Abstract P61: Weighing More than the Risks: Cardiologists' Prescription of Warfarin for Atrial Fibrillation Patients

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Linda S Garavalia ◽  
Brian J Garavalia ◽  
Teresa Simon ◽  
William Daniel ◽  
Carole Decker
Keyword(s):  
Atrial Fibrillation ◽  
Decision Making ◽  
Treatment Guidelines ◽  
Decision Making Process ◽  
Cultural Issues ◽  
Urban Hospital ◽  
Increased Risk ◽  
Clinical Risks ◽  
Drug And Alcohol ◽  
Depth Interviews

Introduction: Prior research indicates underprescription of warfarin to reduce cardioembolism for eligible atrial fibrillation (AF) patients. Physicians' reluctance to prescribe warfarin for AF patients may be due to perceived increased risk of bleeding or underestimation of stroke risk. However, other factors may influence decisions for warfarin treatment. The purpose of the present study was to develop an in-depth understanding of the cardiologist's decision making process for warfarin anticoagulation and the management of AF. Methods: Qualitative in-depth interviews were conducted with 16 (14 male) cardiologists in a large Midwestern cardiology practice affiliated with an urban hospital. Interviews ranged from 15-35 minutes, culminating in nearly 200 pages of transcripts, and took place in person (n=6) at the hospital or over the telephone (n=10). On average, participants had 13 years of experience in treating patients and all had experience with AF patients who had excessive bleeds and/or strokes within the past 12 months. Interviews were conducted until thematic saturation occurred. Results: Descriptive content analysis found that cardiologists reported consideration of a range of clinical factors: rate and rhythm control, CHADS 2 score, patient co-morbidities, and other prescribed medications in their decision to aggressively treat according to accepted AF treatment guidelines. Additionally, their decision also considered more subjective factors such as the likelihood a patient would comply with a complex therapy and knowledge of patients' drug and alcohol use. “You have to risk profile them individually and go from there” was a recurrent observation. Conclusions: The decision making process used by cardiologists in determining warfarin anticoagulation in the treatment of AF is complex. The cardiologist considers a range of factors when prescribing warfarin beyond the clinical risks including more subjective lifestyle and cultural issues. When these other unmeasurable factors, such as the burden of treatment and lifestyle, are entered into the equation by cardiologists, anticoagulation may be less appealing, regardless of actual clinical risk.

scholarly journals Exploring patient–provider decision-making for use of anticoagulation for stroke prevention in atrial fibrillation: Results of the INFORM-AF study

2018 ◽  
Vol 18 (4) ◽  
pp. 280-288 ◽  
Author(s):  
Sean D Pokorney ◽  
Diane Bloom ◽  
Christopher B Granger ◽  
Kevin L Thomas ◽  
Sana M Al-Khatib ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Decision Making ◽  
Stroke Prevention ◽  
Decision Aids ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Decisional Conflict ◽  
Increased Risk ◽  
Outpatient Settings ◽  
Depth Interviews

Background: Atrial fibrillation is associated with stroke, yet approximately 50% of patients are not treated with guideline-directed oral anticoagulants (OACs). Aims: Given that the etiology of this gap in care is not well understood, we explored decision-making by patients and physicians regarding OAC use for stroke prevention in atrial fibrillation. Methods and results: We conducted a descriptive qualitative study among providers ( N=28) and their patients with atrial fibrillation for whom OACs were indicated ( N=25). We used purposive sampling across three outpatient settings in which atrial fibrillation patients are commonly managed: primary care ( n=14), geriatrics ( n=10), and cardiology ( n=4). Eligible patients were stratified by those prescribed OAC ( n=13) and not prescribed OAC ( n=12). Semi-structured, in-depth interviews assessed decision-making regarding risk and OAC use. Classical content analysis was used to code narratives and identify themes. Results among patients consisted of the overarching theme of trust in provider recommendations. Sub-themes included: awareness of increased risk of stroke with atrial fibrillation; willingness to accept medications recommended by their physician; and low demand for explanatory decision aids. Among physicians, the overarching theme was decisional conflict regarding the balance between stroke and bleeding risk, and the optimal medication to prescribe. Subthemes included: absence of decision aids for communication; and misperceptions around the assessment and management of stroke risk with atrial fibrillation. Conclusions: Patient involvement in decision-making around OAC use did not occur in this study of patients with atrial fibrillation. Improved access to decision aids may increase patient engagement in the decision-making process of OAC use for stroke prevention.

