Keywords atrial fibrillation - oral anticoagulation - patients' perceptions - patient survey
- stroke knowledge
Introduction
Recent clinical guidelines on the management of atrial fibrillation (AF) advocate
inclusion of patients' preferences in treatment decisions.[1 ]
[2 ]
[3 ]
[4 ] However, global differences exist in the management of AF, and cultural differences
may influence patient's expectations and perceptions of healthcare. Most research
regarding patient's values and preferences in AF patients has been in relation to
antithrombotic therapy.[5 ]
[6 ]
[7 ]
[8 ]
[9 ]
[10 ]
[11 ] However, patient's perspectives vary from study to study and may be related to actual
differences in preferences, the composition of the cohort (patient's age, sex, socioeconomic
status, comorbidities), whether patients are already receiving oral anticoagulation
(OAC), knowledge of AF and stroke, the way in which risk information is presented,
and the manner in which responses are elicited.[8 ]
[9 ]
[10 ]
[12 ]
[13 ]
Generally, AF patients have poor understanding about AF and its trajectory, and a
paucity of knowledge about the increased risk of stroke and benefits/risks of OAC.[8 ]
[9 ]
[12 ]
[14 ]
[15 ]
[16 ]
[17 ] Although a recent prospective survey in eight European countries demonstrated that
among AF patients taking OAC, 90% knew that OAC was “to thin the blood,” only 26%
were aware that OAC increased the risk of all bleeding, including major bleeding.[18 ] Furthermore, patients' individual circumstances, previous experiences, and current
health status will influence their knowledge and help determine their willingness
to take treatments.[8 ]
[12 ]
[19 ] Indeed, a prospective U.S. survey[12 ] found that knowledge of stroke was better among AF patients with previous stroke,
and stroke survivors were more willing to take OAC.
Studies initiated before the non–vitamin K antagonist oral anticoagulant (NOAC) era
have generally demonstrated that patients place greater importance on avoidance of
a stroke rather than bleeding and other OAC-related issues (i.e., regular monitoring,
drug–food–alcohol interactions).[5 ]
[7 ]
[11 ]
[20 ]
[21 ] Since the introduction of the NOACs, there has been renewed interest in the values
and preferences regarding OAC of AF patients. Only a few studies have compared patient's
preferences for vitamin K antagonists (VKAs) and NOACs[6 ]
[22 ]
[23 ] and examined the attributes that patients perceive as important when choosing OAC.[6 ]
[12 ]
[22 ]
[23 ]
[24 ] Three studies[6 ]
[12 ]
[23 ] reported that patients rate stroke prevention as the most important attribute for
OAC, while others rate ease of administration[22 ] and availability of an antidote[24 ] as of highest importance; however, differences in the methodology of these studies
may account for the disparity in the findings. In addition, these studies did not
examine patient's perceptions of AF and stroke, or knowledge about stroke, which may
drive these preferences.
We performed a prospective, international survey to investigate whether country-specific
differences exist in patient's perceptions of AF, concerns about stroke, stroke knowledge,
preferences for OAC treatment decisions, self-reported OAC medication adherence, and
the attributes of OAC affecting treatment choice. We also examined whether AF patients
who experienced a recent stroke differ in their perceptions about AF, stroke, and
OAC treatment compared with AF patients who were free from recent stroke.
Materials and Methods
Study Design
This was an international, prospective, cross-sectional study of AF patients aged
≥18 years, receiving OAC for stroke prevention. Patients with mechanical valves or
scheduled for heart valve surgery were excluded. Patients were recruited from five
countries—United States, Canada, Germany, France, and Japan—through consumer panels,
physician/nurse referral, and patient associations. These countries were chosen as
they already had wide NOAC usage at the time of the survey and were regarded as representative
of key regions (North America, South-East Asia, and Europe). Patients were recruited
depending on their AF status and stratified into three groups according to predefined
quotas: (1) AF with recent stroke (≤6 months, regardless of when AF was diagnosed);
(2) newly diagnosed AF without recent stroke (diagnosed with AF ≤6 months [United
States, Canada, France, Germany], or ≤12 months in Japan); and (3) established AF
without recent stroke (AF diagnosed 7–24 months previously [United States, Canada,
France, Germany], or 1–3 years previously in Japan).
