title: Women's values and preferences for thromboprophylaxis during pregnancy: a comparison of direct-choice and decision analysis using patient specific utilities.
abstract: BACKGROUND
  Women with a history of venous thromboembolism (VTE) have an increased recurrence risk during pregnancy. Low molecular weight heparin (LMWH) reduces this risk, but is costly, burdensome, and may increase risk of bleeding. The decision to start thromboprophylaxis during pregnancy is sensitive to women's values and preferences. Our objective was to compare women's choices using a holistic approach in which they were presented all of the relevant information (direct-choice) versus a personalized decision analysis in which a mathematical model incorporated their preferences and VTE risk to make a treatment recommendation.
  
  
  METHODS
  Multicenter, international study. Structured interviews were on women with a history of VTE who were pregnant, planning, or considering pregnancy. Women indicated their willingness to receive thromboprophylaxis based on scenarios using personalized estimates of VTE recurrence and bleeding risks. We also obtained women's values for health outcomes using a visual analog scale. We performed individualized decision analyses for each participant and compared model recommendations to decisions made when presented with the direct-choice exercise.
  
  
  RESULTS
  Of the 123 women in the study, the decision model recommended LMWH for 51 women and recommended against LMWH for 72 women. 12% (6/51) of women for whom the decision model recommended thromboprophylaxis chose not to take LMWH; 72% (52/72) of women for whom the decision model recommended against thromboprophylaxis chose LMWH.
  
  
  CONCLUSIONS
  We observed a high degree of discordance between decisions in the direct-choice exercise and decision model recommendations. Although which approach best captures individuals' true values remains uncertain, personalized decision support tools presenting results based on personalized risks and values may improve decision making.
authors.affiliation: Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, USA. Electronic address: mark.eckman@uc.edu.
authors.forename: Mark H
authors.initials: MH
authors.lastname: Eckman
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Iberoamerican Cochrane Centre, CIBERESP-IIB Sant Pau, Barcelona, Spain.
authors.forename: Pablo
authors.initials: P
authors.lastname: Alonso-Coello
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
authors.forename: Gordon H
authors.initials: GH
authors.lastname: Guyatt
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Anaesthesia, McMaster University, Hamilton, ON; Department of Medicine, Stanford University, Stanford; Department of Anaesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.
authors.forename: Shanil
authors.initials: S
authors.lastname: Ebrahim
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Departments of Urology and Public Health, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland.
authors.forename: Kari A O
authors.initials: KA
authors.lastname: Tikkinen
authors.affiliation: Pharmaceutical Sciences, University of Sorocaba, UNISO, Sorocaba, Sao Paolo, Brazil.
authors.forename: Luciane Cruz
authors.initials: LC
authors.lastname: Lopes
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Neumann
authors.affiliation: Departments of Obstetrics & Gynecology, Radiology, and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: Sarah D
authors.initials: SD
authors.lastname: McDonald
authors.affiliation: Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, USA.
authors.forename: Yuqing
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: Qi
authors.initials: Q
authors.lastname: Zhou
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, American University of Beirut, Beirut, Lebanon; Department of Medicine, State University of New York at Buffalo, New York, NY, USA.
authors.forename: Elie A
authors.initials: EA
authors.lastname: Akl
authors.affiliation: Department of Obstetrics & Gynecology, Oslo University Hospital and University of Oslo, Oslo, Norway.
authors.forename: Ann Flem
authors.initials: AF
authors.lastname: Jacobsen
authors.affiliation: Unidad de Hemostasia y Trombosis, Hospital de la Vall d'hebron Sant Pau, Barcelona, Spain.
authors.forename: Amparo
authors.initials: A
authors.lastname: Santamaría
authors.affiliation: Hematology and Hemotherapy Center, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil.
authors.forename: Joyce Maria
authors.initials: JM
authors.lastname: Annichino-Bizzacchi
authors.affiliation: Brooks Memorial Hospital, Dunkirk, NY, USA.
authors.forename: Wael
authors.initials: W
authors.lastname: Bitar
authors.affiliation: Department of Haematology, Oslo University Hospital and University of Oslo, Oslo, Norway.
authors.forename: Per Morten
authors.initials: PM
authors.lastname: Sandset
authors.affiliation: Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.
authors.forename: Shannon M
authors.initials: SM
authors.lastname: Bates
mesh_terms: D000293:Adolescent; D000328:Adult; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D038622:Internationality; D008875:Middle Aged; D010358:Patient Participation / Q000523:psychology / Q000706:statistics & numerical data*; D057240:Patient Preference / Q000523:psychology / Q000706:statistics & numerical data*; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000453:epidemiology / Q000517:prevention & control* / Q000523:psychology; D015995:Prevalence; D011788:Quality of Life / Q000523:psychology; D012945:Social Values; D014600:Utilization Review; D054556:Venous Thromboembolism / Q000453:epidemiology / Q000517:prevention & control* / Q000523:psychology; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents
keywords: Decision making; Decision support techniques; Heparin; Pregnancy; Venous thromboembolism