Engaging older people in decisions about their healthcare: the case for shared decision making

2012 ◽  
Vol 22 (2) ◽  
pp. 99-107 ◽  
Author(s):  
Joanne Lally ◽  
Ellen Tullo
Keyword(s):  
Atrial Fibrillation ◽  
Decision Making ◽  
Clinical Practice ◽  
Healthcare Professional ◽  
Older People ◽  
Shared Decision Making ◽  
Clinical Condition ◽  
Decision Making Process ◽  
Shared Decision ◽  
Risks And Benefits

SummaryShared decision making in clinical practice involves both the healthcare professional, an expert in the clinical condition and the patient who is an expert in what is important to them. A consultation involving shared decision making enables an examination of the options available, consideration of the risks and benefits whilst incorporating the values of the patient into the decision making process. A decision is aimed at, which is both clinically appropriate and is congruent with the patient's values.Older people have been shown to value involvement, to varying degrees, in decisions about their care and treatment. The case of atrial fibrillation shows the opportunities for, and benefits of, sharing with older people decision making about their healthcare.

scholarly journals Indigenous Collaborative Governance: An Understanding of Decision-Making Process at Desa Adat in Bali, Indonesia

2020 ◽  
Vol 4 (2) ◽  
pp. 119
Author(s):  
Md Putri Wiyantari Sutaryantha ◽  
Bevaola Kusumasari
Keyword(s):  
Decision Making ◽  
Conceptual Framework ◽  
Public Administration ◽  
Local Governance ◽  
Practical Implication ◽  
Collaborative Governance ◽  
Decision Making Process ◽  
Common Goal ◽  
Depth Interviews

The decision-making process that took place at desa adat (indigenous village) involved many actors and stakeholders from various elements of the community, to achieve a common goal. This research highlights the linkages of indigenous collaborative governance among actors involved in the decision-making process at Balinese Desa Adat, Indonesia. This research has, thus, discovered how indigenous collaborative governance was linked to the decision-making process and linked to the implementation of local governance, especially in the implementation of Adat in Bali Province. This study emphasizes the extensive use of public administration literature about collaborative governance and the decision-making process. Additionally, in-depth interviews and live experience in desa adat were conducted, as it is aimed to explore and understand more about the case. The result provided aligned with the conceptual framework because all of the actual implementation of the decision-making process at Desa Adat Peliatan met the criteria or indicators of collaborative governance. It showed that there was an involvement of indigenous collaborative governance in the process of decision-making at the desa adat level. The practical implication, in this case, is that collaboration matters in the decision-making process involving various elements of society with diverse interests.

scholarly journals Understanding the barriers to using oral anticoagulants among long-term aspirin users with atrial fibrillation – A qualitative study

2020 ◽  
Author(s):  
Vanessa WS Ng ◽  
Chung-Wah Siu ◽  
Patrick KC Chiu ◽  
Carolyn PL Kng ◽  
Elizabeth Jamieson ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Decision Making ◽  
Stroke Prevention ◽  
Treatment Guidelines ◽  
Oral Anticoagulants ◽  
Structured Interview ◽  
Bleeding Complications ◽  
Suitable Alternative ◽  
Prevention Therapy

Abstract Background: Despite international treatment guidelines currently advocating oral anticoagulants (OACs) as the only appropriate stroke prevention therapy for patients with atrial fibrillation (AF) and evidence that OACs can greatly reduce the risk of stroke with similar risk of bleeding compared with aspirin, the underuse of OACs in patients with AF is common globally, especially in Asia. This study aimed to identify the barriers to prescribing and using OACs among long-term aspirin users with AF.Method: Face-to-face interviews were conducted with fourteen eligible patients with AF using a semi-structured interview guide. The interview recordings were transcribed verbatim and data was analyzed according to the principles of thematic analysis.Results: Five themes were developed: awareness of AF symptoms and diagnosis; knowledge and understanding of AF and stroke prevention therapy; role of decision-making in prescribing; willingness to switch from aspirin to OACs; and impact of OAC regimen on daily living. The majority of the patients were not aware of the symptoms and diagnosis of AF and only had a vague understanding of the illness and stroke prevention therapy, leading to their minimal involvement in decisions relating to their treatment. Some patients and their caregivers were particularly concerned about the bleeding complications from OACs and perceived aspirin to be a suitable alternative as they find the adverse effects from aspirin manageable and so preferred to remain on aspirin if switching to OACs was not compulsory. Lastly, the lifestyle modifications required when using warfarin, e.g. alternative dosing regimen, diet restriction, were seen as barriers to some patients and caregivers.Conclusion: The findings revealed patients’ knowledge gap in AF management which may be targeted using educational interventions to improve patients’ understanding of AF and its management and hence encourage active participation in the decision-making of their treatment in the future.

