title: Development of a tool to improve the quality of decision making in atrial fibrillation.
abstract: BACKGROUND
  Decision-making about appropriate therapy to reduce the stroke risk associated with non-valvular atrial fibrillation (NVAF) involves the consideration of trade-offs among the benefits, risks, and inconveniences of different treatment options. The objective of this paper is to describe the development of a decision support tool for NVAF based on the provision of individualized risk estimates for stroke and bleeding and on preparing patients to communicate with their physicians about their values and potential treatment options.
  
  
  METHODS
  We developed a tool based on the principles of the International Patient Decision Aids Standards. The tool focuses on the patient-physician dyad as the decision-making unit and emphasizes improving the interaction between the two. It is built on the recognition that the application of patient values to a specific treatment decision is complex and that the final treatment choice is best made through a process of patient-clinician communication.
  
  
  RESULTS
  The tool provides education incorporating patients ' illness perceptions to explain the relationship between NVAF and stroke, and then presents individualized risk estimates, derived using separate risk calculators for stroke and bleeding over a clinically meaningful time period (5 years) associated with no treatment, aspirin, and warfarin. Sequelae of both stroke and bleeding outcomes are also described. Patients are encouraged to verbalize how they value the incremental risks and benefits associated with each option and write down specific concerns to address with their physician. A physician prompt to encourage patients to discuss their opinions is included as part of the decision support tool. In pilot testing with 11 participants (mean age 78 ± 9 years, 64% with ≤ high-school education), 8 (72%) rated ease of completion as "very easy," and 9 (81%) rated amount of information as "just right."
  
  
  CONCLUSIONS
  The risks and benefits of different treatment options for reduction of stroke in NVAF vary widely according to patients' comorbidities. This tool facilitates the provision of individualized outcome data and encourages patients to communicate with their physicians about these risks and benefits. Future studies will examine whether use of the tool is associated with improved quality of decision making.
authors: Department of Medicine, Yale University School of Medicine, New Haven, CT, USA. liana.fraenkel@yale.edu
authors: Liana
authors: L
authors: Fraenkel
authors: Richard L
authors: RL
authors: Street
authors: Terri R
authors: TR
authors: Fried
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications* / Q000188:drug therapy; D003661:Decision Support Techniques; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D010358:Patient Participation / Q000523:psychology; D010817:Physician-Patient Relations; D018570:Risk Assessment; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D014859:Warfarin / Q000009:adverse effects / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin; D001241:Aspirin