title: Assessment of Web-based education resources informing patients about stroke prevention in atrial fibrillation.
abstract: OBJECTIVE
  The importance of 'shared decision-making' is much emphasized in recent clinical guidelines regarding stroke management in atrial fibrillation (AF), more so following the inclusion of non-vitamin K oral anticoagulants (NOACs) among the treatment options. It is important that patients are navigated through balanced and unbiased information about the available treatment options, so as to understand the risk and benefits associated with the therapies, and to enable them to accordingly communicate their concerns and views with their clinicians prior to therapy selection. Given the increasing popularity of the Internet as a source of health information, the specific objectives of this study were to identify what aspects of thromboprophylaxis (antithrombotic treatment options) were most commonly described in these resources, both in terms of content, that is to report the information provided (quantitative) and the underlying themes underpinning this content, and in terms of how this information might guide patient preferences (qualitative).
  
  
  METHODS
  Resources for patients were identified via online search engines (Google, Yahoo, Ask, Bing), using the terms 'atrial fibrillation' and 'stroke' combined with patient/consumer information, patient/consumer resources and patient/consumer education. The researchers employed pragmatic (mix-method) approach to analyse the information presented within the resources using manual inductive coding, at two levels of analysis: manifest (reported surface theme or codes that are obvious and are countable) and latent (thematic, interpretative presentation of the content in the data set).
  
  
  CONCLUSIONS
  In total, 33 resources were reviewed. The 'manifest-level' analysis found that warfarin was the most frequently mentioned thromboprophylactic option among the anticoagulants, being cited in all resources, followed by the NOACs - dabigatran (82·3% of resources), rivaroxaban (73·5%) and apixaban (67·6%). Only one-third of resources discussed the role of stroke risk and/or bleeding risk within the decision-making. At the 'latent-level' analysis, three overarching themes emerged: (i) The practical ease of managing NOACs over warfarin; (ii) Unbalanced explanation about stroke risk versus bleeding risk; and (iii) Individualized antithrombotic therapy selection. In general, the benefit of stroke prevention with anticoagulant use was emphasized less compared to the risk of bleeding. Overall, one in four resources had an implied preference for either warfarin or the NOACs.
  
  
  CONCLUSIONS
  The implied inclination of some resources towards particular anticoagulant therapies and imbalanced information about the importance of anticoagulation in AF might misinform and confuse patients. Patients' engagement in shared decision-making and adherence to medicines may be undermined by the suboptimal quality of information provided in the resources. Health professionals have an important role to play in referring patients to appropriate resources to enable patient engagement in shared decision-making when selecting treatment.
authors.affiliation: Graduate School of Health - Discipline of Pharmacy, University of Technology, Sydney, NSW, Australia. Ekta.Y.Pandya@student.uts.edu.au.
authors.forename: E
authors.identifier: http://orcid.org/0000-0001-9350-589X
authors.initials: E
authors.lastname: Pandya
authors.affiliation: Graduate School of Health - Discipline of Pharmacy, University of Technology, Sydney, NSW, Australia.
authors.forename: B V
authors.initials: BV
authors.lastname: Bajorek
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D000069604:Dabigatran / Q000627:therapeutic use; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006470:Hemorrhage / Q000188:drug therapy; D006801:Humans; D020407:Internet; D010353:Patient Education as Topic; D011720:Pyrazoles / Q000627:therapeutic use; D011728:Pyridones / Q000627:therapeutic use; D012307:Risk Factors; D000069552:Rivaroxaban / Q000627:therapeutic use; D020521:Stroke / Q000188:drug therapy / Q000209:etiology / Q000517:prevention & control*; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D014859:Warfarin; D000069552:Rivaroxaban; D000069604:Dabigatran
keywords: Web-based; antithrombotics; assessment; atrial fibrillation; education resource; online; patient education; shared decision making; stroke; thromboprophylaxis