on the decisions of whether and how to anticoagulate and current guidelines urge SDM as a method to individualize therapy. SDM tools, which have been developed for use during the clinical encounter to support the individualization of therapy, frequently include risk calculators to quantify an individual's stroke and bleeding risk. They also include prompts to discuss how the options may interact with patient's daily life including diet, activity, and travel and how their implementation competes for time, energy, attention, and finances. The resulting decision regarding anticoagulation should be consistent with the best evidence (ie, should make intellectual sense as a response to the patient's situation) and should make emotional and practical sense to each patient.3 That is, its implementation in a patient's daily routine should feel like the right thing to do and should be feasible within their complicated lives. However, what this conversation does not do, and cannot do, is anticipate the challenges, both related to the treatment as well as to changing life circumstances, which will occur after the initiation of treatment. These changes may threaten the patient's ability to implement treatments with high fidelity.As noted in the 2019 American College of Cardiology, American Heart Association, and Heart Rhythm Society guidelines, patient adherence to recommended anticoagulant treatment regimens is a multifaceted challenge and often falls short.1 Improving adherence has long been a top priority in AF management in an effort to maximize treatment benefits (namely prevent strokes) and minimize risk (namely severe bleeding). Despite these considerations, lifelong adherence to anticoagulation is notoriously poor with more than half of patients stopping medications within 1 year of starting, exposing many to high stroke risk.4 Historically, warfarin therapy has been especially burdensome for patients due to multiple interactions with other drugs and to the need for frequent laboratory monitoring. Furthermore, careful use of warfarin and periodic monitoring demanded lifestyle adaptations that were not always desirable or feasible. The development of non–vitamin K oral anticoagulants promised to overcome some of these limitations of warfarin. However, they introduced new challenges to high-fidelity use, such as lack of adherence monitoring with INR testing and nurse contact and high out-of-pocket costs. Thus, gains in adherence over warfarin have been modest at best and decline substantially over time.4 Perceptions regarding the benefits of medication may also contribute to nonadherence. As in other forms of prevention, patient do not experience the benefits of intervention; stroke prevention is a nonevent. Conversely, the patient experience of adverse effects and treatment burdens such as bleeding, international normalized ratio testing, and out-of-pocket costs, are readily apparent and cumulative. Finally, it is important to recognize that adherence is an achievement of the collective work of the patient, their family members, caregivers, and multiple actors within the health system including administrators, pharmacists, and clinicians; they and all the processes they enable must be optimized for adherence to occur.Can SDM contribute to improved adherence in patients with AF? Yes. But to do so, SDM must be reconceptualized as a method of ongoing care for patients with AF, by which patients and clinicians work together to respond to the evolving problematic human situation of patients. It is an ongoing process that starts during the initial conversation about treatment and continues over time as a series of problem-solving conversations leading to fine tuning of the care plans that result in patients being able to implement care in their lives while living well with AF (Figure). During these ongoing conversations, it is critical to remind patients why treatment is important and to ensure that the original decision still responds well to the patient situation and reflects the patient's priorities. Together, clinician and patient must also identify who and what facilitates adherence. This work includes the enrollment of others, such as family members and local pharmacists, in the tasks of accessing (eg, overcoming cost barriers and avoiding fill gaps), organizing (eg, using fixed packaging or pill boxes), and administering (eg, implementing reminders at home and at work) medications.5 SDM here requires finding ways of monitoring adherence—a critical issue in the absence of the international normalized ratio signal with non–vitamin K oral anticoagulants—and of appraising the value of treatment given the nonevent nature of prevention. Thought in this way, the implementation of SDM in clinical encounters for this purpose does not follow the traditional approach of presenting options and working with patients to select the best one. Rather, it takes an iterative approach, uncovering what aspect of the patient situation demands action and what action the situation demands, an approach better suited for the purpose of solving problems.6In the course of working together to prevent and respond to problems of adherence, patients and clinicians will face structural challenges to adherence such as health-related trauma, socioeconomic injustice, and distrust which may interfere with the patient-clinician relationship, with access to timely and high-quality care, and to the resources—personal, social, professional—that make adherence possible. The poor outcomes associated with nonadherence are yet another mechanism by which these structural factors contribute to healthcare inequities and poor outcomes among those rendered vulnerable by injustice. SDM cannot be expected to solve these problems but should lead to empathic solutions that consider these and seek to address them through more intense support. The partnership inherent in caring with SDM should also remind clinicians that they have a role outside the clinic to improve outcomes by working for a more just society.In summary, SDM, defined as a one-time conversation, cannot improve the fidelity with which anticoagulation is implemented to reduce the risk of strokes over time. Rather, a close partnership between patient and clinician, manifested in a problem-solving SDM approach, and the alignment of healthcare and community entities to support patients, particularly those less fortunate, may realize the promise of healthcare progress as improved outcomes for all.Sources of FundingThis research was supported by the Strategically Focused Research Network Award from the American Heart Association and Patient-Centered Outcomes Research Institute: 18SFRN34110489. The views in this publication are solely the responsibility of the authors and do not necessarily represent the views of the American Heart Association or the Patient-Centered Outcomes Research Institute.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Sarah McCarthy, PhD, MPH, Department of Psychiatry & Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. 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March 2020Vol 13, Issue 3 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.119.006080PMID: 32126804 Originally publishedMarch 4, 2020 Keywordsatrial fibrillationanticoagulantdecision making, sharedcaregiversPDF download Advertisement SubjectsAtrial Fibrillation
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