Lora Arduser

Developing an Atrial Fibrillation Guideline Support Tool (AFGuST) for shared decision making

Abstract Objective: Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients’ preferences into this decision. Materials and methods: CHA2DS2VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational engine to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy. Results: Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patient-specific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video, were developed through an iterative process with clinicians and patient focus groups. Key limitations: Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy. Conclusions: We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient’s stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.

Integrating Real-Time Clinical Information to Provide Estimates of Net Clinical Benefit of Antithrombotic Therapy for Patients With Atrial Fibrillation

Background—Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS2 or the CHA2DS2VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy. Methods and Results—This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatment and treatment recommended by an Atrial Fibrillation Decision Support Tool. Current treatment was discordant from treatment recommended by the Atrial Fibrillation Decision Support Tool in 931 patients. A clinically significant gain in quality-adjusted life expectancy (defined as ≥0.1 quality-adjusted life-years) was projected in 832 patients. Subgroups were examined. For example, oral anticoagulant therapy was recommended for 188 who currently were receiving no antithrombotic therapy. For the entire cohort, a total of 736 quality-adjusted life-years could be gained were treatment changed to that recommended by the Atrial Fibrillation Decision Support Tool. Conclusions—Use of a decision support tool that integrates patient-specific stroke and bleeding risk could result in significant gains in quality-adjusted life expectancy for a primary care population of patients with atrial fibrillation.

Impact of an Atrial Fibrillation Decision Support Tool on thromboprophylaxis for atrial fibrillation.

BACKGROUND Appropriate thromboprophylaxis for patients with atrial fibrillation (AF) remains a national challenge. METHODS We hypothesized that provision of decision support in the form of an Atrial Fibrillation Decision Support Tool (AFDST) would improve thromboprophylaxis for AF patients. We conducted a cluster randomized trial involving 15 primary care practices and 1,493 adults with nonvalvular AF in an integrated health care system between April 2014 and February 2015. Physicians in the intervention group received patient-level treatment recommendations made by the AFDST. Our primary outcome was the proportion of patients with antithrombotic therapy that was discordant from AFDST recommendation. RESULTS Treatment was discordant in 42% of 801 patients in the intervention group. Physicians reviewed reports for 240 patients. Among these patients, thromboprophylaxis was discordant in 63%, decreasing to 59% 1 year later (P = .02). In nonstratified analyses, changes in discordant care were not significantly different between the intervention group and control groups. In multivariate regression models, assignment to the intervention group resulted in a nonsignificant trend toward decreased discordance (P = .29), and being a patient of a resident physician (P = .02) and a higher HAS-BLED score predicted decreased discordance (P = .03), whereas female gender (P = .01) and a higher CHADSVASc score (P = .10) predicted increased discordance. CONCLUSIONS Among patients whose physicians reviewed recommendations of the decision support tool discordant therapy decreased significantly over 1 year. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy.

Using an Atrial Fibrillation Decision Support Tool for Thromboprophylaxis in Atrial Fibrillation: Effect of Sex and Age

To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment.

Designing a Successful Group-Report Experience

Lisa Gueldenzoph Snyder, PhD, is an associate professor in the School of Business and Economics at North Carolina AT email: lguelden@ncat.edu.

Splitting Women, Producing Biocitizens, and Vilifying Obamacare in the 2012 Presidential Campaign

This article examines the 2012 Republican presidential campaign, exposing the articulation of two incongruous discourses: arguments for increasingly strict regulations on womens reproductive rights and antiregulatory attacks on Obamacare. Drawing on articulation theory and on a Foucauldian understanding of biocitizenship, we argue that womens reproductive and sexual capacities were discursively disarticulated or split from their status as free citizens and rhetorically affiliated with Obamacare as both entities came to be seen as potentially dangerous.

Examining usability in the communication design of health wearables

This panel consists of six case studies that investigate how emerging contexts for use created by health wearables present UX designers with challenges related to agency, surveillance, and health outcomes, as wearables assess the body in new, potentially unforeseen ways.

Remediating Diagnosis: A Familiar Narrative Form or Emerging Digital Genre?

Scholars in the humanities, social sciences, and medicine are paying increasing attention to the genre of illness narratives. Little of this scholarship, however, focuses on online settings. To better understand these online stories and their structures, the author undertakes the analysis of a collection of patient diagnosis vlogs to argue that the characteristics of YouTube and the Internet more generally enable fluctuations or oscillations in these illness vlogs. These fluctuations foster genre emergence online and reflect the experiences of people living with these illnesses in a way discursive genres cannot. Paying attention to these fluctuations can add to our knowledge of the role of medium in genre emergence online and give us a potential mechanism to help explain the emergence, proliferation, and variability of online genres.

Mapping the Terrain: Examining the Conditions for Alignment Between the Rhetoric of Health and Medicine and the Medical Humanities

ABSTRACT This article offers an empirical study of literature in the rhetoric of health and medicine (RHM) and the medical humanities (MH). Article traces the topics, funding mechanisms, research methods, theoretical frameworks, evidence types, audience, discourse arrangement patterns, and action orientation that constitute the scholarship in the sample to offer a landscape of the current state of RHM and the MH. Findings can be leveraged to assess the potential for alignment between these fields for future research.

Impatient patients: a DIY usability approach in diabetes wearable technologies

As wearable medical technologies take on an increasingly prominent role in how health care is delivered, pressure to make the development process for such devices shorter increases. This case study will recount one attempt at a do-it-yourself (DIY) development process and collaborative usability testing. I argue that these efforts can complement traditional usability methods used in the development process of a wearable diabetes technology and provide more immediate access to technologies that can meet the diverse needs of end users. The case involves an open source DIY project developed by parents of children with type 1 diabetes in order to remotely monitor the blood sugar levels of their children.