Abstract
BackgroundOral anticoagulation prevents strokes in patients with atrial fibrillation but, for reasons that remain unclear, less than 40% of all patients with atrial fibrillation receive warfarin. The literature postulates that patient and clinician preferences may explain this low utilization.DesignThe proposed research seeks to answer the following questions: i) When assessed systematically, do patients' and clinicians' preferences explain the utilization of warfarin to prevent strokes associated with atrial fibrillation? ii) To what extent do patients' and clinicians' treatment preferences differ? iii) What factors explain any differences that exist in treatment preferences between patients and clinicians? To answer these questions we will conduct a two-phase study of patient and clinician preferences for health states and treatments. In the first phase of this study we will conduct structured interviews to determine their treatment preferences for warfarin vs. aspirin to prevent strokes associated with atrial fibrillation using the probability trade-off technique. In the same interview, we will conduct preference-elicitation exercises using the feeling thermometer to identify the utilities that patients place on taking medication (warfarin and aspirin), and on having a mild stroke, a severe stroke, and a major bleed. In the second phase of the study we will convene focus groups of clinicians and patients to explore their answers to the exercises in the first phase.DiscussionThis is a study of patient and clinician preferences for health states and treatments. Because of its clinical importance and our previous work in this area, we will conduct our study in the clinical context of the decision to use antithrombotic agents to reduce the risk of stroke in patients with non-valvular chronic atrial fibrillation
Highlights
A number of lines of evidence, including our own prior study, suggest that differences between clinician and patient preferences regarding warfarin versus alternative management of atrial fibrillation may explain this apparent underutilization of anticoagulation
Development and testing of interventions to increase rates of anticoagulation in patients with atrial fibrillation should become a matter of urgency
Our review of the evidence suggests that it is more likely that we will confirm substantially different treatment choices in clinicians and patients. This result would suggest that current low rates of anticoagulation in atrial fibrillation reflect clinician and not patient values, and mandate urgent development and testing of interventions to increase rates of anticoagulation, and prevent unnecessary strokes
Summary
Thousands of patients with atrial fibrillation will suffer preventable strokes this year because they do not receive anticoagulation. Our review of the evidence suggests that it is more likely that we will confirm substantially different treatment choices in clinicians and patients This result would suggest that current low rates of anticoagulation in atrial fibrillation reflect clinician and not patient values, and mandate urgent development and testing of interventions to increase rates of anticoagulation, and prevent unnecessary strokes. Such findings would not, explain why clinician and patient choices differ. AF: atrial fibrillation; EC: extracranial; N: sample size; SD: standard deviation; SEM: Standard error of the mean
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