title: Complex antithrombotic therapy: determinants of patient preference and impact on medication adherence.
abstract: OBJECTIVE
  For years, older patients have been prescribed multiple blood-thinning medications (complex antithrombotic therapy [CAT]) to decrease their risk of cardiovascular events. These therapies, however, increase risk of adverse bleeding events. We assessed patient-reported trade-offs between cardioprotective benefit, gastrointestinal bleeding risk, and burden of self-management using adaptive conjoint analysis (ACA). As ACA could be a clinically useful tool to obtain patient preferences and guide future patient-centered care, we examined the clinical application of ACA to obtain patient preferences and the impact of ACA on medication adherence.
  
  
  METHODS
  An electronic ACA survey led 201 respondents through medication risk-benefit trade-offs, revealing patients' preferences for the CAT risk/benefit profile they valued most. The post-ACA prescription regimen was categorized as concordant or discordant with elicited preferences. Adherence was measured using VA pharmacy refill data to measure persistence of use prior to and 1 year following preference-elicitation. Additionally, we analyzed qualitative interviews of 56 respondents regarding their perception of the ACA and the preference elicitation experience.
  
  
  RESULTS
  Participants prioritized 5-year cardiovascular benefit over preventing adverse events. Medication side effects, medication-associated activity restrictions, and regimen complexity were less important than bleeding risk and cardioprotective benefit. One year after the ACA survey, a 15% increase in adherence was observed in patients prescribed a preference-concordant CAT strategy. An increase of only 6% was noted in patients prescribed a preference-discordant strategy. Qualitative interviews showed that the ACA exercise contributed to increase inpatient activation, patient awareness of preferences, and patient engagement with clinicians about treatment decisions.
  
  
  CONCLUSIONS
  By working through trade-offs, patients actively clarified their preferences, learning about CAT risks, benefits, and self-management. Patients with medication regimens concordant with their preferences had increased medication adherence at 1 year compared to those with discordant medication regimens. The ACA task improved adherence through enhanced patient engagement regarding treatment preferences.
authors.affiliation: Division of Gastroenterology, Mayo Clinic, Scottsdale, AZ, USA ; Divison of Healthcare Policy and Research, Department of Health Services Research, Rochester, MN, USA.
authors.forename: Neena S
authors.initials: NS
authors.lastname: Abraham
authors.affiliation: Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA ; Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Aanand D
authors.initials: AD
authors.lastname: Naik
authors.affiliation: Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA ; Department of Medicine, Baylor College of Medicine, Houston, TX, USA ; Department of Communication, Texas A&M University, College Station, TX, USA.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Street
authors.affiliation: Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA.
authors.forename: Diana L
authors.initials: DL
authors.lastname: Castillo
authors.affiliation: Cardiology, Michael E DeBakey VAMC, Houston, TX, USA.
authors.forename: Anita
authors.initials: A
authors.lastname: Deswal
authors.affiliation: Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA ; Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Richardson
authors.affiliation: Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA.
authors.forename: Christine M
authors.initials: CM
authors.lastname: Hartman
authors.affiliation: Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA ; Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
authors.forename: George
authors.initials: G
authors.lastname: Shelton
authors.affiliation: Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA ; Department of Medicine, Yale University, New Haven, CT, USA.
authors.forename: Liana
authors.initials: L
authors.lastname: Fraenkel
keywords: cardiovascular medications; gastrointestinal bleeding; medication adherence; patient activation; patient preference; risk–benefit communication