"Part of the Ritual": Exploring Patient and Physician Decision Making Regarding Anticoagulation Use in Obstetric Antiphospholipid Syndrome

Patient and healthcare providers' perspectives on participation in a postpartum pilot trial of venous thromboembolism prophylaxis: a qualitative study

BACKGROUND

There is a need to better understand barriers to recruitment and participation in randomized controlled trials evaluating postpartum thromboprophylaxis, as previous trials had low recruitment and were not feasible.

OBJECTIVES

In a qualitative interview study of a feasibility trial of low-dose aspirin vs placebo for 6 weeks postpartum (pilot PARTUM (Postpartum Aspirin to Reduce Thromboembolism Undue Morbidity) trial), we explored the facilitators and barriers to trial involvement.

METHODS

Patients eligible for the pilot PARTUM trial, including those who declined to join the trial, were invited to participate in a qualitative study. Physicians whose clinical practice included caring for eligible patients were also invited to participate. Thirty-minute semistructured interviews were conducted by 2 researchers. Data were analyzed iteratively using reflexive thematic analysis.

RESULTS

There were 19 patients and 13 physician interviews conducted at a single Canadian center. Nine pilot PARTUM participants and 10 nonparticipants were included. Patients identified the simple study design and familiar oral medication ("Participating as an Easy Ask") and helping other parents ("Helping Other Parents by Providing Knowledge") as facilitators to participate in the trial. Most patients invoked altruism; however, their decision to participate in the trial was influenced by their perception of venous thromboembolism risk ("Venous Thromboembolism Risk Perception and Communication"), their birth experience ("Birth Experience Informs Perspective"), and their opinion of their obstetrical care provider ("Engaging Trusted Care Providers").

CONCLUSION

Trial participation is uniquely affected by experiences during pregnancy, delivery, and new parenthood. Improved understanding of the factors most important to patients will inform the design and conduct of future patient-focused clinical trials.

Patients with antiphospholipid antibodies preferentially seek health information from physicians: a cross-sectional online patient quantitative survey

Little is known about how patients with antiphospholipid syndrome (APS) or antiphospholipid antibodies (aPL) access and trust health information. This research aimed to: describe the sources of information most frequently accessed/trusted by patients with APS/aPL; identify if individuals with APS/aPL perceived their health had been negatively impacted by various sources and document obstacles to accessing health information. Patients meeting Revised Sapporo Criteria for APS or with ≥1 positive aPL on ≥2 occasions were recruited to an online survey regarding their health information use at diagnosis and within 6 months preceding survey completion. McNemar tests were used to compare percentages accessing and trusting each source at diagnosis/currently. 69 patients completed the survey; 88.4% were female, mean age was 47.4 years (SD 15.1). The sources most frequently accessed at diagnosis and currently were rheumatologists/lupus specialists, hematologists, and family physicians, yet patients accessed family physicians (47.8% vs. 31.9%, difference -15.9%, 95% CI - 29.2%, -2.7%) and hematologists (47.8% vs. 31.9%, difference -15.9%, 95% CI -31.1%, -0.8%) less frequently from diagnosis to currently. The most trusted sources at diagnosis and currently were rheumatologists/lupus specialists (82.6% vs. 92.8%) and family physicians (66.7% vs. 68.1%). Few respondents reported negative impacts from advocacy organizations (4.4%), websites (5.8%) and social media (4.4%). 20.3% reported challenges communicating with healthcare providers. Patients with aPL/APS preferentially seek health information from and trust their physicians. However, 20.3% of patients felt communication with healthcare providers was an obstacle to accessing information. There is a need for enhanced patient-physician communication.

Values and preferences towards the use of prophylactic low-molecular-weight heparin during pregnancy: a convergent mixed-methods secondary analysis of data from the decision analysis in shared decision making for thromboprophylaxis during pregnancy (DASH-TOP) study

BACKGROUND

Venous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and mortality, and the use of preventive low-molecular-weight heparin (LMWH) can be challenging. Clinical guidelines recommend eliciting pregnant individuals' preferences towards the use of daily injections of LMWH and discussing the best option through a shared decision-making (SDM) approach. Our aim was to identify individuals' preferences concerning each of the main clinical outcomes, and categorize attributes influencing the use of LMWH during pregnancy.

METHODS

Design: Convergent mixed-methods.

PARTICIPANTS

Pregnant women or those planning a pregnancy with VTE recurrence risk.

INTERVENTION

A SDM intervention about thromboprophylaxis with LMWH in pregnancy.

ANALYSIS

Quantitatively, we report preference scores assigned to each of the health states. Qualitatively, we categorized preference attributes using Burke's pentad of motives framework: act (what needs to be done), scene (patient's context), agent (perspectives and influence of people involved in the decision), agency (aspects of the medication), and purpose (patient's goals). We use mixed-method convergent analysis to report findings using side-by-side comparison of concordance/discordance.

