Decision Making Around Dosing of NOACs


Manesh Patel, MD: Rob, maybe I’ll come to you at this part of the question. You know some of the trends we’ve been seeing are in market-scanned data or other things like that. Tell us a little about what you think about how we can better support the decision making around dosing?

Robert M. Califf, MD, MACC: I look at something like atrial fibrillation [AFib] and decision support and say, “Why should it be any different if you’re in Rochester, Minnesota; San Francisco; Illinois; or Ohio?” It’s the same questions. The risk factors are the same. The doses have been worked out in clinical trials. You know, maybe it should be available to the public. In a way, if I went to you as a doctor, and you said, “I’m going to put you on 2.5 mg of apixaban,” and the decision support said that’s wrong, you would have some way of addressing that problem other than trying to find another doctor. For most people, that is just way beyond what they could possibly muster the know-how and energy to do. It would make it very hard for that to happen.

I think we should look at the data. We now live in an environment where can stomp out bad variation. Then the job of a good clinician, because there is a standard, but I can find the exceptions to the standard that deal with the individual people, and I can talk with people about what they’re thinking.

Bernard J. Gersh, MBChb, DPhil, MACC: Rob, I totally agree. But I think we’re getting there. One of the problems I have found with shared decision making using support systems is they’re incredibly time consuming. We have an ongoing grant that a colleague might have that may right now be looking at this.

It’s the right thing to do. It’s very time consuming. I think if we’re going to have shared decision making—and I couldn’t agree more that we should use decision-support systems—then the administrators and payers are going to have to provide the staff to do that.

Robert M. Califf, MD, MACC: I think you’re thinking about it in an old-fashioned way, with all due respect. The idea that all the discussion about decision support should happen in a doctor’s office just seems crazy. If you want to go out and eat Italian food, you call it up on your cell phone, you get a list of the restaurants, you get the reviews, you see where it is, and you get a lot of information about it. Why shouldn’t a person be really prepared when they come to the doctor’s office with all that stuff and then save the human discussion for what’s really important?

Bernard J. Gersh, MBChb, DPhil, MACC: Rob, it’s great that you’re doing this, because right now if you want to get funded for shared decision making, with decision-support systems, and you want the NHLBI [National Heart, Lung, and Blood Institute] to fund that, it’s all in the doctor’s office. I agree, that’s not a practical way to go in the future.

Manesh Patel, MD: I think what I would say to your question, first, I agree with the term clinician. Don’t get me wrong, I think it’s an important one. Now we’re going to get to the good stuff of how we help our clinicians through what the questions are.

No. 2, Rob, there’s a word that we should use for both sides of the equation, and that word is trust. Patients still come to my office because they trust the doctors and the clinicians, and they may be trusting them less and less, so we need to work on making sure they’re empowered with information. But misinformation or bad information exists in lots of places, 1 of which is certainly the Internet. I would suggest that I think you’re right. What we have to do is figure out a way, and I know you’re tackling—which is the thing—how do we get truth, or at least peer reviewed information, in a way that can be understandable to people?

Let’s take the AFib patient who comes in who’s getting the wrong dose and make sure that they understand this isn’t very complicated. Then they can have the conversation with their doctor about why that dose is being chosen. Is it because I’m older? Is it because I have renal dysfunction? Is it because I’ve fallen? Are those the conversations you could have? We should be working to make sure our colleagues don’t just go with what I’ll say is a reflective action.

Robert M. Califf, MD, MACC: I agree with what you said. There’s 1 other point that needs to be added. Those people who trust you when they come to your office are only the people who have managed somehow to make it to your office.

Manesh Patel, MD: Sure, sure.

Robert M. Califf, MD, MACC: For every 1 of those there are dozens out there who are not making it to any competent office right now. They may have to drive 2 hours for a visit. They wait in the waiting room, they get 15 minutes, and they’re out of there. I can tell you, they’re searching Google as soon as they leave the office on whatever cell phone they have trying to figure out what the hell you were talking about, because there’s not enough time to remember it. I certainly don’t pretend that what’s on the Internet is great information that we all need to work on.

Christopher Granger, MD: Let me just make 1 other point that Sean talked about earlier. We talk about underdosing. But remember, the worst dose is 0 mg.

Manesh Patel, MD: Yeah, that’s right.

Christopher Granger, MD: And almost half our patients are on 0 mg. But that’s also a responsibility. Rob, you were hopeful with this trial that Sean actually led, which was going to patients through the Sentinel Initiative data set, and going out to patients who had diagnoses of atrial fibrillation, had not been on an anticoagulant for the last year—and basically telling the patient, it looks to us as though your clinician has not succeeded in doing a good job in addressing your health concerns. Going to the patient—we’ll see, Sean, what kind of an effect that has, but we’re hoping that maybe it will move the needle some.

Sean D. Pokorney, MD: I think, Rob, this is your point: patients need to really be the agent of change. I think they need to be educated, and they need to be able to engage in their own health decisions. I think providing decision support and help through Google and providing valid resources that can help them accomplish that is critical.

Transcript edited for clarity.

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