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Benjamin EJ, Thomas KL, Go AS, Desvigne-Nickens P, Albert CM, Alonso A, Chamberlain AM, Essien UR, Hernandez I, Hills MT, Kershaw KN, Levy PD, Magnani JW, Matlock DD, O'Brien EC, Rodriguez CJ, Russo AM, Soliman EZ, Cooper LS, Al-Khatib SM. Transforming Atrial Fibrillation Research to Integrate Social Determinants of Health: A National Heart, Lung, and Blood Institute Workshop Report. JAMA Cardiol 2023; 8:182-191. [PMID: 36478155 PMCID: PMC10993288 DOI: 10.1001/jamacardio.2022.4091] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Only modest attention has been paid to the contributions of social determinants of health to atrial fibrillation (AF) risk factors, diagnosis, symptoms, management, and outcomes. The diagnosis of AF provides unique challenges exacerbated by the arrhythmia's often paroxysmal nature and individuals' disparate access to health care and technologies that facilitate detection. Social determinants of health affect access to care and management decisions for AF, increasing the likelihood of adverse outcomes among individuals who experience systemic disadvantages. Developing effective approaches to address modifiable social determinants of health requires research to eliminate the substantive inequities in health care delivery and outcomes in AF. Observations The National Heart, Lung, and Blood Institute convened an expert panel to identify major knowledge gaps and research opportunities in the field of social determinants of AF. The workshop addressed the following social determinants: (1) socioeconomic status and access to care; (2) health literacy; (3) race, ethnicity, and racism; (4) sex and gender; (5) shared decision-making in systemically disadvantaged populations; and (6) place, including rurality, neighborhood, and community. Many individuals with AF have multiple adverse social determinants, which may cluster in the individual and in systemically disadvantaged places (eg, rural locations, urban neighborhoods). Cumulative disadvantages may accumulate over the life course and contribute to inequities in the diagnosis, management, and outcomes in AF. Conclusions and Relevance Workshop participants identified multiple critical research questions and approaches to catalyze social determinants of health research that address the distinctive aspects of AF. The long-term aspiration of this work is to eradicate the substantive inequities in AF diagnosis, management, and outcomes across populations.
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Affiliation(s)
- Emelia J Benjamin
- Cardiovascular Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Kevin L Thomas
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Medicine, Stanford University, Stanford, California
- Department of Medicine, University of California, San Francisco
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Christine M Albert
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Alanna M Chamberlain
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Utibe R Essien
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Inmaculada Hernandez
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego
| | | | - Kiarri N Kershaw
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Phillip D Levy
- Department of Emergency Medicine and Integrated Biosciences Center, Wayne State University, Detroit, Michigan
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel D Matlock
- Division of Geriatrics, University of Colorado, Anschutz Medical Campus, Aurora
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Carlos J Rodriguez
- Division of Cardiovascular Medicine and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, New York
| | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, New Jersey
| | - Elsayed Z Soliman
- Section on Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lawton S Cooper
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Sana M Al-Khatib
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Noseworthy PA, Branda ME, Kunneman M, Hargraves IG, Sivly AL, Brito JP, Burnett B, Zeballos-Palacios C, Linzer M, Suzuki T, Lee AT, Gorr H, Jackson EA, Hess E, Brand-McCarthy SR, Shah ND, Montori VM. Effect of Shared Decision-Making for Stroke Prevention on Treatment Adherence and Safety Outcomes in Patients With Atrial Fibrillation: A Randomized Clinical Trial. J Am Heart Assoc 2022; 11:e023048. [PMID: 35023356 PMCID: PMC9238511 DOI: 10.1161/jaha.121.023048] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Guidelines promote shared decision-making (SDM) for anticoagulation in patients with atrial fibrillation. We recently showed that adding a within-encounter SDM tool to usual care (UC) increases patient involvement in decision-making and clinician satisfaction, without affecting encounter length. We aimed to estimate the extent to which use of an SDM tool changed adherence to the decided care plan and clinical safety end points. Methods and Results We conducted a multicenter, encounter-level, randomized trial assessing the efficacy of UC with versus without an SDM conversation tool for use during the clinical encounter (Anticoagulation Choice) in patients with nonvalvular atrial fibrillation considering starting or reviewing anticoagulation treatment. We conducted a chart and pharmacy review, blinded to randomization status, at 10 months after enrollment to assess primary adherence (proportion of patients who were prescribed an anticoagulant who filled their first prescription) and secondary adherence (estimated using the proportion of days for which treatment was supplied and filled for direct oral anticoagulant, and as time in therapeutic range for warfarin). We also noted any strokes, transient ischemic attacks, major bleeding, or deaths as safety end points. We enrolled 922 evaluable patient encounters (Anticoagulation Choice=463, and UC=459), of which 814 (88%) had pharmacy and clinical follow-up. We found no differences between arms in either primary adherence (78% of patients in the SDM arm filled their first prescription versus 81% in UC arm) or secondary adherence to anticoagulation (percentage days covered of the direct oral anticoagulant was 74.1% in SDM versus 71.6% in UC; time in therapeutic range for warfarin was 66.6% in SDM versus 64.4% in UC). Safety outcomes, mostly bleeds, occurred in 13% of participants in the SDM arm and 14% in the UC arm. Conclusions In this large, randomized trial comparing UC with a tool to promote SDM against UC alone, we found no significant differences between arms in primary or secondary adherence to anticoagulation or in clinical safety outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: clinicaltrials.gov. Identifier: NCT02905032.
