Mark H Eckman1, Pablo Alonso-Coello2, Gordon H Guyatt3, Shanil Ebrahim4, Kari A O Tikkinen5, Luciane Cruz Lopes6, Ignacio Neumann7, Sarah D McDonald8, Yuqing Zhang9, Qi Zhou10, Elie A Akl11, Ann Flem Jacobsen12, Amparo Santamaría13, Joyce Maria Annichino-Bizzacchi14, Wael Bitar15, Per Morten Sandset16, Shannon M Bates17. 1. Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, USA. Electronic address: mark.eckman@uc.edu. 2. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Iberoamerican Cochrane Centre, CIBERESP-IIB Sant Pau, Barcelona, Spain. 3. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada. 4. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Anaesthesia, McMaster University, Hamilton, ON; Department of Medicine, Stanford University, Stanford; Department of Anaesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada. 5. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Departments of Urology and Public Health, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland. 6. Pharmaceutical Sciences, University of Sorocaba, UNISO, Sorocaba, Sao Paolo, Brazil. 7. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile. 8. Departments of Obstetrics & Gynecology, Radiology, and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. 9. Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, USA. 10. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. 11. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, American University of Beirut, Beirut, Lebanon; Department of Medicine, State University of New York at Buffalo, New York, NY, USA. 12. Department of Obstetrics & Gynecology, Oslo University Hospital and University of Oslo, Oslo, Norway. 13. Unidad de Hemostasia y Trombosis, Hospital de la Vall d'hebron Sant Pau, Barcelona, Spain. 14. Hematology and Hemotherapy Center, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil. 15. Brooks Memorial Hospital, Dunkirk, NY, USA. 16. Department of Haematology, Oslo University Hospital and University of Oslo, Oslo, Norway. 17. Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.
Abstract
BACKGROUND: Women with a history of venous thromboembolism (VTE) have an increased recurrence risk during pregnancy. Low molecular weight heparin (LMWH) reduces this risk, but is costly, burdensome, and may increase risk of bleeding. The decision to start thromboprophylaxis during pregnancy is sensitive to women's values and preferences. Our objective was to compare women's choices using a holistic approach in which they were presented all of the relevant information (direct-choice) versus a personalized decision analysis in which a mathematical model incorporated their preferences and VTE risk to make a treatment recommendation. METHODS: Multicenter, international study. Structured interviews were on women with a history of VTE who were pregnant, planning, or considering pregnancy. Women indicated their willingness to receive thromboprophylaxis based on scenarios using personalized estimates of VTE recurrence and bleeding risks. We also obtained women's values for health outcomes using a visual analog scale. We performed individualized decision analyses for each participant and compared model recommendations to decisions made when presented with the direct-choice exercise. RESULTS: Of the 123 women in the study, the decision model recommended LMWH for 51 women and recommended against LMWH for 72 women. 12% (6/51) of women for whom the decision model recommended thromboprophylaxis chose not to take LMWH; 72% (52/72) of women for whom the decision model recommended against thromboprophylaxis chose LMWH. CONCLUSIONS: We observed a high degree of discordance between decisions in the direct-choice exercise and decision model recommendations. Although which approach best captures individuals' true values remains uncertain, personalized decision support tools presenting results based on personalized risks and values may improve decision making.
BACKGROUND:Women with a history of venous thromboembolism (VTE) have an increased recurrence risk during pregnancy. Low molecular weight heparin (LMWH) reduces this risk, but is costly, burdensome, and may increase risk of bleeding. The decision to start thromboprophylaxis during pregnancy is sensitive to women's values and preferences. Our objective was to compare women's choices using a holistic approach in which they were presented all of the relevant information (direct-choice) versus a personalized decision analysis in which a mathematical model incorporated their preferences and VTE risk to make a treatment recommendation. METHODS: Multicenter, international study. Structured interviews were on women with a history of VTE who were pregnant, planning, or considering pregnancy. Women indicated their willingness to receive thromboprophylaxis based on scenarios using personalized estimates of VTE recurrence and bleeding risks. We also obtained women's values for health outcomes using a visual analog scale. We performed individualized decision analyses for each participant and compared model recommendations to decisions made when presented with the direct-choice exercise. RESULTS: Of the 123 women in the study, the decision model recommended LMWH for 51 women and recommended against LMWH for 72 women. 12% (6/51) of women for whom the decision model recommended thromboprophylaxis chose not to take LMWH; 72% (52/72) of women for whom the decision model recommended against thromboprophylaxis chose LMWH. CONCLUSIONS: We observed a high degree of discordance between decisions in the direct-choice exercise and decision model recommendations. Although which approach best captures individuals' true values remains uncertain, personalized decision support tools presenting results based on personalized risks and values may improve decision making.
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