This study indicates that use of SDM can help empower patients with AF to make decisions relating to the management of stroke prevention. The findings show that after viewing SDM resources, patients with AF in Taiwan felt less anxiety about their condition and its treatment, in addition to having greater confidence in their healthcare professionals.
These findings are clinically significant as AF has a prevalence of 1.4% of men and 0.7% of women in Taiwan7, with the overall prevalence rate of AF in Taiwan projected to increase to 4.0% by 205012. Additionally, stroke is the third leading cause of death and the most common cause of complex disability in Taiwan13. Evidence suggests that patients are often not aware of the increased risk of stroke associated with AF14; hence, raising patient awareness of the risks associated with AF is important. The current study provides clinically useful insights on how empowering patients through SDM may help in the management of stroke prevention in AF.
The results align with published studies of SDM for stroke prevention in AF, some of which have been shown to produce small improvements in patient knowledge and reductions in decisional conflict15–17. Tools for SDM should be feasible to implement in busy clinical practices15. In the current study, the SDM materials, which comprised a short presentation on AF and its diagnosis and treatment, were introduced in three tertiary medical centers in Taiwan. Participants believed the materials provided sufficient information and were deemed by participants to be beneficial in terms of understanding the disease and its treatment, and in facilitating better communication with, and greater confidence in, healthcare professionals.
A previous international, cross-sectional survey found country-specific differences exist in patients’ perceptions of AF, and preference for involvement in oral anticoagulant treatment decisions. Patients in the United States, Canada, Germany, and those without recent stroke preferred to be involved in oral anticoagulant treatment decisions (either SDM or patient’s choice), while French and Japanese patients and those with recent stroke preferred their doctor to choose14. The current analysis suggests that SDM is an acceptable approach among patients with AF in Taiwan.
With regards to factors influencing NOAC choice or preference, results of the current study are in agreement with previous publications showing that efficacy and avoidance of strokes is a key attribute determining patient choice, followed by safety14,18, and notably, 90% of patients selected dabigatran as their NOAC treatment of choice after reviewing the SDM materials. Results from Stage II suggest that SDM had a positive impact on medication adherence and compliance, as participants who had viewed the SDM materials prior to initiating dabigatran had higher adherence than the control group who had not viewed the SDM materials. The SDM may allow patients to make decisions better aligned with their personal values and preferences, while improving overall AF care. We also believe that increased patient satisfaction after SDM could improve the physician-patient relationship.
Although there were defined criteria for patient enrollment, a potential limitation of this study is selection bias arising from investigator participation in the enrollment of study participants and the determination of their clinical profiles. Recall bias could also not be eliminated entirely, especially in control group. In addition, the study is hospital-based, rather than community-based, and therefore it was limited by potential geographic variables such as environmental exposure. As all participants in this study were recruited from three tertiary healthcare medical centers, this study population may not be representative of the overall cohort of Taiwanese patients with AF who are at risk of stroke. The sample size of current study is relatively small. Female participants in this study tended to have a higher CHA2DS2VASc score than male participants, so potential sex-specific associations in the use of SDM warrants further investigation. We did not extensively evaluate the satisfaction of physicians and its impact on AF care. Despite these limitations, our study is the first to suggest that SDM in stroke prevention in AF may lessen patient anxiety and increase the trust between medical teams and patients. Our findings can be used to base further research in examining optimal timing for SDM to promote mutual respect between patient and physicians. Further large and long-term studies to evaluate the effect of SDM on NOAC safety and AF outcomes could be considered.