Complex antithrombotic therapy: determinants of patient preference and impact on medication adherence

Neena S Abraham,^1,2 Aanand D Naik,^3,4 Richard L Street Jr,^3–5 Diana L Castillo,³ Anita Deswal,⁶ Peter A Richardson,^3,4 Christine M Hartman,³ George Shelton Jr,^3,4 Liana Fraenkel<sup>7,8

1</sup>Division of Gastroenterology, Mayo Clinic, Scottsdale, AZ, USA; ²Divison of Healthcare Policy and Research, Department of Health Services Research, Rochester, MN, USA; ³Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA; ⁴Department of Medicine, Baylor College of Medicine, Houston, TX, USA; ⁵Department of Communication, Texas A&M University, College Station, TX, USA; ⁶Cardiology, Michael E DeBakey VAMC, Houston, TX, USA; ⁷Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA; ⁸Department of Medicine, Yale University, New Haven, CT, USA


Purpose: For years, older patients have been prescribed multiple blood-thinning medications (complex antithrombotic therapy [CAT]) to decrease their risk of cardiovascular events. These therapies, however, increase risk of adverse bleeding events. We assessed patient-reported trade-offs between cardioprotective benefit, gastrointestinal bleeding risk, and burden of self-management using adaptive conjoint analysis (ACA). As ACA could be a clinically useful tool to obtain patient preferences and guide future patient-centered care, we examined the clinical application of ACA to obtain patient preferences and the impact of ACA on medication adherence.
Patients and methods: An electronic ACA survey led 201 respondents through medication risk–benefit trade-offs, revealing patients’ preferences for the CAT risk/benefit profile they valued most. The post-ACA prescription regimen was categorized as concordant or discordant with elicited preferences. Adherence was measured using VA pharmacy refill data to measure persistence of use prior to and 1 year following preference-elicitation. Additionally, we analyzed qualitative interviews of 56 respondents regarding their perception of the ACA and the preference elicitation experience.
Results: Participants prioritized 5-year cardiovascular benefit over preventing adverse events. Medication side effects, medication-associated activity restrictions, and regimen complexity were less important than bleeding risk and cardioprotective benefit. One year after the ACA survey, a 15% increase in adherence was observed in patients prescribed a preference-concordant CAT strategy. An increase of only 6% was noted in patients prescribed a preference-discordant strategy. Qualitative interviews showed that the ACA exercise contributed to increase inpatient activation, patient awareness of preferences, and patient engagement with clinicians about treatment decisions.
Conclusion: By working through trade-offs, patients actively clarified their preferences, learning about CAT risks, benefits, and self-management. Patients with medication regimens concordant with their preferences had increased medication adherence at 1 year compared to those with discordant medication regimens. The ACA task improved adherence through enhanced patient engagement regarding treatment preferences.

Keywords: patient preference, patient activation, medication adherence, risk–benefit communication, cardiovascular medications, gastrointestinal bleeding

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