Qualitative interviews were performed with 16 AF patients (6 in Germany, 10 in the
United States) prior to release of the online survey, to test and optimize the readability
of questions and patient information. For the online survey, a total of 517,692 individuals
were contacted, 517,203 of those through country-specific consumer panels (6 or 7
different panels per country). A total of 489 were contacted via phone (all countries)
or face-to-face (France, Japan) from physician/nurse/pharmacist referral. Referral
from patient associations was more common outside of North America; online forums/social
media were employed in Germany and Japan. Of 89,481 individuals who connected to the
online survey, 7,889 eligible AF patients were identified, of which 937 (11.9%) completed
the 30-minute survey in their native language between April and November 2015. The
questionnaire consisted of 22 questions to elicit demographic data (age, sex, country/region,
highest level of education), past medical history, and the outcomes of interest. All
data were collected anonymously and analyzed in an aggregated fashion.
For the current analyses, the outcomes of interest were patient's perceptions of the
seriousness of AF and their concerns about stroke, patient's knowledge about stroke,
self-reported adherence to OAC, patient's preference for involvement in OAC treatment
choice, and attributes of OAC affecting treatment choice by the patient. Assessment
of stroke knowledge is summarized in [Fig. 1 ]. In addition, patients were asked how familiar they were with standardized information
about AF and stroke, but this was separate to the assessment of stroke knowledge.
The modified Rankin's score (mRS) in patients with a recent stroke was self-reported
according to predefined mRS scale descriptors.[25 ]
Fig. 1 Scoring system to categorize patients' level of stroke knowledge (from open-ended
questions).
Sample sizes/quotas were determined according to feasibility estimates and to allow
meaningful comparisons across the three predefined AF groups and countries. Participants
gave informed consent by completing and submitting the online survey. The survey was
conducted in accordance with the principles of the Declaration of Helsinki.
Statistical Analysis
Descriptive statistics are presented as mean and standard deviation (SD) for normally
distributed continuous variables; categorical data are presented as actual count and
percentage. Analyses were conducted by country and separately by AF status at baseline
(AF with recent stroke vs. AF without recent stroke). To examine differences between
countries and between AF groups, means were compared using t -tests and categorical data were compared using chi-squared tests. Since heterogeneity
was present in the data, we used the unequal variances t -test (Welch–Satterthwaite test) to detect differences in means of samples; this test
is robust for analyzing equality of means when the homogeneity assumption is not satisfied.
Data were analyzed using Sawtooth: Lighthouse Studio v9.0.1 and SPSS PASW Statistics,
version 18, with p- values <0.05 considered statistically significant. p -values comparing more than three subgroups relate to data of one group compared with
the data of all other groups together.
Results
In total, 937 AF patients were recruited with an overall mean (SD) age of 54.3 (16.6)
years; 37.1% were female. One-third of patients were from the United States, with
between 15 and 18% recruited from Canada, Japan, France, and Germany. Significantly
more American women and significantly fewer Japanese women were recruited compared
with other countries. Significantly more Americans and Japanese were educated to university/technical
college level. Stroke risk was lower among patients from France and Germany and highest
among patients from Japan ([Table 1 ]).
