Improving Outcomes in Atrial Fibrillation Through Patient-Centered Decision Making

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Project Summary Dr. Martinez is a junior faculty member at the Medicine Institute Center for Value-Based Care Research and Associate Staff in the Department of Internal Medicine at the Cleveland Clinic in Cleveland, OH. The goal of this career development award is to provide training in administrative data analysis, risk modeling, and qualitative research methods to examine variation in evidence-based anticoagulation among patients with atrial fibrillation, and to identify strategies to improve outcomes in atrial fibrillation through patient-centered decision making. Atrial fibrillation is the most common cardiac rhythm disorder and is associated with a five-fold increased risk of stroke. Treatment with anticoagulation can reduce stroke risk by up to 60%, yet these drugs are widely underutilized. Anticoagulation poses a risk of bleeding, which must be weighed against the predicted benefit of stroke reduction. However, physicians and patients value the tradeoffs associated with anticoagulation differently. Patients prioritize avoiding disabling strokes, while physicians are wary of causing bleeds. Physicians often overestimate individual patients’ bleeding risk, thereby failing to prescribe anticoagulation to patients likely to benefit. Risk prediction tools can help physicians make evidence-based anticoagulation decisions, but use of these tools is inconsistent. Patient preferences for the tradeoffs associated with anticoagulation vary, but are rarely assessed. Given patients’ higher valuation of stroke reduction, improved patient-centered decision making may increase the uptake of anticoagulation among patients likely to benefit. In this career development award, Dr. Martinez proposes four phases of investigation, and in so doing will acquire new skills and competencies critical to achieving her goal of becoming an expert in patient-centered decision making for anticoagulation. In Aim 1, Dr. Martinez will use a decision analytic model to examine optimal versus actual anticoagulation prescribing in a large integrated health system. In Aim 2, she will evaluate the nature of patient and physician communication regarding anticoagulation decisions, with a particular emphasis on how physicians present anticoagulation risks and benefits. Because a key barrier to optimal prescribing is physician over-valuation of bleeding risk, Aim 3 will be a pilot study to evaluate the impact of a pharmacist-led decision intervention on improving evidence-based and patient-centered anticoagulation decision making. Finally, in Aim 4, Dr. Martinez will convene patient focus groups and conduct physician interviews to identify specific opportunities to improve patient-centered decision making for anticoagulation. In addition to advanced training through formal coursework, this career development award is supported by an exceptional mentoring team, including nationally-recognized experts in risk modeling and patient-centered outcomes research. The combination of formal training and mentored research outlined in this application is specifically designed to ensure Dr. Martinez emerges from this award as an independent investigator and an expert in patient-centered decision making in atrial fibrillation.