INTRODUCTION
Atrial fibrillation (AF) management remains challenging and recurrence
is common even after several treatment modalities (lifestyle changes,
medications, and catheter ablation) have been
implemented.1—3Patients may continue to report a variety of physical and mental
symptoms, including dyspnea, chest pain, fatigue, anxiety, and
palpitations, that limit daily functioning and health-related quality of
life.2,3Treatment options for AF include medication management and catheter
ablation, a minimally invasive, percutaneous procedure to restore and
maintain normal sinus rhythm, primarily comprised of antral pulmonary
venous
isolation.4,5While clinical guidelines recommend ablations as a treatment strategy in
certain clinical contexts, in practice these decisions must be made by
assessing procedure risks and
benefits.6Prior studies underscore the complexity of this decision choice; the
recent Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial
Fibrillation (CABANA) trial randomized controlled trial showed that AF
recurred after ablation in 50% of cases, and almost 20% needed a
repeat
ablation.7Yet, at the same time, AF
symptoms8,9and quality of
life9,10may independently improve after ablation and other studies have reported
that patients feel symptom reduction represents success for an ablation,
regardless of the effect on rhythm
control.11Thus, the definition of a successful ablation may vary between patients,
and depend on their specific clinical characteristics as well as their
values and goals of care.
Shared decision-making (SDM) is the ideal paradigm for exploring the
complex risk and benefit choices surrounding ablation to arrive at a
high-quality decision. SDM involves a discussion of risks and benefits
of treatment options in the context of a patient’s values, expectations,
and preferences with the goal of selecting a treatment that aligns with
these priorities. Decision aids, structured instruments that explicitly
describe the decision to be made and present unbiased information about
options (including the option of taking no action), help patients become
more involved in the SDM process and are demonstrated to improve patient
knowledge, engagement, goals-values concordance of decisions, and
satisfaction in
SDM.12
SDM has been strongly encouraged for anticoagulation treatment decisions
for AF patients with high stroke
risk.13,14Accordingly, a number of decision aids have been developed to support
patients deciding on an anticoagulant for stroke
prevention.15–18However, SDM around rhythm and symptom control has yet to be explored.
In fact, a recent study of nearly 1,000 patients with AF found that only
22% reported participating in SDM to select a rhythm control strategy,
and 52% of patients who did not participate in SDM reported that they
did not understand different rhythm control
options.19Moreover, very few decision aids exist to support patients in selecting
a rhythm and symptom control
strategy.20,21
The objective of this study was to measure decision quality and describe
decision-making processes among patients and clinicians involved in
decision-making around catheter ablation for AF. The International
Patient Decision Aids Standards (IPDAS) has determined that an important
first step in developing a decision aid is to characterize patient
involvement in the decision-making process and define decision
quality.22Thus, in this paper we report on the initial needs assessment conducted
as part of a larger body of work to develop a decision aid for AF rhythm
and symptom control.