scholarly journals Understanding the Barriers to Using Oral Anticoagulants Among Long-Term Aspirin Users With Atrial Fibrillation – A Qualitative Study

2020 ◽  
Author(s):  
Vanessa WS Ng ◽  
Chung-Wah Siu ◽  
Patrick KC Chiu ◽  
Carolyn PL Kng ◽  
Elizabeth Jamieson ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Decision Making ◽  
Stroke Prevention ◽  
Treatment Guidelines ◽  
Oral Anticoagulants ◽  
Structured Interview ◽  
Bleeding Complications ◽  
Suitable Alternative ◽  
Prevention Therapy

Abstract Background: Despite international treatment guidelines currently advocating oral anticoagulants (OACs) as the only appropriate stroke prevention therapy for patients with atrial fibrillation (AF) and evidence that OACs can greatly reduce the risk of stroke with similar risk of bleeding compared with aspirin, the underuse of OACs in patients with AF is common globally, especially in Asia. This study aimed to identify the barriers to prescribing and using OACs among long-term aspirin users with AF.Method: Face-to-face interviews were conducted with fourteen eligible patients with AF using a semi-structured interview guide. The interview recordings were transcribed verbatim and data was analyzed according to the principles of thematic analysis.Results: Five themes were developed: awareness of AF symptoms and diagnosis; knowledge and understanding of AF and stroke prevention therapy; role of decision-making in prescribing; willingness to switch from aspirin to OACs; and impact of OAC regimen on daily living. The majority of the patients were not aware of the symptoms and diagnosis of AF and only had a vague understanding of the illness and stroke prevention therapy, leading to their minimal involvement in decisions relating to their treatment. Some patients and their caregivers were particularly concerned about the bleeding complications from OACs and perceived aspirin to be a suitable alternative as they find the adverse effects from aspirin manageable and so preferred to remain on aspirin if switching to OACs was not compulsory. Lastly, the lifestyle modifications required when using warfarin, e.g. alternative dosing regimen, diet restriction, were seen as barriers to some patients and caregivers. Conclusion: The findings revealed patients’ knowledge gap in AF management which may be targeted using educational interventions to improve patients’ understanding of AF and its management and hence encourage active participation in the decision-making of their treatment in the future.

scholarly journals “Silent Voices”: A Description of Views and Attitudes of Health Professionals towards Reproduction by HIV Positive People

2014 ◽  
Vol 2014 ◽  
pp. 1-6
Author(s):  
Vezumuzi Ndlovu
Keyword(s):  
Decision Making ◽  
Health Professionals ◽  
Opportunistic Infections ◽  
Negative Attitude ◽  
Hiv Positive ◽  
Decision Making Process ◽  
Depth Interviews ◽  
Hiv Aids

Objective. The role of health professionals in the decision making process of patients is usually heard or seen from the perspective of the patients. This paper gives the usually silent and invisible health professionals voice and visibility. It describes their views and attitudes towards reproduction by couples who are HIV positive and attempts to understand their perspectives. Methods. In-depth interviews were conducted with twelve health professionals at an opportunistic infections clinic. Transcribed interviews were analysed using the grounded approach to identify patterns and themes concerning views and attitudes of health professionals towards reproduction by HIV positive people. Results. The study found that most health professionals generally had a negative attitude towards childbearing by HIV positive couples. Their views and approaches on the issue were based mainly on biomedical considerations. The main discourses on childbearing that emerged from the study were the conditional choice, the antichildbearing, and the prorights. Conclusion. Most of the health professionals interviewed tend to take a generally negative stance towards reproduction by people with HIV/AIDS. There is a need for a clear set of guidelines for health professionals (HPs) on how to deal with HIV positive people who may desire to reproduce.

scholarly journals ANALISIS PENGAMBILAN KEPUTUSAN UNTUK TINDAKAN SECTIO CAESAREA PADA IBU HAMIL DI RUMAH SAKIT SYAFIRA PEKANBARU

