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Atrial fibrillation guidelines recommend shared decision-making between patients and clinicians for choosing stroke prevention therapies. While decision aids improve patient’s knowledge and decisional conflicts, there is no decision aid for stroke-prevention strategies in people with atrial fibrillation receiving hemodialysis. We aimed to develop and field test the first decision aid (AFHD-DA) for stroke prevention in atrial fibrillation and hemodialysis.
We conducted a sequential three-phase mixed methods study following the International Patient Decision Aid Standards and the Ottawa Decision Support Framework in two ambulatory hemodialysis centers in Canada. We included adults with atrial fibrillation receiving hemodialysis and clinicians (physicians, pharmacists or nurse practitioners) involved in their care. In phase 1, we conducted one systematic and two rapid reviews and formed the steering committee to pilot the first version of AFHD-DA. In phase 2, we refined the AFHD-DA through four rounds of focus groups and interviews, using a qualitative analysis of transcripts and a descriptive analysis of acceptability and usability scores. In phase 3, we field-tested the decision aid during 16 simulated clinical consultations. We assessed decisional conflict and patient knowledge using before-and-after paired t-tests and compared the proportion of patients with high decisional conflict using McNemar’s test. We used the Ottawa Hospital preparation for decision-making scale and participants’ feedback to evaluate how AFHD-DA facilitated shared decision-making.
The development and rationale of AFHD-DA was described qualitatively. The systematic review of the available evidence on stroke prevention interventions in atrial fibrillation and dialysis will be published separately. We enrolled eight patients and ten clinicians in phase 2. The predefined usability and acceptability thresholds (68% and 66%, respectively) were reached. Theme saturation was achieved in the fourth round of focus groups and interviews. Four major themes emerged: acceptability, usability, decision-making process and scientific value of the decision aid. Sixteen patients and ten clinicians field-tested the decision aid in phase 3. AFHD-DA significantly decreased the mean decisional conflict score from 41% to 14% (P<0.001) and the proportion of patients with decisional conflicts from 81% to 19% (P=0.002). It improved the patients’ mean knowledge score from 63% to 77% (P=0.001) and 81% of patients and 90% of clinicians felt highly prepared for decision-making. Clinical consultations lasted on average 21 (standard deviation = 8) minutes. This study’s main limitations were the low quality of the existing literature, the small number of participants and the absence of a control group.
The decision aid facilitated time-efficient shared decision-making between clinicians and patients, improved patients’ knowledge and reduced decisional conflict around selecting a stroke prevention strategy for patients with atrial fibrillation receiving maintenance hemodialysis.