Are Older Adults Willing to Consider New Strategies to Reduce Stroke Risk?

Abstract

Atrial fibrillation (AF) is a common arrhythmia that increases patients’ risk of stroke, and determining an optimal prevention therapy is a preference-sensitive decision appropriate for shared decision making (SDM). Utilizing community-based focus groups, we explored beliefs and values around options for stroke prevention. Interview transcripts from five independent focus groups were qualitatively assessed and organized into themes. Most participants were taking a blood thinner (93%) and more than half of participants (64%) reported having AF. Few participants were familiar with newer therapies. Qualitative analysis revealed three themes: (a) fearing loss of self-control through debilitating stroke, (b) recognizing uncertainty in how to weigh risks and benefits of new treatments, and (c) needing mutual respect between clinicians and patients to consider new/alternative treatment regimens. These findings help direct future research efforts examining optimal timing for SDM and decision aids to promote mutual respect.

Keywords

anticoagulation atrial fibrillation patient engagement patient preferences shared decision making qualitative community-based focus groups Northern New England

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References

Aliot

Breithardt

Brugada

Camm

Lip

G. Y.

Vardas

P. E.

. . . World Heart

(2010). An international survey of physician and patient understanding, perception, and attitudes to atrial fibrillation and its contribution to cardiovascular disease morbidity and mortality. Europace, 12, 626–633. doi:10.1093/europace/euq109

Alston

Berger

Brownlee

Elwyn

Fowler

Jr. Hall

. . . Henderson

(2014). Shared decision-making strategies for best care: Patient decision aids. Retrieved from http://nam.edu/wp-content/uploads/2015/06/SDMforBestCare2.pdf.

Basch

C. E.

(1987). Focus group interview: an underutilized research technique for improving theory and practice in health education. Health Education Quarterly, 14, 411–448. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/3319971

Blackshear

J. L.

Odell

J. A.

(1996). Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. The Annals of Thoracic Surgery, 61, 755–759. doi:10.1016/0003-4975(95)00887-X

Colilla

Crow

Petkun

Singer

D. E.

Simon

Liu

(2013). Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. American Journal of Cardiology, 112, 1142–1147. doi:10.1016/j.amjcard.2013.05.063

Corbin

J. M.

Strauss

(1990). Grounded theory research: Procedures, canons, and evaluative criteria. Qualitative Sociology, 13(1), 3–21.

European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery., Camm

A. J.

Kirchhof

Lip

G. Y.

Schotten

. . . Rutten

F. H.

(2010). Guidelines for the management of atrial fibrillation: The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). European Heart Journal, 31, 2369–2429. doi:10.1093/eurheartj/ehq278

Elwyn

Lloyd

May

van der Weijden

Stiggelbout

Edwards

et al (2014). Collaborative deliberation: A model for patient care. Patient Education and Counseling, 97(2), 158–164.

Elwyn

Rasmussen

Kinsey

Firth

Marrin

Edwards

et al (2016). On a learning curve for shared decision making: Interviews with clinicians using the knee osteoarthritis Option Grid. Journal of Evaluation in Clinical Practice. Retrieved from http://doi.wiley.com/10.1111/jep.12665

10.

Epstein

R. M.

Peters

(2013). Beyond information: Exploring patients’ preferences. Journal of the American Medical Association, 302(2), 195–197.

11.

Epstein

R. M.

Street

R. L.

(2011). The Values and Value of Patient-Centered. Annals of Family Medicine, 9(2), 100–103.

12.

Fay

Grande

S. W.

Donnelly

Elwyn

(2016). Using option grids: Steps toward shared decision-making for neonatal circumcision. Patient Education and Counseling, 99(2), 236–242.

13.

Glazer

N. L.

Dublin

Smith

N. L.

French

Jackson

L. A.

Hrachovec

J. B.

. . . Heckbert

S. R.

(2007). Newly detected atrial fibrillation and compliance with antithrombotic guidelines. Archives of Internal Medicine, 167, 246–252. doi:10.1001/archinte.167.3.246

14.