2021 ◽  
Vol 1 (2) ◽  
pp. 516-524
Author(s):  
Puji Astuti ◽  
Aldiga Rienarti Abidin ◽  
Ahmad Satria Efendi
Keyword(s):  
Decision Making ◽  
Socioeconomic Status ◽  
Pregnant Women ◽  
Descriptive Study ◽  
Qualitative Approach ◽  
Sectio Caesarea ◽  
Decision Making Process ◽  
Collection Method ◽  
Depth Interviews

Setiap orang atau pasien dalam pengambilan keputusan untuk melakukan tindakan Sectio Caesarea tentu berdeda-beda, banyak alasan yang melatar belakangi keputusan tersebut dimulai dari indikasi media maupun tanpa indikasi medis sekalipun. Secara umum pengambilan keputusan merupakan pendekatan yang digunakan dalam proses pengambilan keputusan atau proses memilih tindakan sebagai cara pemecahan masalah. Agar individu mecapai hasil yang maksimal maka proses pengambilan keputusan harus rasional. Adapun jumlah ibu hamil yang memutuskan untuk melakukan tindakan sectio Caesarea Di Rumah Sakit Syafira tahun 2017 sebanyak 560, tahun 2018 sebanyak 1415, dan tahun 2019 sebanyak 1694. Penelitian ini bertujuan untuk mengetahui peran Pengetahuan, Sosial Ekonomi, Estetika dan Keluarga. Jenis penelitian ini adalah penelitian deskriptif dengan pendekatan kualitatif. Lokasi dan waktu penelitian adalah di Rumah Sakit Syafira Pekanbaru pada Bulan Januari sampai Juli 2020. Subjek penelitian ini adalah Ibu Hamil dan Dokter Spesialis Obgyn yang berjumlah 6 Informan. Metode pengambilan data diperoleh dari hasil wawancara mendalam. Berdasarkan penelitian ini diperoleh kesimpulan bahwa Ibu Hamil yang memutuskan untuk melakukan tindakan Sectio Caesarea memiliki pengetahuan yang sangat baik, Memiliki status Sosial Ekonomi yang cukup tinggi, Estetika menjadi salah satu aspek yang dipertimbangkan ibu hamil terhadap pengambilan keputusan tindakan Sectio Caesarea, dan persetujuan keluarga merupakan aspek yang paling penting terhadap pengambilan keputusan Tindakan Sectio Caesarea   Every person or patient in deciding to perform the Sectio Caesarea certainly varies, many reasons behind the decision begin with media indication or even without medical indication. In general, decision-making is an approach used in the decision-making process or the process of choosing as a way of problem-solving. For an individual to achieve maximum results, the decision-making process must be rational.  As for the pregnant women who decided to perform Caesarean sectio measures at Syafira Hospital in 2017 was 560, in 2018 as many as 1415, and 1694 in 2019. This study aimed to determine the role of Knowledge, Socioeconomic Economics, Aesthetics, and Family. This type of research is a descriptive study with a qualitative approach.  The location and time of the study were at Pekanbaru Syafira Hospital from January to July 2020. The subjects of this study were Pregnant Women and Obgyn Specialists, totaling 6 Informants. The data collection method was obtained from in-depth interviews.  Based on this study, it was concluded that pregnant women who decide to take action on Caesarean Sectio have very good knowledge and high socioeconomic status. Aesthetics is one of the aspects considered by pregnant women for decision making on Caesarean Sectio action, and family approval is the most important aspect in the decision making of the Caesarean Sectio Action

Using Continuing Medical Education to Promote Shared Decision-Making in Patients Diagnosed with Multiple Myeloma

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2388-2388 ◽  
Author(s):  
Joseph D. Tariman ◽  
Krista Vahey-Marcello ◽  
Carol Ann Huff ◽  
Shaji Kumar ◽  
Angelique Vinther ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Data ◽  
Patient Preferences ◽  
Research Funding ◽  
Treatment Guidelines ◽  
Treatment Decision ◽  
Program Completion ◽  
Decision Making Process ◽  
Shared Decision ◽  
Treatment Decision Making