Table 1
Patient baseline demographic and clinical characteristics overall and by country
Characteristic
Overall (n = 937)
USA (n = 322)
Canada (n = 145)
Japan (n = 139)
France (n = 171)
Germany (n = 160)
Mean (SD) age, y
54.3 (16.6)
56.0 (16.9)[a ]
52.8 (17.4)
59.1 (11.8)[b ]
49.6 (18.8)[b ]
53.0 (14.6)
≥65 y
309 (33.0)
128 (39.8)[b ]
45 (31.0)
48 (34.5)
45 (26.3)[a ]
43 (26.9)
Female, n (%)
348 (37.1)
151 (46.9)[b ]
55 (37.9)
32 (23.0)[b ]
56 (32.7)
54 (33.8)
Mean (SD) CHA2 DS2 -VASc score
2.6 (1.7)
2.8 (1.6)[b ]
2.7 (1.5)
3.1 (2.1)[b ]
2.1 (1.7)[b ]
2.3 (1.4)[b ]
CHA2 DS2 -VASc ≥2 (female); ≥1 (male), n (%)
796 (85.0)
280 (87.0)
129 (89.0)
123 (88.5)
130 (76.0)[b ]
134 (83.8)
Educational level,[c ] n (%)
University/technical college
391 (41.8)
178 (55.3)[b ]
55 (37.9)
83 (60.1)[b ]
38 (22.2)[b ]
37 (23.1)[b ]
Community college
263 (28.1)
75 (23.3)[a ]
46 (31.7)
31 (22.5)
55 (32.2)
56 (35.0)[a ]
High-school diploma
255 (27.2)
68 (21.1)[b ]
36 (24.8)
21 (15.2)[b ]
63 (36.8)[b ]
67 (41.9)[b ]
No school leaving certificate
27 (2.9)
1 (0.3)[b ]
8 (5.5)[a ]
3 (2.2)
15 (8.8)[b ]
0[a ]
AF groups, n (%)
AF with recent stroke
194 (20.7)
63 (19.6)
31 (21.4)
35 (25.2)
34 (19.9)
31 (19.4)
Recent AF, no recent stroke
342 (36.5)
123 (38.2)
50 (34.5)
50 (36.0)
59 (34.5)
60 (37.5)
Established AF, no recent stroke
401 (42.8)
136 (42.2)
64 (44.1)
54 (38.8)
78 (45.6)
69 (43.1)
Abbreviations: AF, atrial fibrillation; SD, standard deviation.
a
p < 0.05.
b
p < 0.001 versus other countries pooled.
c One patient did not report educational level.
Patient's Perceptions about AF, Stroke, and OAC Medication by Country
AF was perceived by American patients as more serious and by French and German patients
as less serious, while 41% of Japanese patients perceived AF as not serious ([Table 2 ]). There were no differences in stroke knowledge between the five countries ([Table 2 ]). American patients were more concerned about stroke, while French patients were
less frequently concerned about stroke ([Table 2 ]).
Table 2
Patients' perceptions about AF and stroke, level of stroke knowledge, self-reported
adherence to OAC, and preference for involvement in OAC treatment choice overall and
by country
Overall (n = 937)
USA (n = 322)
Canada (n = 145)
Japan (n = 139)
France (n = 171)
Germany (n = 160)
Perception of seriousness of AF (%)
Extremely/very serious
39.4
54.0[a ]
40.0
35.3
28.7[a ]
24.4[a ]
Somewhat serious
41.6
33.9[a ]
47.6
23.7[a ]
55.0[a ]
53.1[a ]
Not at all/not serious
19.0
12.1[a ]
12.4[b ]
41.0[a ]
16.4
22.5
Concern about stroke (%)
Often/always
43.4
50.0[a ]
36.6
50.4
32.2[a ]
42.5
Occasionally
45.4
41.0
55.2[a ]
34.5[a ]
52.6[b ]
46.9
Never/don't know
11.2
9.0
8.3
15.1
15.2
10.6
Knowledge of stroke (%)
Good/moderate
47.4
45.3
49.7
48.2
42.7
53.8
Low/none
52.6
54.7
50.3
51.8
57.3
46.2
Self-reported adherence to OAC
Always take as prescribed
79.9
83.5[b ]
84.8
67.4[a ]
80.1
78.8
Often take as prescribed
17.4
15.2
13.8
26.8[a ]
18.1
16.2
Sometimes take as prescribed
2.4
0.9[b ]
1.4
5.1[b ]
1.2
5.0[b ]
Rarely take as prescribed
0.3
0.3
0
0.7
0.6
0
Patient's preference for involvement in OAC treatment choice
Patient's choice
19.6
19.9
22.1
18.0
14.6
23.8
Patient–doctor's choice
35.6
41.9[a ]
37.2
23.7[a ]
25.7[a ]
42.5[b ]
Doctor's choice
44.7
38.2[a ]
40.7
58.3[a ]
59.6[a ]
33.8[a ]
Abbreviations: AF, atrial fibrillation; OAC, oral anticoagulation.
a
p < 0.001 versus other countries pooled.
b
p < 0.05.