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Affiliation(s)
- Peter A Noseworthy
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN.,Heart Rhythm Services Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Megan E Branda
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN.,Division of Biomedical Statistics and Informatics Department of Health Sciences Research Mayo Clinic Rochester MN.,Department of Biostatistics and Informatics Colorado School of Public Health University of Colorado-Denver Anschutz Medical Campus Aurora CO
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN.,Biomedical Data Sciences Leiden University Medical Center Leiden the Netherlands
| | - Ian G Hargraves
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN
| | - Angela L Sivly
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN
| | - Juan P Brito
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation ServicesPark Nicollet Health Services St Louis Park MN
| | | | - Mark Linzer
- Department of Medicine Hennepin Healthcare, and the University of Minnesota Minneapolis MN
| | - Takeki Suzuki
- Department of Medicine Krannert Institute of CardiologyIndiana University Indianapolis IN
| | - Alexander T Lee
- Division of Biomedical Statistics and Informatics Department of Health Sciences Research Mayo Clinic Rochester MN
| | - Haeshik Gorr
- Department of Medicine Hennepin Healthcare, and the University of Minnesota Minneapolis MN
| | - Elizabeth A Jackson
- Division of Cardiovascular Disease Department of Internal Medicine University of Alabama at Birmingham Birmingham AL
| | - Erik Hess
- Department of Emergency Medicine for Vanderbilt University Medical Center Nashville TN
| | - Sarah R Brand-McCarthy
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN.,Department of Psychiatry and Psychology Mayo Clinic Rochester MN
| | - Nilay D Shah
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN
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Schott SL, Berkowitz J, Dodge SE, Petersen CL, Saunders CH, Sobti NK, Xu K, Coylewright M. Personalized, Electronic Health Record-Integrated Decision Aid for Stroke Prevention in Atrial Fibrillation: A Small Cluster Randomized Trial and Qualitative Analysis of Efficacy and Acceptability. Circ Cardiovasc Qual Outcomes 2021; 14:e007329. [PMID: 34107740 DOI: 10.1161/circoutcomes.120.007329] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Shared decision-making in cardiology is increasingly recommended to improve patient-centeredness of care. Decision aids can improve patient knowledge and decisional quality but are infrequently used in real-world practice. This mixed-methods study tests the efficacy and acceptability of a decision aid integrated into the electronic health record (Integrated Decision Aid [IDeA]) and delivered by clinicians for patients with atrial fibrillation considering options to reduce stroke risk. We aimed to determine whether the IDeA improves patient knowledge, reduces decisional conflict, and is seen as acceptable by clinicians and patients. METHODS A small cluster randomized trial included 6 cardiovascular clinicians and 66 patients randomized either to the IDeA (HealthDecision) or usual care (clinician discretion) during a clinical encounter when stroke prevention treatment options were discussed. The primary outcome was patient knowledge of personalized stroke risk. Exploratory outcomes included decisional conflict, values concordance, trust, the presence of a shared decision-making process, and patient knowledge related to time spent using the IDeA. Additionally, we conducted semistructured interviews with clinicians and patients who used the IDeA were conducted to assess acceptability and predictions of future use. RESULTS The IDeA significantly increased patients' knowledge of their stroke risk (odds ratio, 3.88 [95% CI, 1.39-10.78]; P<0.01]). Patients had less uncertainty about their final decision (P=0.04). There were no significant differences in values concordance, trust in clinician or shared decision-making. Despite training, each clinician used the IDeA differently. Qualitative analysis revealed patients prefer using the IDeA earlier in their diagnosis. Clinicians were satisfied with the IDeA, yet varied in the contexts in which they planned to use it in the future. CONCLUSIONS Using an Integrated Decision Aid, or IDeA, increases patient knowledge and lessens uncertainty for decision-making around stroke prevention in atrial fibrillation. Qualitative data provide insight into potential implementation strategies in real-world practice.
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Affiliation(s)
- Stacey L Schott
- Division of Cardiology, Johns Hopkins University School of Medicine (S.L.S.)
| | - Julia Berkowitz
- Geisel School of Medicine at Dartmouth, Hanover, NH (J.B.).,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.)
| | - Shayne E Dodge
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (S.E.D., K.X., M.C.)
| | - Curtis L Petersen
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.)
| | - Catherine H Saunders
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.)
| | - Navjot Kaur Sobti
- Division of Cardiology, Department of Medicine, New York Presbyterian Hospital, Weill Cornell Medicine (N.K.)
| | - Keren Xu
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (S.E.D., K.X., M.C.)
| | - Megan Coylewright
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.).,Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (S.E.D., K.X., M.C.)
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