Design and development of a digital shared decision-making tool for stroke prevention in atrial fibrillation

Abstract

Background: Shared decision-making (SDM) is an approach in which patients and clinicians act as partners in making medical decisions. Patients receive the information needed to decide and are encouraged to balance risks, benefits, and preferences. Informative materials are vital to SDM. Atrial fibrillation (AF) is the most common cardiac arrhythmia and responsible for 10% of ischemic strokes, however 1/3 of patients are not on appropriate anticoagulation. Decision sharing may facilitate treatment acceptance, improving outcomes.

Aims: To develop a framework of the components needed to create novel SDM tools and to provide practical examples through a case-study of stroke prevention in AF.

Methods: We analyze the design values of a web-based SDM tool created to better inform AF patients about anticoagulation. The tool was developed in partnership with patient advocates, multi-disciplinary investigators, and private design firms. It was refined through iterative, recursive testing in patients with AF. Its effectiveness is being evaluated in a multisite clinical trial led by Stanford University and sponsored by the American Heart Association.

Findings: The main components considered when creating the Stanford AFib tool included: design and software; content identification; information delivery; inclusive communication, user engagement; patient feedback; clinician experience; and anticipation of implementation and dissemination. We also highlight the ethical principles underlying SDM; matters of diversity and inclusion, linguistic variety, accessibility, and health literacy. The Stanford AFib Guide patient tool is available at: https://afibguide.com and the clinician tool at https://afibguide.com/clinician.

Conclusion: Attention to a range of vital development and design factors can facilitate tool adoption and information acquisition by diverse cultural, educational, and socioeconomic subpopulations. With thoughtful design, digital tools may decrease decision regret and improve treatment outcomes across many decision-making situations in healthcare.

Keywords: atrial fibrillation; medical design; patient decision aid; research tools; shared decision-making.

Figure 1.

Flowchart of design, software, and timeline considerations. Phase 1 focused on understanding the needs of patients and stakeholders; research insights informed the design of a prototype. In Phase 2, test builds were continuously reviewed for final production of the research tool.

Figure 2.

Opening page and learning pathway. (A) The opening page highlights the objective of the digital tool and offers information regarding authorship and financial disclosures. (B) Patients start interacting with the tool by engaging with “Hearty,” the tool’s main character. They follow a learning path that starts with a video and finishes with the fillable worksheet to be brought to the physician appointment.

Figure 3.

Excerpt from the introductory video and key messages. (A) The video displays cartoon depictions of the mechanism of atrial fibrillation, how to measure stroke risk, when to start an anticoagulant, and what are the anticoagulation options. The intent of the video is to introduce the conceptual knowledge required for decision-making. (B) After the initial presentation, patients assimilate the newly acquired knowledge through visual representations and repetition of the main learning topics.

Figure 4.

Most common questions with answers and the check-in quiz. (A) The tool offers a list of common questions answered in clear, accessible language. Additionally, short audio stories from real patients are included to add peer-to-peer perspectives. (B) After the initial video and Q&A, patients reinforce their knowledge with a short quiz. If a question is answered incorrectly, a video excerpt allows for review of the specific topic.

Figure 5.

The clinician tool. (A) The animations in the clinician tool are also available without sounds, allowing clinicians to use the illustrations as a background to their explanations during a patient encounter. (B) Useful resources such as risk score calculators are included for easy access and real-time demonstration of risk.