Eckman Mark H, Wise Ruth E, Naylor Katherine, Arduser Lora, Lip Gregory Y H, Kissela Brett, Flaherty Matthew, Kleindorfer Dawn, Khan Faisal, Schauer Daniel P, Kues John, Costea Alexandru
Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati , Cincinnati, OH , USA.
Curr Med Res Opin. 2015 Apr;31(4):603-14. doi: 10.1185/03007995.2015.1019608. Epub 2015 Mar 13.
Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients' preferences into this decision.
CHA2DS2VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational engine to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy.
Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patient-specific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video, were developed through an iterative process with clinicians and patient focus groups.
Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy.
We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient's stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.
当存在影响生活质量的权衡取舍时，如在考虑抗凝治疗的心房颤动（AF）患者中预防中风和出血之间的权衡，患者的价值观和偏好是决策的重要组成部分。我们的目标是描述心房颤动指南支持工具（AFGuST）的开发，以协助将患者偏好纳入这一决策过程。
使用CHA2DS2VASc和HAS - BLED来计算中风和出血风险。我们开发了一个马尔可夫决策分析模型作为计算引擎，以整合患者特异性的中风和出血风险以及个体患者对抗凝治疗决策中相关结果的价值观。
个体患者对健康相关结果的偏好可能对最佳抗血栓治疗的选择产生或多或少的影响，这取决于患者特异性缺血性中风和大出血风险的平衡。这些因素已被纳入针对患者定制的手册中，该手册与一个信息视频一起，通过与临床医生和患者焦点小组的迭代过程而开发。
AFGuST中使用的当前出血风险预测模型，如HAS - BLED，并未纳入所有潜在的重要风险因素。最近在美国、加拿大和欧洲批准使用的新型口服抗凝剂未被纳入AFGuST。相反，华法林已被用作所有口服抗凝治疗的保守替代物。
我们展示了一个概念验证，即一个针对患者定制的决策支持工具可以通过纳入个体患者的中风和出血风险以及他们对大出血事件和中风的价值观来弥合指南与实践之间的差距，以促进共同决策过程。如果有效，AFGuST可作为已发表指南的辅助工具，以加强关于抗凝管理的以患者为中心的沟通。
