How Much Do Negative Perceptions of Anticoagulation Influence Patients' Choice of Procedural Intervention?
Jason J. Han, Akhil Rao, Max Shin, Mark R. Helmers, Amit Iyengar, Benjamin Smood, William L. Patrick, John J. Kelly, Peter Altshuler, Alan Herbst, Pavan Atluri
Hospital of the University of Pennsylvania, Philadelphia, PA, USA
BACKGROUND: Cardiac surgery patients are generally apprehensive regarding lifelong anticoagulation (AC) given its significant associated risks and restrictions; however, AC is required for certain operations that promise survival benefit (e.g. mechanical valve among young patients). To what extent patients may prefer options that do not require AC even in the setting of having inferior outcomes has not been explored.
METHODS: A 24-question survey was distributed to users older than 55 years of age from 10/1 to 10/20/2021 using Amazon Mechanical Turk (Seattle, WI), a virtual crowdsourcing platform. The survey provided hypothetical comparisons between two open heart surgery options that does and does not require AC (i.e. bioprosthetic vs. mechanical aortic valve replacement). Five-point Likert scale questions evaluated the salience and the degree of fear associated with a list of common operative complications and concerns. No financial incentive was offered. Chi-squared/Fisher’s exact test or Mann-Whitney U-tests were utilized.
RESULTS: Fifty-three individuals completed the survey with a median age of 62 [57-69] years. Of the group, 42% were male, 79% were Caucasian, 38% had bachelor’s or more advanced degrees, 42% were retired and 34% had an annual income of less than ,000. Given a choice between two surgical options that does and does not require lifelong AC, 75.5% replied they would consider AC only if it "adds significant benefit" while 24.5% replied they would unconditionally refuse it. Employed (67% vs 27%, p=0.02) and those with income < ,000 (41% vs 8%, p=0.04) were more likely to unconditionally refuse lifelong AC. There were no differences based on age, degree of education or marital status (p>0.05). On the Likert scale, these individuals also ranked avoiding blood thinners (average 4.1/5) their most important decision-making factor when choosing an operation, even above the risk of stroke (3.9), re-operation (3.9), intubation (3.6), and increased length of stay (3.3).
When asked to quantify the relative gain in years-of-life one would need to choose the option requiring AC, 22.6% of all individuals required at least 1 year, 15.1% required at least 3 years, and 45.3% required at least 5 years of life gained (Figure 1).
CONCLUSIONS: In a shared decision-making paradigm, lifelong AC introduces both benefits and risks that individuals may process differently. A significant minority may consider AC a point of contraindication to a potentially life-prolonging option, and should be more strategically addressed by providers. 