Self-reported OAC adherence was high overall, but American patients reported greater
OAC adherence while Japanese patients reported poorer adherence ([Table 2 ]). The majority of French and Japanese patients (60 and 58%, respectively) preferred
their doctor to choose OAC treatment; in contrast, 62, 59, and 66% of American, Canadian,
and German patients, respectively, preferred shared decision making or to choose the
OAC themselves ([Table 2 ]). Stroke prevention was the most important factor for 47.4% of AF patients when
choosing OAC ([Fig. 2 ]), followed by risk of major bleeding. Dosing frequency was rated as most important
by only 8.2% of the patients. Japanese patients were more concerned about other side
effects and dosing frequency than patients from other countries ([Fig. 2 ]). Ranking of OAC attributes demonstrated a very similar pattern when analyzed by
age (<65 and ≥65 years), sex, or educational level (data not shown).
Fig. 2 The most important factor in the choice of oral anticoagulation rated by atrial fibrillation
patients for the cohort overall and by country. a
p < 0.05 versus other countries pooled. b
p < 0.001 versus other countries pooled. Percentages do not always equal to 100 due
to rounding.
Patient's Perceptions about AF, stroke, and OAC Medication among AF Patients with
Recent Stroke versus those with No Recent Stroke
Recent stroke occurred in 194 (20.7%) patients; one-third of patients were female.
Patients with recent stroke were significantly younger (47.6 [17.5] years vs. 56.0
[15.9] years, respectively) and had a significantly higher CHA2 DS2 -VASc score (4.3 [1.3] vs. 2.2 [1.5]) than patients without a recent stroke (both
p < 0.001). Of those with a recent stroke, 149 of 193 (77.2%) had a moderate to severe
disability (mRS: 2–5); mean mRS (SD) score was 2.5 (1.2).
Patients with recent stroke were significantly more likely to perceive AF as an extremely
serious or very serious condition and were often more concerned about stroke than
those without a recent stroke ([Table 3 ]). Those with less functional disability after a stroke (mRS score: 0–1) were more
likely to perceive AF as not serious compared with those with moderate to severe disability
(18.2 vs. 3.4%, respectively). Good levels of stroke knowledge were significantly
lower in patients with a recent stroke compared with those without (9.8 vs. 22.1%,
respectively, p < 0.001). There were high levels of self-reported adherence to OAC therapy, but recent
stroke survivors reported significantly lower adherence to OAC compared with patients
without a recent stroke. AF patients with a recent stroke preferred their doctor to
make the OAC treatment choice, whereas patients without a recent stroke were more
likely to prefer being involved in the decision ([Table 3 ]).
Table 3
Patients' perceptions about AF and stroke, level of stroke knowledge, self-reported
adherence to OAC, and preference for involvement in OAC treatment choice overall and
by recent stroke/no recent stroke
Recent stroke (n = 194)
No recent stroke (n = 743)
Perception of seriousness of AF (%)
Extremely/
very serious
55.2[a ]
35.3
Somewhat serious
37.6
42.7
Not at all/
not serious
7.2[a ]
22.1
Concern about stroke (%)
Often/always
68.0[a ]
37.0
Occasionally
28.4[a ]
49.8
Never/
don't know
3.6[a ]
13.2
Knowledge of stroke (%)
Good
9.8[a ]
22.1
Moderate
27.3
28.0
Low
30.4
29.6
None
32.5[a ]
20.3
Familiarity with information on AF and stroke (%)[b ]
Familiar
53.1
35.3
Self-reported adherence to OAC
Always take as prescribed
73.6[c ]
81.6
Often take as prescribed
21.2
16.4
Sometimes take as prescribed
4.7[c ]
1.7
Rarely take as prescribed
0.5
0.3
Patient's preference for involvement in OAC treatment choice
Patient's choice
22.7
18.8
Patient–doctor's choice
18.6[a ]
40.1
Doctor's choice
58.6[a ]
41.0
Abbreviations: AF, atrial fibrillation; OAC, oral anticoagulation.
a
p < 0.001.
b 8–10 on a 10-point scale; see supplement.
c
p < 0.05.
