title: Developing an Atrial Fibrillation Guideline Support Tool (AFGuST) for shared decision making.
abstract: OBJECTIVE
  Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients' preferences into this decision.
  
  
  METHODS
  CHA2DS2VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational engine to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy.
  
  
  RESULTS
  Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patient-specific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video, were developed through an iterative process with clinicians and patient focus groups.
  
  
  CONCLUSIONS
  Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy.
  
  
  CONCLUSIONS
  We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient's stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.
authors.affiliation: Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati , Cincinnati, OH , USA.
authors.forename: Mark H
authors.initials: MH
authors.lastname: Eckman
authors.forename: Ruth E
authors.initials: RE
authors.lastname: Wise
authors.forename: Katherine
authors.initials: K
authors.lastname: Naylor
authors.forename: Lora
authors.initials: L
authors.lastname: Arduser
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
authors.forename: Brett
authors.initials: B
authors.lastname: Kissela
authors.forename: Matthew
authors.initials: M
authors.lastname: Flaherty
authors.forename: Dawn
authors.initials: D
authors.lastname: Kleindorfer
authors.forename: Faisal
authors.initials: F
authors.lastname: Khan
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Schauer
authors.forename: John
authors.initials: J
authors.lastname: Kues
authors.forename: Alexandru
authors.initials: A
authors.lastname: Costea
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy / Q000523:psychology; D003657:Decision Making; D003658:Decision Making, Computer-Assisted; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced / Q000517:prevention & control; D006801:Humans; D008297:Male; D008875:Middle Aged; D010358:Patient Participation; D057240:Patient Preference; D016730:Program Development; D011788:Quality of Life; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D014481:United States; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Atrial fibrillation; Decision analysis; Decision support tools; Shared decision making