Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA.
Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA.
Med Decis Making. 2023 Feb;43(2):263-269. doi: 10.1177/0272989X221121350. Epub 2022 Sep 5.
Patients with atrial fibrillation (AF) must decide between warfarin and direct oral anticoagulants (DOACs), a decision involving important tradeoffs. Our objective was to understand whether physicians engage patients in informed decision making for anticoagulants.
We performed an analysis of recorded conversations between physicians and anticoagulation-naïve patients in the Verilogue Point-of-Practice database. We assessed the presence of 7 elements of informed decision making, as well as a discussion of financial costs.
Of 37 encounters with 21 physicians, 92% resulted in a DOAC prescription and 8% resulted in a warfarin prescription. Seventy percent met criteria for discussion of pros and cons, 70% for discussion of the alternatives, 43% presented the decision, 30% included an assessment of patient understanding, 22% included an explanation of the patient's role in decision making, 22% included an assessment of patient preferences, and 19% included a discussion of uncertainty. Two encounters (5%) included all 7 elements and 9 (24%) included none. Physicians discussed treatment costs with patients in 43% of encounters.
We assessed informed decision making in a single encounter. Physicians and patients may have had other discussions that were not captured in our data.
Physicians often presented the alternatives but did not generally engage patients in informed decision making. The high rate of DOAC prescriptions is likely the result of physician preferences, as patient preferences were rarely assessed.
Strategies to support physicians in engaging patients in informed decision making for anticoagulation are needed.
While physicians discussed the alternatives and presented pros and cons with patients, they rarely assessed patient preferences, explained the patient's role in decision making, or addressed uncertainty.The cost of treatment with DOACs versus warfarin was discussed by physicians in less than half of encounters, limiting patients' ability to make informed decisions for anticoagulation.Only 2 encounters (5%) fulfilled all 7 elements of informed decision making.
房颤（AF）患者必须在华法林和直接口服抗凝剂（DOAC）之间做出选择，这是一个涉及重要权衡的决策。我们的目的是了解医生是否让患者参与抗凝药物的知情决策。
我们对 Verilogue 实践点数据库中医生与抗凝治疗初治患者之间的记录对话进行了分析。我们评估了知情决策的 7 个要素的存在情况，以及对财务成本的讨论。
在 21 名医生的 37 次就诊中，92%的患者开了 DOAC 处方，8%的患者开了华法林处方。70%的患者达到了讨论利弊的标准，70%的患者讨论了替代方案，43%的患者提出了决策，30%的患者评估了患者的理解，22%的患者解释了患者在决策中的作用，22%的患者评估了患者的偏好，19%的患者讨论了不确定性。有 2 次就诊（5%）包含了所有 7 个要素，有 9 次就诊（24%）则一个要素都没有。在 43%的就诊中，医生与患者讨论了治疗费用。
我们在单次就诊中评估了知情决策。医生和患者可能进行了其他讨论，但未被我们的数据所捕获。
医生经常向患者提供替代方案，但通常没有让患者参与知情决策。高比例的 DOAC 处方可能是由于医生的偏好，因为很少评估患者的偏好。
需要制定策略来支持医生让患者参与抗凝药物的知情决策。
虽然医生与患者讨论了替代方案并向患者介绍了利弊，但他们很少评估患者的偏好、解释患者在决策中的角色或解决不确定性。只有不到一半的就诊中，医生讨论了 DOAC 与华法林治疗的成本，限制了患者对抗凝治疗做出知情决策的能力。只有 2 次就诊（5%）满足了知情决策的所有 7 个要素。