Stroke prevention was the most important factor for all AF patients when choosing
OAC, followed by major bleeding ([Fig. 2 ]). AF patients with a recent stroke were less concerned about stroke prevention and
more concerned about dietary restrictions, taking medication with/without food, dosing
frequency, and antidote availability compared with those without recent stroke ([Fig. 3 ]).
Fig. 3 The most important factor in the choice of oral anticoagulation rated by atrial fibrillation
patients with a recent stroke (A ) and those without a recent stroke (B ). a
p < 0.05 versus no recent stroke. b
p < 0.001 versus no recent stroke. Percentages do not always equal to 100 due to rounding.
Discussion
In this prospective, international survey of AF patients receiving OAC, there were
significant between-country differences in patient's perceptions about AF, stroke,
and OAC treatment, and differences between AF patients with and without recent stroke.
Concern about stroke was greater among those with recent stroke, while stroke knowledge
was poorer. Importantly, AF patients with recent stroke preferred their doctor to
make the OAC treatment choice, while patients without recent stroke preferred involvement
in this decision making. Finally, stroke prevention was rated as the most important
factor when choosing OAC, regardless of country of residence, whether they had experienced
a recent stroke, and age, sex, or educational level.
In this survey, country differences in patient's perceptions were evident. American
patients perceived AF more seriously and were more concerned about stroke than French
patients. Japanese patients were more likely to perceive AF as not serious, but half
were highly concerned about stroke. Patients in the United States, Canada, and Germany
preferred to be involved in the OAC treatment decision (either shared decision making
or patient's choice), while those in France and Japan preferred their doctor to choose.
Patients with recent stroke and those with greater functional disability perceived
AF as more serious. Country differences may reflect different cultural backgrounds,
such as how the physician's role and responsibility is generally perceived in a society,
but also specific factors such as educational programs on AF and/or anticoagulation
or differences in healthcare systems. Although generic education on AF should be given
to all AF patients, our findings suggest that country-specific approaches may be required
for certain aspects, such as the discussion about potential consequences of AF to
enable patients to understand the seriousness of AF. Importantly, our results suggest
that physicians should be aware about the patients' desire to be involved in the OAC
treatment decision and act accordingly when talking with the patient as this differs
between countries.
Before the initiation of the present study, only a few studies had examined patient's
preferences regarding OAC,[7 ]
[11 ]
[14 ] predominantly relating to patient's preferences for VKAs[11 ] as most were conducted before NOACs became available. Given the greater choice of
OAC, the differing clinical risk profile (efficacy/safety), differing dosing regimens,
and other attributes of the NOACs (reversibility, taking with/without food, etc.)—all
of which may affect patient's preference for OAC treatment—this study was advantageous.
More recently, there have been a few published studies on patient's preferences for
OAC including the NOACs,[6 ]
[18 ]
[22 ]
[23 ]
[24 ]
[26 ] but the majority have recruited AF patients from just one country, have much smaller
sample sizes, and included more selected AF populations; to our knowledge, the only
exception to this was the European Heart Rhythm Association (EHRA) survey.[18 ]
[26 ]
The present survey recruited a large sample of AF patients from five countries (three
outside Europe), including newly diagnosed AF patients and those with recent experience
of stroke, thereby offering a more diverse picture of patient's perceptions of AF
and preferences for OAC treatment.