Glotzer

T. V.

Daoud

E. G.

Wyse

D. G.

Singer

D. E.

Ezekowitz

M. D.

Hilker

. . . Ziegler

P. D.

(2009). The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circulation. Arrhythmia and Electrophysiology, 2, 474–480. doi:10.1161/CIRCEP.109.849638

15.

Glotzer

T. V.

Hellkamp

A. S.

Zimmerman

Sweeney

M. O.

Yee

Marinchak

, . . . MOST Investigators. (2003). Atrial high rate episodes detected by pacemaker diagnostics predict death and stroke: Report of the Atrial Diagnostics Ancillary Study of the MOde Selection Trial (MOST). Circulation, 107, 1614–1619. doi:10.1161/01.CIR.0000057981.70380.45

16.

A. S.

Hylek

E. M.

Phillips

K. A.

Chang

Henault

L. E.

Selby

J. V.

. . . Singer

D. E.

(2001). Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: The AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. Journal of the American Medical Association, 285, 2370–2375. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11343485

17.

Godolphin

(2009). Shared decision-making. Healthcare Quarterly, 12, e186–190.

18.

Grande

S. W.

Faber

M. J.

Durand

M-A.

Thompson

Elwyn

(2014). A classification model of patient engagement methods and assessment of their feasibility in real-world settings. Patient Education and Counseling, 95(2), 281–287.

19.

Hsu

J. C.

Maddox

T. M.

Kennedy

K. F.

Katz

D. F.

Marzec

L. N.

Lubitz

S. A.

. . . Marcus

G. M.

(2016). Oral anticoagulant therapy prescription in patients with atrial fibrillation across the spectrum of stroke risk: Insights from the NCDR PINNACLE Registry. JAMA Cardiology, 1(1), 55–62. doi:10.1001/jamacardio.2015.0374

20.

Huisman

M. V.

Rothman

K. J.

Paquette

Teutsch

Diener

H. C.

Dubner

S. J.

, . . . GLORIA-AF Investigators. (2017). The changing landscape for stroke prevention in AF: Findings from the GLORIA-AF Registry Phase 2. Journal of the American College of Cardiology, 69, 777–785. doi:10.1016/j.jacc.2016.11.061

21.

Hyde

Howlett

Brady

Drennan

(2005). The focus group method: Insights from focus group interviews on sexual health with adolescents. Social Science & Medicine, 61, 2588–2599. doi:10.1016/j.socscimed.2005.04.040

22.

Jensen

Chin

Ashby

Long

Schafer

Hakim

(2016). Decision memo for percutaneous left atrial appendage (LAA) closure therapy (CAG-00445N). Centers for Medicare and Medicaid Services. Retrieved from https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=281

23.

Kiesler

D. J.

Auerbach

S. M.

(2006). Optimal matches of patient preferences for information, decision-making and interpersonal behavior: Evidence, models and interventions. Patient Education and Counseling, 61(3), 319–341.

24.

Lahaye

Regpala

Lacombe

Sharma

Gibbens

Ball

. . . Francis

(2014). Evaluation of patients’ attitudes towards stroke prevention and bleeding risk in atrial fibrillation. Thrombosis and Haemostasis, 111, 465–473. doi:10.1160/TH13-05-0424

25.

Lane

D. A.

Aguinaga

Blomström-Lundqvist

Boriani

Dan

G-A.

Hills

M.T.

et al (2015). Cardiac tachyarrhythmias and patient values and preferences for their management: The European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace, 17(12),1747–1769.

26.

Lenert

Dunlea

Del Fiol

Hall

L. K.

(2014). A model to support shared decision making in electronic health records systems. Medical Decision Making, 34(8), 987–995.

27.

Lewis

W. R.

Fonarow

G. C.

LaBresh

K. A.

Cannon

C. P.

Pan

Super

D. M.

. . . Schwamm

L. H.

(2009). Differential use of warfarin for secondary stroke prevention in patients with various types of atrial fibrillation. American Journal of Cardiology, 103, 227–231. doi:10.1016/j.amjcard.2008.08.062

28.

