Abstract
Purpose
For years, older patients have been prescribed multiple blood-thinning medications (complex antithrombotic therapy [CAT]) to decrease their risk of cardiovascular events. These therapies, however, increase risk of adverse bleeding events. We assessed patient-reported trade-offs between cardioprotective benefit, gastrointestinal bleeding risk, and burden of self-management using adaptive conjoint analysis (ACA). As ACA could be a clinically useful tool to obtain patient preferences and guide future patient-centered care, we examined the clinical application of ACA to obtain patient preferences and the impact of ACA on medication adherence.
Patients and methods
An electronic ACA survey led 201 respondents through medication risk–benefit trade-offs, revealing patients’ preferences for the CAT risk/benefit profile they valued most. The post-ACA prescription regimen was categorized as concordant or discordant with elicited preferences. Adherence was measured using VA pharmacy refill data to measure persistence of use prior to and 1 year following preference-elicitation. Additionally, we analyzed qualitative interviews of 56 respondents regarding their perception of the ACA and the preference elicitation experience.
Results
Participants prioritized 5-year cardiovascular benefit over preventing adverse events. Medication side effects, medication-associated activity restrictions, and regimen complexity were less important than bleeding risk and cardioprotective benefit. One year after the ACA survey, a 15% increase in adherence was observed in patients prescribed a preference-concordant CAT strategy. An increase of only 6% was noted in patients prescribed a preference-discordant strategy. Qualitative interviews showed that the ACA exercise contributed to increase inpatient activation, patient awareness of preferences, and patient engagement with clinicians about treatment decisions.
Conclusion
By working through trade-offs, patients actively clarified their preferences, learning about CAT risks, benefits, and self-management. Patients with medication regimens concordant with their preferences had increased medication adherence at 1 year compared to those with discordant medication regimens. The ACA task improved adherence through enhanced patient engagement regarding treatment preferences.
Supplementary material
Table S1 Patient perception of preference-elicitation exercise (N=56)
Acknowledgments
The authors thank Ms Barbara Corn for assistance with recruitment and data collection, and Ms Sonora Hudson for assistance with manuscript preparation.
Author contributions
Dr Abraham is the guarantor of the paper. Dr Abraham conceived, designed, and conducted the study, acquired necessary funding, interpreted the data, prepared the manuscript, and had final approval of this research. Drs Hartman and Richardson provided analytic support in programming, statistical analysis, and interpretation of results. Ms Castillo, and Drs Naik, Shelton, Street, Hartman, Richardson, Deswal, and Fraenkel assisted Dr Abraham in preparation of the manuscript. All authors contributed toward data analysis, drafting and critically revising the paper and agree to be accountable for all aspects of the work.
Disclosure
The research was supported by a grant from the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (IIR08-028); Principal Investigator: Neena S Abraham. This work was accomplished using the facilities and resources of the Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). The authors report no other conflicts of interest in this work.