Man-Son-Hing Malcolm, Gage Brian F, Montgomery Alan A, Howitt Alistair, Thomson Richard, Devereaux P J, Protheroe Joanne, Fahey Tom, Armstrong David, Laupacis Andreas
Elisabeth Bruyere Research Institute and Division of Geriatric Medicine, University of Ottawa, Ottawa, Ontario, Canada.
Med Decis Making. 2005 Sep-Oct;25(5):548-59. doi: 10.1177/0272989X05280558.
Patient preferences and expert-generated clinical practice guidelines regarding treatment decisions may not be identical. The authors compared the thresholds for antithrombotic treatment from studies that determined or modeled the treatment preferences of patients with atrial fibrillation with recommendations from clinical practice guidelines.
Methods included MEDLINE identification, systematic review, and pooling with some reanalysis of primary data from relevant studies.
Eight pertinent studies, including 890 patients, were identified. These studies used 3 methods (decision analysis, probability tradeoff, and decision aids) to determine or model patient preferences. All methods highlighted that the threshold above which warfarin was preferred over aspirin was highly variable. In 6 of 8 studies, patient preferences indicated that fewer patients would take warfarin compared to the recommendations of the guidelines. In general, at a stroke rate of 1% with aspirin, half of the participants would prefer warfarin, and at a rate of 2% with aspirin, two thirds would prefer warfarin. In 3 studies, warfarin must provide at least a 0.9% to 3.0% per year absolute reduction in stroke risk for patients to be willing to take it, corresponding to a stroke rate of 2% to 6% on aspirin.
For patients with atrial fibrillation, treatment recommendations from clinical practice guidelines often differ from patient preferences, with substantial heterogeneity in their individual preferences. Since patient preferences can have a substantial impact on the clinical decision-making process, acknowledgment of their importance should be incorporated into clinical practice guidelines. Practicing physicians need to balance the patient preferences with the treatment recommendations from clinical practice guidelines.
患者对于治疗决策的偏好与专家制定的临床实践指南可能并不相同。作者比较了确定或模拟房颤患者治疗偏好的研究中抗血栓治疗的阈值与临床实践指南的推荐意见。
方法包括通过医学文献数据库检索、系统评价以及对相关研究的原始数据进行汇总并重新分析。
共纳入8项相关研究，涉及890例患者。这些研究采用了3种方法（决策分析、概率权衡和决策辅助工具）来确定或模拟患者偏好。所有方法均强调，华法林优于阿司匹林的阈值差异很大。在8项研究中的6项中，患者偏好表明与指南推荐相比，愿意服用华法林的患者更少。一般来说，阿司匹林导致的卒中发生率为1%时，一半的参与者会选择华法林；阿司匹林导致的卒中发生率为2%时，三分之二的参与者会选择华法林。在3项研究中，华法林必须每年至少使卒中风险绝对降低0.9%至3.0%，患者才愿意服用，这相当于阿司匹林治疗时卒中发生率为2%至6%。
对于房颤患者，临床实践指南的治疗推荐往往与患者偏好不同，且患者个体偏好存在很大异质性。由于患者偏好会对临床决策过程产生重大影响，因此应在临床实践指南中承认其重要性。执业医师需要在患者偏好与临床实践指南的治疗推荐之间取得平衡。