RESULTS

We comprehensively determined preferences for using LMWH by pregnant individuals at risk of VTE: through value elicitation exercises we found that the least valued health state was to experience a pulmonary embolism (PE), followed by major obstetrical bleeding (MOB), deep vein thrombosis (DVT), and using daily injections of LMWH (valued as closest to a 'healthy pregnancy'); through interviews we found that: previous experiences, access to care (scene) and shared decision-making (agent) affected preferences. LMWH's benefits were noted, but substantial drawbacks were described (agency). For participants, the main goal of using LMWH was avoiding any risks in pregnancy (purpose). Side-by-side comparisons revealed concordance and discordance between health states and motives.

CONCLUSIONS

Mixed-methods provide a nuanced understanding of LMWH preferences, by quantifying health states preferences and exploring attributes qualitatively. Incorporating both methods may improve patient-centered care around preference-sensitive decisions in thromboprophylaxis during pregnancy.

A qualitative investigation of the experiences of patients living with antiphospholipid antibodies

OBJECTIVE

Substantial morbidity and mortality affect those with antiphospholipid antibodies (aPLs) and antiphospholipid syndrome (APS), yet patient experiences remain poorly understood. This research investigated patient experiences of aPL/APS diagnosis; effects on daily life; and healthcare and treatment.

METHODS

Patients aged ≥18 years with APS per the Revised Sapporo criteria or with ≥1 positive aPL on ≥2 occasions were recruited from a Canadian multidisciplinary APS clinic to participate in semi-structured in-depth interviews. Interviews were conducted virtually and transcribed verbatim for subsequent thematic analysis.

RESULTS

Twenty-one patients with aPLs/APS participated; 95.2% were female, mean (SD) age was 45.6 (15.0) years. Most (71.4%) had APS, and 71.4% had aPLs/APS with SLE. Results are presented around patient experiences of aPL/APS diagnosis, effects on daily life, and healthcare and treatment. Participants described medical complications/physical symptoms and the healthcare, lifestyle, and emotional impacts experienced around the time of aPLs/APS diagnosis. In addition to the physical and psychosocial impacts of living with aPLs/APS, patients reported modified leisure activities, altered employment trajectories, and positive and negative impacts on relationships. Impacts on family planning were also a critical component of the aPL/APS lived experience; participants shared experiences of miscarriage, other pregnancy complications, and medication-related challenges (e.g., with low-molecular-weight heparin injections). Challenging aspects of aPL/APS healthcare and treatment were also discussed, particularly related to the lifestyle, physical, and emotional burden of medication use. Although a lack of resources was described, participants expressed trust in healthcare providers when making management decisions or when seeking information. Suggestions for resources included the need for additional medication-related information, examples to help contextualize management behaviours, and additional information for those with aPLs/APS without SLE.

CONCLUSION

Patients highlighted how the diverse manifestations of aPLs/APS, accentuated by management-related challenges, impose considerable physical and psychosocial burdens. Results will inform the development of patient resources aligned with patient priorities.

Barriers and facilitators of adherence to low-dose aspirin during pregnancy: A co-produced systematic review and COM-B framework synthesis of qualitative evidence

INTRODUCTION

Women at increased risk of developing pre-eclampsia are advised to take a daily low-dose of aspirin from 12 weeks of pregnancy to reduce their risks. Despite the well-established prophylactic effect of aspirin, adherence to this therapy is low. This systematic review aimed to summarise evidence on the barriers and facilitators of adherence to low-dose aspirin to inform intervention development to support decision making and persistence with aspirin use for pre-eclampsia prevention.

MATERIALS AND METHODS

A systematic review and meta-synthesis of qualitative research was co-produced by representatives from charities, and public, clinical and academic members. Eight electronic databases (MEDLINE, PsycINFO, CINAHL, Web of Science, Scopus, EMBASE, Prospero, OpenGrey), archives of charities and professional organisations were searched (between October and November 2023 and re-run in August 2023) using predefined search terms. Studies containing qualitative components related to barriers and facilitators of adherence to low-dose aspirin during pregnancy were included. Quality assessment was performed using the Critical Appraisal Skills Programme checklist for qualitative research. A combination of the COM-B framework with phases of adherence process as defined by international taxonomy was used as the coding framework. Co-production activities were facilitated by use of 'Zoom' and 'Linoit'.

RESULTS

From a total of 3377 papers identified through our searches, five published studies and one dissertation met our inclusion criteria. Studies were published from 2019 to 2022 covering research conducted in the USA, Canada, UK, Netherlands and Australia. Barriers and facilitators to adherence were mapped to six categories of the COM-B for three phases of adherence: initiation, implementation, and discontinuation. The discontinuation phase of adherence was only mentioned by one author. Four key themes were identified relating to pregnancy: 'Insufficient knowledge', 'Necessity concerns balance', 'Access to medicine', 'Social influences', and 'Lack of Habit'.

CONCLUSIONS

The COM-B framework allowed for detailed mapping of key factors shaping different phases of adherence in behavioural change terms and now provides a solid foundation for the development of a behavioural intervention. Although potential intervention elements could be suggested based on the results of this synthesis, additional co-production work is needed to define elements and plan for the delivery of the future intervention.

TRIAL REGISTRATION

PROSPERO CRD42022359718. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022359718.

