An Individualized Shared Decision-making Intervention for Atrial Fibrillation Stroke Prevention

Principal Investigator
Wilton, Stephen (Department of Cardiac Sciences & Medicine, University of Calgary)

Mentor
Sheldon, Robert & Ghali, William

Network Affiliation
Canadian Stroke Prevention Intervention Network

 

1. The Health Problem/Issue

When faced with important choices about their health, most people want their doctor to give them complete and unbiased information about the pros and cons of each option. Most people also want advice that takes their personal preferences into account, and to be involved in the final decision. Too often however, decision-making is one-sided. In addition to disempowering patients, this practice is an major cause of poor health outcomes. Shared Decision-Making, or SDM, is a research area focused on engaging patients in medical decisions. SDM includes tools called decision-aids that clarify choices by showing the pros and cons in an intuitive way. SDM improves people’s knowledge, and comfort with their choices, and may lead to better quality of care.
 
The decision to take an anticoagulant medication to reduce the risk of stroke due to atrial fibrillation, or Afib, is a prime area for SDM research. Afib causes 15% of all strokes, most of which could be prevented by anticoagulants. However, only half of eligible people are treated, in part because of inaccurate perception of the risks involved. Decision-aids for Afib stroke prevention exist, but none compare all of the available options, and none have been designed and tested by their intended users: patients and care providers. As such, they are rarely used.
 

2. The Objectives 

Our long-term objective is to reduce preventable strokes due to Afib using effective SDM. In this 3-year program, we will design and test a new decision aid for Afib stroke prevention. The interactive computerized decision-aid will show a suggested treatment choice based on an individual’s risk profile, and allow them to modify the choice based on their personal preferences. For example, are they more concerned about costs or convenience? The tool will be built within APPROACH, a web-based registry of heart patients in use in many places in Canada. To increase the chances of success, we are working in partnership with Afib patients and clinicians from the start. This work will lay the necessary foundation for a future randomized clinical trial to determine the impact of our SDM tool on stroke risk.
 

3. The Approach

This proposal includes 3 linked projects. In the first project we will speak with Afib patients, doctors and nurses in focus groups. The purpose is to understand their experiences with stroke prevention decision-making, and find out what they would want in a computerized decision-aid tool. The second project is to design a new computerized decision-aid, and make sure it works as intended. Again, Afib patients and clinicians will participate in the design and testing. The third project is to evaluate the how the new tool works in real life. We will start using it in a specialized Afib clinic for 6 months, and measure patients’ knowledge, and comfort with the choice they made. We will also determine how many patients choose a recommended treatment. All results will be compared with the 6 months before we started using the tool. This evaluation is critical for planning our future large-scale project to determine the impact of our SDM tool on stroke risk.
 

4. The Unique Factors

There are several innovative features of this program. First, we are building on an existing partnership between the Calgary Afib Clinic and APPROACH, to build and test our decision aid tool. The Afib Clinic sees over 500 patients per year, and is staffed by expert nurses and doctors. APPROACH software is used in the Clinic, and adding a decision aid to this is both practical and efficient. Next, we will work with a unique patient engagement research group, called PACER, for our first project. PACER trains patients with chronic illnesses to run focus groups, allowing for a peer-to-peer information exchange. Finally, we are designing the decision-aid with Dr. Jeff Caird, a psychologist who leads a research program to optimize human-computer interaction in health care. His expertise is crucial to developing a tool that works well for both patients and clinicians.
 

5. How the project is relevant to the objectives of the initiative 

Reducing death and disability due to Afib-associated stroke is the main goal of the CSPIN network. It is also a key part of the Heart and Stroke Foundation’s mission. In addition, making health care more patient-centered care is leading medical research institutes in Canada and worldwide. This proposal directly targets these objectives, using a unique approach to SDM.
 

6. The Impact

Achieving patient-centered care is the next frontier in clinical science. This program of patient-centered research will have both near- and long- term benefits. The projects will advance the science of SDM, and the findings will be helpful to researchers in many areas. Also, our decision aid will allow patients with Afib to make a decision about stroke prevention treatment that is both truly informed and in step with their priorities. If it works as expected, an SDM approach using this decision aid will lead to more patients receiving appropriate treatment, and fewer preventable strokes.
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