Design and development of a digital shared decision-making tool for stroke prevention in atrial fibrillation

How is digital technology used to facilitate shared decision-making between healthcare professionals and patients in cardiovascular care? A scoping review

AIMS

To (i) identify characteristics of digital technologies (DTs) used to facilitate shared decision-making (SDM) within the field of cardiovascular care, (ii) examine conceptualizations of SDM underpinning these DTs, and (iii) summarize designs and outcomes of evaluation studies concerning these DTs.

METHODS AND RESULTS

We conducted a scoping review following methodological guidelines by the Joanna Briggs Institute. Ten scientific databases were searched. We selected peer-reviewed articles in cardiovascular care, with SDM and DT in the title and/or abstract published between January 2000 and March 2023. We extracted data on the type of DT, intended user(s), time point and mode of use, purpose, decision topic, underlying SDM model, and designs and outcomes of evaluation studies. Data were analysed descriptively in a narrative synthesis. From 4432 search results, 48 articles reporting on 31 DTs were included. Half of the articles were published after 2018, with most published in 2022. Most DTs are web-based applications for interactive use before and during the encounter between patient and healthcare professional, to convey information on cardiovascular care, calculate personal risk, and/or recommend treatment options. Shared decision-making conceptualizations refer to the International Patient Decision Aid Standards and authors in the field. Thirty-seven evaluation studies report on 31 DTs, with heterogeneous results related to variation in intervention designs, measurement time points, and outcome measures.

CONCLUSION

A recent increase in the reporting of DTs to facilitate SDM in cardiovascular care indicates their potential. This scoping review offers researchers, developers, and clinicians a comprehensive overview of this literature.

REGISTRATION

Open Science Framework: https://doi.org/10.17605/OSF.IO/TRGQ5.

Patient-Selection of a Clinical Trial Primary Outcome: The ENHANCE-AF Outcomes Survey

INTRODUCTION

Before the initiation of the ENHANCE-AF clinical trial, which tested a novel digital shared decision-making tool to guide the use of anticoagulants in stroke prevention for patients with atrial fibrillation, this study aimed to identify the most appropriate, patient-selected primary outcome and to examine whether outcome selection varied by demographic and clinical characteristics.

METHODS

Our cross-sectional survey asked 100 participants with atrial fibrillation to rank two alternative scales based on the scales' ability to reflect their experiences with decision-making for anticoagulation. The Decisional Conflict Scale (DCS), a 16-item scale, measures perceptions of uncertainty in choosing options. The 5-item Decision Regret Scale (DRS) focuses on remorse after a healthcare decision. We included adults with non-valvular AFib and CHA2DS2VASc scores of at least 2 for men and 3 for women. Multivariable logistic regression with backward selection identified characteristics independently associated with scale choice.

RESULTS

The DCS was chosen over the DRS by 77% [95% confidence interval (CI) 68 to 85%] of participants. All subgroups designated a preference for the DCS. Those with higher CHA2DS2VASc scores (≥5, n = 26) selected the DCS 54% of the time compared with 86% of those with lower scores (<5, n = 74; p =  0.002). Multiple logistic regression confirmed a weaker preference for the DCS among those with higher CHA2DS2VASc scores.

CONCLUSIONS

Individuals with atrial fibrillation preferred the DCS over the DRS for measuring their decision-making experiences. As a result of this survey, the DCS was designated as the ENHANCE-AF clinical trial's primary endpoint.

Older rural women's pre-visit planning and involvement in South Australian general practices: A candidacy theory perspective

OBJECTIVE

To explain older rural women's participation in clinical decision-making with GPs and explore factors associated with their pre-visit planning and involvement in treatment processes.

METHODS

A sequential, theory-driven mixed-method study was conducted. Women aged 65 years or above who had visited a GP three months prior were recruited from five rural towns in South Australia through the local Rotary Club. Data collection utilised an 18-item scale and a semi-structured interview guide. Quantitative data were analysed using chi-square tests and multinomial logit models, whereas qualitative data were coded into themes. As applied in the discussion, the candidacy theory provided a framework for further adding meaning to the results.

RESULTS

Seventy-one older rural women completed surveys. Across the domains, including health knowledge, GP visit preparation, participation in discussion, and attitudes towards shared decision-making, most items indicated a moderate level of women's health knowledge and involvement in GP treatments. Multivariate analysis revealed having less than a basic education, not speaking English at home, and being in the youngest-old age group (65-74 years) were positively associated with low levels of pre-visit planning and involvement in GP treatments. Analysis of interviews with 21 women identified three themes: capacity for health planning and preparedness, communication styles and preferences, and accessibility and continuity of care.

CONCLUSION

The findings of this study underscore the urgent need for redesigning GP services. By considering the intersection between behavioural and clinical aspects of older rural women's pre-visit planning and involvement in GP treatment processes in rural South Australia, we can inspire positive change in healthcare delivery.

PRACTICE IMPLICATIONS

Practice Implications: our study provides actionable insights on how and where to intervene to enhance older rural women's capacity to engage in pre-visit planning for successful GP consultations. This knowledge can empower healthcare professionals and policymakers to implement effective strategies.

Development of web- and mobile-based shared decision-making tools in the neurological intensive care unit

In the neurological intensive care unit (neuroICU), patients with severe acute brain injury (SABI) are rendered unable to make their own healthcare decisions. The responsibility of making life-or-death decisions, such as goals of care, is carried by surrogate decision-makers, usually families. In addition to the burden of decision-making, the emotional burden on families is further compounded by prognostication uncertainty, time-pressure for decision-making, and difficulties in understanding and interpreting the patient's values and preferences, ultimately resulting in potential clinician-family communication breakdown. Despite these challenges, there is currently no guidance on how to best approach these difficult decisions. Shared decision-making (SDM) has emerged as the recommended approach to improve clinician-family communication, empowering surrogates to take an active role in decision-making by providing a structured framework for information exchange, deliberation, and treatment decisions. Decision aids (DAs) facilitate SDM by offering balanced, accessible, unbiased information and helping surrogates decide according to patients' values. This review highlights the potential advantage of digital over paper-based DAs, including improved accessibility, interactivity, and personalization, and the integration of emerging technologies to enhance DA effectiveness. Additionally, we review the current digital DAs developed for the neuroICU setting.