Perceptions of Atrial Fibrillation and Concerns about Stroke
Previous studies have demonstrated that patients often do not perceive AF as a serious
condition and are not aware of the increased risk of stroke associated with AF.[8 ]
[9 ]
[12 ]
[14 ]
[15 ]
[16 ] Generally, patients' knowledge about AF and stroke prevention is poor,[8 ]
[9 ]
[12 ]
[15 ]
[16 ] and educational level does not always differentiate those who know the purpose of
OAC from those who do not.[18 ]
[26 ] However, the majority of studies report that patients are concerned about the risk
of stroke and wish to avoid this.[7 ]
[10 ]
[20 ]
[21 ] Indeed, a Canadian study[7 ] elicited health utilities using an iPad questionnaire and found that patients viewed
minor stroke as slightly worse than a major bleed, whereas a moderate stroke was viewed
as virtually equivalent to death and a major stroke as worse than death. Studies have
generally shown that patients are prepared to accept a higher risk of OAC-related
bleeding to prevent stroke.[7 ]
[10 ]
[21 ] How AF patients are informed about their risk profile and available treatments can
affect treatment choice, and this is likely to be highly variable in clinical practice.
A recent EHRA survey[27 ] found that 51% of centers had structured education programs for stroke prevention
for AF patients. According to respondents, patient's preferences for OAC were considered
important when making treatment decisions in the majority of centers (64.7%). Although
some centers have resources/programs in place to educate patients about their stroke
risk profile and treatment, there was a disparity in what was delivered and delivery
strategies employed.[27 ]
Participation in the Oral Anticoagulation Decision
In line with the recommended shared decision-making approach,[28 ]
[29 ]
[30 ]
[31 ]
[32 ] it is evident from the present study that a large proportion of AF patients prefer
to be involved in the choice regarding OAC (55.3% overall), while many others prefer
the physician to choose the OAC. However, country-specific differences and experience
of stroke can affect a patient's desire to participate in decision making and may
reflect different sociocultural role expectations in the patient–physician interaction;
educational level did not influence this preference. One small cross-sectional study
reported that 98% would like to participate in the OAC decision;[24 ] however, several factors, including the small sample size, an all-male U.S. veteran
cohort, and a mixture of patients with and without AF—with some of them receiving
OAC—limit these findings. A qualitative study[20 ] of AF patients requiring OAC showed that AF patients prefer consultations that provide
the opportunity to make an informed decision, and that they favor an individual approach
based on their risk profile (stroke and bleeding) and the attributes that are important
to them.
Although some patients may not wish to participate in the treatment decision, at the
very least an approach that encourages patient–physician dialogue should be advocated
to increase the likelihood of healthcare professionals (HCPs) imparting adequate information
to the patient in order for them to understand the condition and the need for OAC
treatment and, hence, the potential implications of treatment decisions (advantages
and disadvantages). A contemporary EHRA consensus document highlights the importance
of education of AF patients[8 ] and repetition of information over time, from various sources.
Self-reported Adherence to Oral Anticoagulation
Adherence to OAC medication is essential to minimize thromboembolic or hemorrhagic
complications, and physicians are often concerned about patient adherence to OAC.[33 ]
[34 ]
[35 ] Overall, self-reported adherence to OAC was high in the present study (79.9%). American
patients reported greater adherence to OAC (83.5%), while Japanese patients reported
poorer adherence (67.4%), which inversely correlated with the perception of seriousness
of AF (41% of Japanese patients believed AF was not serious compared with only 12%
of American patients). Patients with recent stroke reported lower adherence, which
may be due to cognitive impairment, or reflect limited trust in the efficacy of OAC
or vice versa being a cause for the patient to have suffered a (hemorrhagic) stroke.
Self-reported adherence to OAC was around 75% in a recent EHRA survey of 1,147 patients
with AF from eight European countries;[26 ] adherence was significantly lower in men versus women and younger versus older patients
(<65 vs. ≥65 years). Other studies employing more objective measures of adherence
(e.g., proportion of days medication is taken as prescribed based on prescriptions
or electronic monitoring devices)[36 ]
[37 ]
[38 ]
[39 ] demonstrates that NOAC adherence is generally 80% or better, but adherence rates
vary between cohorts and by the definition, and measure, of adherence employed.