How I diagnose and treat antiphospholipid syndrome in pregnancy

ABSTRACT

Antiphospholipid syndrome (APS) is a rare autoimmune disease characterized by arterial, venous, or microvascular thrombosis, pregnancy morbidities, or nonthrombotic manifestations in patients with persistently positive antiphospholipid antibodies. These antibodies bind cellular phospholipids and phospholipid-protein complexes resulting in cellular activation and inflammation that lead to the clinical features of APS. Our evolving understanding of APS has resulted in more specific classification criteria. Patients meeting these criteria should be treated during pregnancy according to current guidelines. Yet, despite treatment, those positive for lupus anticoagulant have at least a 30% likelihood of adverse pregnancy outcomes. Patients with recurrent early miscarriage or fetal death in the absence of preeclampsia or placental insufficiency may not meet current classification criteria for APS. Patients with only low titer anticardiolipin or anti-β(2)-glycoprotein I antibodies or immunoglobulin M isotype antibodies will not meet current classification criteria. In such cases, clinicians should implement management plans that balance potential risks and benefits, some of which involve emotional concerns surrounding the patient's reproductive future. Finally, APS may present in pregnancy or postpartum as a thrombotic microangiopathy, a life-threatening condition that may initially mimic preeclampsia with severe features but requires a very different treatment approach.

Assessment of a venous thromboembolism prophylaxis shared decision-making intervention (DASH-TOP) using the decisional conflict scale: a mixed-method study

BACKGROUND

Venous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and death. The use of low-molecular-weight heparin (LMWH), despite being the standard of care to prevent VTE, comes with some challenges. Shared decision-making (SDM) interventions are recommended to support patients and clinicians in making preference-sensitive decisions. The quality of the SDM process has been widely assessed with the decisional conflict scale (DCS). Our aim is to report participants' perspectives of each of the components of an SDM intervention (DASH-TOP) in relation to the different subscales of the DCS.

METHODS

Design: A convergent, parallel, mixed-methods design.

PARTICIPANTS

The sample consisted of 22 health care professionals, students of an Applied Clinical Research in Health Sciences (ICACS) master program.

INTERVENTION

We randomly divided the participants in three groups: Group 1 received one component (evidence -based information), Group 2 received two components (first component and value elicitation exercises), and Group 3 received all three components (the first two and a decision analysis recommendation) of the SDM intervention.

ANALYSIS

For the quantitative strand, we used a non-parametric test to analyze the differences in the DCS subscales between the three groups. For the qualitative strand, we conducted a content analysis using the decisional conflict domains to deductively categorize the responses.

RESULTS

Groups that received more intervention components experienced less conflict and better decision-making quality, although the differences between groups were not statistically significant. The decision analysis recommendation improved the efficacy with the decision-making process, however there are some challenges when implementing it in clinical practice. The uncertainty subscale showed a high decisional conflict for all three groups; contributing factors included low certainty of the evidence-based information provided and a perceived small effect of the drug to reduce the risk of a VTE event.

CONCLUSIONS

The DASH-TOP intervention reduced decisional conflict in the decision -making process, with decision analysis being the most effective component to improve the quality of the decision. There is a need for more implementation research to improve the delivery of SDM interventions in the clinical encounter.

Women's values and preferences on low-molecular-weight heparin and pregnancy: a mixed-methods systematic review

BACKGROUND

Venous thromboembolism (VTE) in pregnancy is an important cause of maternal morbidity and mortality. Low-molecular-weight heparin (LMWH) is the cornerstone of prophylaxis and treatment of thrombotic events during pregnancy. LMWH has fewer adverse effects than other anticoagulants, does not cross the placenta, and is safe for the fetus. However, the use of LMWH during pregnancy is sensitive to womens' underlying preferences. The objective of this review is to systematically assess women's values and preferences research evidence on this topic.

METHODS

We searched four electronic databases from inception to March 2022, and included studies examining values and preferences of using LMWH among pregnant women at risk of VTE. We followed a convergent integrated mixed-methods design to compare and contrast quantitative outcomes (utility and non-utility measures) and qualitative findings. We assessed the certainty of the values and preferences evidence with the GRADE approach for quantitative findings, and with GRADE-CERqual for qualitative evidence. Results were presented in a conjoint display.

RESULTS

We screened 3,393 references and identified seven eligible studies. The mixed methods analysis resulted in four themes. Datasets confirmed each other in that: 1) the majority of women consider that benefits of treatment outweigh the inconveniences of daily injections; and 2) main concerns around medication are safety and injections administration. Quantitative outcomes expanded on the qualitative findings in that: 3) participants who perceived a higher risk of VTE were more willing to take LMWH. Finally, we found a discrepancy between the datasets around: 4) the amount of information preferred to make the decision; however, qualitative data expanded to clarify that women prefer making informed decisions and receive support from their clinician in their decision-making process.

CONCLUSIONS

We are moderately confident that in the context of pregnancy, using LMWH is preferred by women given its net beneficial balance. Integrating data from different sources of evidence, and representing them in a jointly manner helps to identify patient's values and preferences. Our results may inform clinical practice guidelines and support shared decision-making process in the clinical encounter for the management of VTE in the context of pregnancy.