MacLean

Mulla

Akl

E. A.

Jankowski

Vandvik

P. O.

Ebrahim

. . . Guyatt

G. H.

(2012). Patient values and preferences in decision making for antithrombotic therapy: A systematic review: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice guidelines. Chest, 141(2 Suppl.), e1S–23S. doi:10.1378/chest.11-2290

29.

Miles

M. B.

Huberman

A. M.

(1994). Qualitative data analysis: An expanded sourcebook (2nd ed.). Thousand Oaks, CA: Sage.

30.

O’Brien

E. C.

Simon

D. N.

Allen

L. A.

Singer

D. E.

Fonarow

G. C.

Kowey

P. R.

. . . Peterson

E. D.

(2014). Reasons for warfarin discontinuation in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). American Heart Journal, 168, 487–494. doi:10.1016/j.ahj.2014.07.002

31.

Ogilvie

I. M.

Newton

Welner

S. A.

Cowell

Lip

G. Y.

(2010). Underuse of oral anticoagulants in atrial fibrillation: A systematic review. The American Journal of Medicine, 123, 638–645.e4. doi:10.1016/j.amjmed.2009.11.025

32.

Politi

M. C.

Street

R. L.

(2011). The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice, 17, (4), 579–584.

33.

Rothwell

Anderson

Botkin

J. R.

(2016). Deliberative discussion focus groups. Qualitative Health Research, 26(6), 734–740.

34.

Tiedje

Shippee

N. D.

Johnson

A. M.

Flynn

P. M.

Finnie

D. M.

Liesinger

J. T.

et al (2013). They leave at least believing they had a part in the discussion: Understanding decision aid use and patient-clinician decision-making through qualitative research. Patient Education and Counseling, 93(1),86–94.

35.

Towle

Godolphin

(2009). Educating and training of healthcare professionals. In: Edwards

Elwyn

(Eds.), Shared decision-making in health Care: Achieving evidence-based patient choice (pp. 381–388). Oxford, UK: Oxford University Press.

36.

US Department of Health and Human Services. (2015). WATCHMAN LAA Closure Technology-P130013. Retrieved from http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm440621.htm

37.

Waldo

A. L.

Becker

R. C.

Tapson

V. F.

Colgan

K. J.

, & NABOR Steering Committee. (2005). Hospitalized patients with atrial fibrillation and a high risk of stroke are not being provided with adequate anticoagulation. Journal of the American College of Cardiology, 46, 1729–1736. doi:10.1016/j.jacc.2005.06.077

38.

Yao

Abraham

N. S.

Alexander

G. C.

Crown

Montori

V. M.

Sangaralingham

L. R.

. . . Noseworthy

P. A.

(2016). Effect of adherence to oral anticoagulants on risk of stroke and major bleeding among patients with atrial fibrillation. Journal of the American Heart Association, 5(2), e003074. doi:10.1161/JAHA.115.003074

39.

Ziegler

P. D.

Glotzer

T. V.

Daoud

E. G.

Wyse

D. G.

Singer

D. E.

Ezekowitz

M. D.

. . . Hilker

C. E.

(2010). Incidence of newly detected atrial arrhythmias via implantable devices in patients with a history of thromboembolic events. Stroke, 41, 256–260. doi:10.1161/STROKEAHA.109.571455

40.

Zikmund-Fisher

B. J.

Couper

M. P.

Singer

Ubel

P. A.

Ziniel

Fowler

F. J.

et al (2010). Deficits and variations in patients’ experience with making 9 common medical decisions: The DECISIONS survey. Medical Decision Making, 30(Suppl. 5),S85–S95.

41.

Zimetbaum

P. J.

Thosani

H. T.

Xiong

Lin

Kothawala

Emons

(2010). Are atrial fibrillation patients receiving warfarin in accordance with stroke risk? The American Journal of Medicine, 123(5), 446–453.

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