This project addresses recent clinical practice guidelines that recommend "administration of antithrombotic therapy to all patients with atrial fibrillation (AF), except those with lone AF, to prevent thromboembolism." AF is the most common risk factor for stroke. Despite strong evidence that use of anticoagulation in AF reduces the risk of strokes, only about half of AF out-patients receive anti-thrombotics. Reasons for the low rates of guideline adherence include patient, provider, and system barriers. Despite barriers, research shows that veterans have a strong desire for information and want to share in decisions with providers. Further, the VHA "promotes system-wide implementation of shared decision making" and it is well-known that sharing decisions is effective. Thus, this project will be the first step in developing a video on shared decision-making and anti-thrombotic choices that nurses can disseminate to veterans in the hospital, in outpatient clinics, and in their homes.
The objectives of this study are to: 1) describe patient's knowledge, attitudes, and beliefs about anti-thrombotics, and 2) develop and evaluate a script & video design to improve shared decision-making for stroke prevention.
To achieve objective #1, we conducted qualitative interviews with 8 veterans who were diagnosed with AF. We used an interview guide that was based on the Transtheoretical Model and integrated the concepts of self-efficacy and decisional balance. Interviews were audio-taped verbatim and then transcribed and verified. The constant comparative method was used to analyze the data. To achieve objective #2, we used the direct-to-consumer approach that has been used successfully by pharmaceutical companies to frame the development of the video script. The results from the subject interviews and from media audience research were used to determine the form and content of the written script. To review the draft video script and make recommendations for improvement, we convened a focus group of 9 providers. We also re-interviewed three veterans who participated in our initial interviews to give us feedback. The interviews were audio-taped verbatim, transcribed and verified, and analyzed using the constant comparative method. Based on these results, we revised the video script.
Objective #1: The first round of interviews with veterans revealed several themes about preferences for shared decision making, AF, and treatments. Most of the veterans stated that they were content to defer treatment decisions to providers. A theme about warfarin use was that it helped the veterans return to a normal life. Although veterans reported some lifestyle changes, they indicated that they had faith in warfarin to prevent stroke. The veterans described the decision to take warfarin as one based on fear of consequences (stroke) and death. Knowledge about AF and warfarin varied.
Objective #2: Based on the veteran interviews and the media audience research that found that the target audience received much of the health information from television viewing of the golf and classic movies channels, a draft video script was developed. Feedback concerning the video script in the focus group with providers and individual interviews with veterans was primarily positive. Providers provided advice on ways to revise the content related to diet restrictions, monitoring with INR blood tests, and treatment options related to stroke prevention. The majority of providers voiced their concerns about disseminating the videos to newly diagnosed patients with AF before they talked with their providers about warfarin. Based on these recommendations, the video script was revised. Future efforts are aimed at finding additional funding to produce the video and then to test the video and disseminate it VA system-wide.
By interviewing veterans and providers, a video script was developed to activate and empower veterans with AF to share in decisions related to stroke prevention treatments. Partnerships with experts in journalism and communication assured that the video script presented a clear and persuasive message. Direct-to-consumer marketing and social modeling theories were found to be promising approaches for changing patient behaviors related to anti-thrombotic use to prevent strokes.
External Links for this Project
- Uphold CR, Wilson D, Beyth RJ, Treise D, Wing KL, Hanjian J, Shorr R. Direct-to-Consumer Approach to Improve Outcomes in Atrial Fibrillation. Poster session presented at: VA QUERI National Meeting; 2008 Dec 11; Phoenix, AZ. [view]