Abstract Background: The process known as shared decision-making (SDM) helps patients and providers make collaborative health care decisions that consider the available clinical evidence as well as the patient's values and preferences. Engaging the patient's participation in their own medical care is also a pillar of the National Strategy for Quality Improvement in Health Care. However, studies have shown a disconnect between provider perception of their ability to engage patients in their own care and patients' perception that their experiences and preferences are not being considered in the treatment decision-making process. Multiple Myeloma (MM) in particular is a complicated disease to manage with rapidly-evolving data and treatment standards. Treatment guidelines list multiple reasonable treatment options and often do not provide recommendations that are specific for individual patients. Therefore, patient-provider collaboration in treatment decision-making is a particularly important aspect of optimal MM care. This report aims to examine whether continuing medical education (CME) programming can help prepare physicians and other care providers to integrate the latest clinical data as well as the preferences of their patients into the decision-making process. Methods: A CME-certified, video-based educational program was developed and posted on the Clinical Care Options' website on July 16, 2015. The educational program covered SDM concepts along with review of the clinical data and treatment guidelines critical to make optimal treatment decisions for patients with MM. Program participants were asked a series of 3 questions at the start of the program (baseline) and again after program completion (post-education). Data were collected from July 16, 2015 to December 4, 2015 from the 1253 program participants (64% MDs/NPs/PAs, 7% nurses; Figure 1) The impact of the education was calculated and reported as a Cohen's d effect using a matched-pair response comparison (n = 85) from the baseline and post-education questions. Results: At baseline, only 24% of program participants indicated that they would consider patient preferences as part of their decision-making process (Table 1). This significantly increased to 69% (45% improvement; P < .0001) among those that completed the program. The second question exposed program participants to a case vignette that challenged their ability to consider the available data along with patient preferences when making a treatment decision for a patient with MM. At baseline, only 51% of participants chose a treatment course that matched expert recommendations. However, after program completion, 90% chose the optimal answer, representing a 39% improvement (P = .0003). Finally, when asked to explain and manage a treatment-related adverse event, 47% of participants chose the optimal response at baseline and after completing the educational activity, 90% chose the optimal response, representing a 43% improvement (P = .0008). Overall, practical significance testing indicated that the activity had a positive impact on learners, with a Cohen's d effect size calculation of +1.41. In a post activity survey, each participant was asked how many of their patients were likely to benefit from their participation in this activity; the results totaled 7993 patients. Conclusions: These data strongly suggest that CME programs focused on SDM can help prepare providers to consider patient preferences along with the available clinical data to make treatment decisions most likely to result in outcomes that matter most to their patients. Further randomized studies would be warranted to confirm these results. A full review of the study results and recommendations will be presented. This program was supported by independent educational grants from Celgene Corporation, Onyx Pharmaceuticals, and Takeda Pharmaceuticals North America, Inc. Overall Learner Breakdown by Degree and Specialty Overall Learner Breakdown by Degree and Specialty Figure 1 Figure 1. Disclosures Kumar: Skyline: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Research Funding; BMS: Consultancy; Onyx: Consultancy, Research Funding; Kesios: Consultancy; Sanofi: Consultancy, Research Funding; AbbVie: Research Funding; Glycomimetics: Consultancy; Janssen: Consultancy, Research Funding; Millennium: Consultancy, Research Funding; Array BioPharma: Consultancy, Research Funding; Noxxon Pharma: Consultancy, Research Funding.

Decision Making in Naval Aviation: Contextual Factors Influencing Cue and Factor Saliency

2007 ◽  
Vol 51 (4) ◽  
pp. 333-337
Author(s):  
Melissa B. Denihan
Keyword(s):  
Decision Making ◽  
Contextual Factors ◽  
Decision Making Process ◽  
Commercial Aviation ◽  
Decision Method ◽  
Military Aviation ◽  
Two Factors ◽  
Naval Aviators ◽  
The Military ◽  
Depth Interviews

Aeronautical decision making research has focused almost exclusively on general and commercial aviation - with little attention given to the military aviation domain. This research has also been limited by its lack of realism and/or inability to probe aviators for additional clarifying information relevant to their decisions. This study addresses these shortcomings by using in-depth interviews of critical incidents guided by the critical decision method to gain a deeper understanding of the decision making process of experienced naval aviators during novel or unexpected situations in flight. Through this method, two contextual factors in the military aviation environment not previously addressed were identified: (a) the purpose of the flight; and (b) the flight operation environment. These two factors were found to influence each other in addition to impacting the saliency of certain cues and factors for the aviators. Implications for military aviator training and other domains of aviation are discussed.

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