Improving Outcomes in Atrial Fibrillation Through Patient-Centered Decision Making

项目摘要 马丁内斯博士是医学研究所基于价值的护理研究中心的初级教员， 俄亥俄州克利夫兰克利夫兰诊所内科助理工作人员。的目标是 该职业发展奖旨在提供管理数据分析、风险建模和 质化研究方法检验房颤患者循证抗凝的变化 房颤，并通过以患者为中心的决策确定改善房颤预后的策略 制作。房颤是最常见的心脏节律紊乱，与五倍 中风的风险增加。抗凝治疗可以降低高达60%的中风风险，然而这些药物 普遍未得到充分利用。抗凝剂有出血的风险，必须与 中风减少的预期益处。然而，医生和患者重视与以下相关的权衡 抗凝效果不同。患者优先考虑避免致残性中风，而医生则对导致中风持谨慎态度 血流不止。医生经常高估个别病人的出血风险，因此未能开出处方。 抗凝给患者带来的好处很有可能。风险预测工具可以帮助医生以证据为基础 抗凝决定，但这些工具的使用是不一致的。患者对权衡的偏好 与抗凝相关的因素各不相同，但很少被评估。鉴于患者对中风的较高评价 减少，改善以患者为中心的决策可能会增加抗凝治疗的摄入量 患者可能从中受益。在这个职业发展奖中，马丁内斯博士提出了四个阶段的调查， 通过这样做，她将获得新的技能和能力，这对实现她成为专家的目标至关重要 以病人为中心的抗凝决策。在目标1中，马丁内斯博士将使用决策分析模型 检查大型综合卫生系统中最佳抗凝处方与实际抗凝处方的对比。在《目标2》中，她 将评估患者和医生关于抗凝决策的沟通的性质， 特别强调医生如何呈现抗凝的风险和好处。因为一个关键的障碍是 最佳处方是医生高估出血风险，目标3将是一项试点研究，以评估 药师主导的决策干预对改善循证和以患者为中心的影响 抗凝决策。最后，在目标4中，马丁内斯医生将召集患者焦点小组并进行 医生面谈，以确定改善以患者为中心的决策的具体机会 抗凝剂。除了通过正式课程进行高级培训外，这一职业发展奖还 由一支出色的指导团队提供支持，其中包括国家公认的风险建模和 以患者为中心的结果研究。将正规培训和指导性研究结合在一起 应用程序是专门设计的，以确保马丁内斯博士从这个奖项中脱颖而出 研究人员和以患者为中心的房颤决策专家。

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.