Little Derek H W, Robertson Tara, Douketis James, Dionne Joanna C, Holbrook Anne, Xenodemetropoulos Ted, Siegal Deborah M
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Department of Medicine, University of Toronto, Toronto, ON, Canada.
J Thromb Haemost. 2021 Jan;19(1):153-160. doi: 10.1111/jth.15111. Epub 2020 Oct 21.
Essentials The factors influencing anticoagulation management after gastrointestinal bleeding are unclear. Focus groups and a discrete choice experiments survey of health-care providers were conducted. Re-bleeding risk and thrombosis risk were the most important factors influencing decision making. Preference variability exists with a minority most sensitive to the anticoagulation indication. ABSTRACT: Background Oral anticoagulants (OACs) are permanently discontinued in up to 50% of patients after gastrointestinal (GI) bleeding despite evidence of benefit to restarting. Objectives We aimed to identify factors influencing health-care provider decision making regarding resuming OAC after GI bleeding and to identify preference groups. Patients/Methods We conducted focus group discussions (FGDs) with health-care providers. Themes identified and ranked through a dot voting exercise became the attributes for a discrete choice experiment survey of health-care providers developed using Sawtooth (Sawtooth Software, Provo, UT, USA). Hierarchical Bayes analysis was used to estimate preference coefficients (utilities) for each attribute. Preference groups were identified using latent class analysis. Results We conducted four FGDs involving 29 participants. The five most important factors identified in the FGDs were included in the survey. There were 250 survey respondents (mean age 45 years, 53% male). The most important factor was re-bleeding risk followed by thrombosis risk, index bleed severity, indication for OAC, and patient characteristics. Two preference groups were identified, a majority group (87% of respondents) placed the highest utility on re-bleeding risk followed by thrombosis risk, while a minority group (13% of respondents) placed the highest utility on OAC indication. Conclusions Overall, the most important factor influencing provider decision making was re-bleeding risk followed closely by thrombosis risk, although the indication for OAC was most important for a minority of respondents. This highlights variability among providers in an area lacking high-quality data to guide practice. Further research is needed to determine absolute rates of outcomes and patient values and preferences.
要点 胃肠道出血后影响抗凝管理的因素尚不清楚。我们开展了焦点小组讨论以及针对医疗服务提供者的离散选择实验调查。再出血风险和血栓形成风险是影响决策的最重要因素。存在偏好差异，少数人对抗凝指征最为敏感。摘要：背景 尽管有证据表明重新启用口服抗凝剂（OAC）有益，但在胃肠道（GI）出血后，高达50%的患者永久性停用了OAC。目的 我们旨在确定影响医疗服务提供者关于胃肠道出血后恢复使用OAC决策的因素，并确定偏好群体。患者/方法 我们与医疗服务提供者进行了焦点小组讨论（FGD）。通过点投票练习确定并排序的主题成为使用Sawtooth（Sawtooth Software，美国犹他州普罗沃）开发的针对医疗服务提供者的离散选择实验调查的属性。使用分层贝叶斯分析来估计每个属性的偏好系数（效用）。使用潜在类别分析确定偏好群体。结果 我们进行了4次FGD，涉及29名参与者。FGD中确定的5个最重要因素被纳入调查。有250名调查受访者（平均年龄45岁，53%为男性）。最重要的因素是再出血风险，其次是血栓形成风险、首次出血严重程度、OAC指征和患者特征。确定了两个偏好群体，一个多数群体（87%的受访者）将最高效用置于再出血风险，其次是血栓形成风险，而一个少数群体（13%的受访者）将最高效用置于OAC指征。结论 总体而言，影响提供者决策的最重要因素是再出血风险，其次是血栓形成风险，尽管OAC指征对少数受访者最为重要。这凸显了在缺乏高质量数据指导实践的领域中提供者之间的差异。需要进一步研究以确定结局的绝对发生率以及患者的价值观和偏好。