Factors Important in Oral Anticoagulation Choice
The present study found that patients place greater importance on avoidance of a stroke
than bleeding, and on efficacy over factors associated with treatment burden (e.g.,
dosing frequency, dietary restrictions, taking the medication with or without food)
when ranking attributes of OAC treatment. This finding concurs with most other studies,[6 ]
[23 ]
[25 ]
[40 ] including a systematic review of patient's values and preferences in decision making
for antithrombotic therapy.[11 ] A study of AF patients with and without stroke demonstrated that reducing the risk
of ischemic stroke was the primary factor for OAC treatment choice, followed by the
medication with least side effects, then intracranial hemorrhage, then ease of use
(e.g., once-daily dosing), and finally cost.[12 ]
A recent Canadian survey[6 ] of 266 AF patients receiving OAC (warfarin or NOACs) for stroke prevention found
that views on importance of OAC attributes differed between patients and physicians.
Another multicenter German study of AF patients receiving uninterrupted OAC over the
previous 3 months (either VKA or rivaroxaban)[22 ] employed discrete choice experiment methodology to rate (yes/no) the treatment-related
attributes of OAC preferred. Patients preferred OAC treatment that was easy to administer
(no bridging, once daily, no food interactions, without international normalized ratio
checks/dose adjustment), and less distance to travel to their HCP. However, this study
did not include efficacy and safety attributes among the choices, which is problematic
given that these factors are likely to affect which attributes the patient perceives
as “most important” and may alter treatment preferences. A Swiss prospective, observational,
cross-sectional study (PRiSMA-AF [AF Patient Preferences toward NOAC versus VKA Treatment:
A Patient Preference Study]) employing the same methodology and attributes as the
study by Böttger et al[22 ] is also examining AF patients' preferences for OAC (VKA and the four NOACs). In
a smaller study of U.S. veterans,[24 ] the most important factors associated with opting for a particular OAC (from most
to least important) were availability of an antidote, quality of life, physician recommendation,
length of time available in the marketplace, more information before the decision,
and lower stroke risk.
Limitations
All patients in the present study were receiving OAC and therefore their previous
experiences (good or bad) with OAC could have influenced their responses. Patients
may have wanted to prevent cognitive dissonance (internal mental conflict) and therefore
replied so that their responses matched their current medication, or may have given
the answer they felt was required rather than their true preference (social desirability
bias). The opportunistic sampling strategy based on patients' willingness to complete
an online survey may have biased the sample toward being younger (and more technology-savvy),
as evident from the mean age of the cohort, and may have influenced the findings and
importance of certain attributes. Therefore, the findings may not be representative
of older AF patients or those patients not receiving OAC. Also, respondents may be
more knowledgeable about AF and OAC treatment than “general” AF patients, and therefore
more willing to volunteer to participate in a survey on preferences and knowledge,
limiting the generalizability of the results. However, this study recruited a large
number of patients from several countries, where differences in the management of
AF and cultural differences in the perception of healthcare may affect the outcomes
of interest, and therefore the results may be more representative of AF patients globally.
Furthermore, preferences for OAC attributes were independent of age, sex, and educational
level. In addition, this study included a range of AF patients, those with a recent
stroke, newly diagnosed, and established AF, as different experiences of living with
AF, OAC treatment exposure, and the adverse consequences of AF (i.e., a recent stroke)
will likely affect patient's perceptions and treatment preferences, as demonstrated
by other studies.[6 ]
[12 ]
[22 ]
[24 ]
Conclusion
Country-specific differences exist in AF patients' perceptions of AF, concerns about
stroke, and preference for involvement in OAC treatment decisions; recent experience
of stroke also significantly influenced patients' perceptions of AF and stroke, and
preference for involvement in the OAC decision. With the availability of NOACs, physicians
have greater choice for OAC, which differ in terms of their clinical profile (risk/benefit),
dosing regimen (once vs. twice daily), and other attributes; however, patient's preferences
concerning anticoagulation therapy in this context have only been partly evaluated.
Regardless of country of residence or whether they had experienced a recent stroke,
all patients rated stroke prevention as the most important factor when choosing OAC
treatment. Enhancing physician–patient dialogue is important to educate patients about
AF and treatment options and to inform physicians about patients' preferred level
of involvement in treatment decisions, as this is likely to increase patient's satisfaction,
which may result in improved adherence. The findings of this survey could be used
to inform patient–physician communication training and patient education programs.
