ABC | Volume 110, Nº1, January 2018

Original Article Oral Anticoagulation in Atrial Fibrillation: Development and Evaluation of a Mobile Health Application to Support Shared Decision-Making Laura Siga Stephan, Eduardo Dytz Almeida, Raphael Boesche Guimarães, Antonio Gaudie Ley, Rodrigo Gonçalves Mathias, Maria Valéria Assis, Tiago Luiz Luz Leiria Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS – Brazil Mailing Addres: Tiago Luiz Luz Leiria • Av. Princesa Isabel, 370. Postal Code 90620-000, Santana, Porto Alegre, RS – Brazil E-mail: pesquisa.leiria@gmail.com, editoracao-pc@cardiologia.org.br Manuscript received November 17, 2016, revised manuscript June 23, 2017, accepted August 29, 2017 DOI: 10.5935/abc.20170181 Abstract Background: Atrial fibrillation is responsible for one in four strokes, which may be prevented by oral anticoagulation, an underused therapy around the world. Considering the challenges imposed by this sort of treatment, mobile health support for shared decision-making may improve patients’ knowledge and optimize the decisional process. Objective: To develop and evaluate a mobile application to support shared decision about thromboembolic prophylaxis in atrial fibrillation. Methods: We developed an application to be used during the clinical visit, including a video about atrial fibrillation, risk calculators, explanatory graphics and information on the drugs available for treatment. In the pilot phase, 30 patients interacted with the application, which was evaluated qualitatively and by a disease knowledge questionnaire and a decisional conflict scale. Results: The number of correct answers in the questionnaire about the disease was significantly higher after the interaction with the application (from 4.7 ± 1.8 to 7.2 ± 1.0, p < 0.001). The decisional conflict scale, administered after selecting the therapy with the app support, resulted in an average of 11 ± 16/100 points, indicating a low decisional conflict. Conclusions: The use of a mobile application during medical visits on anticoagulation in atrial fibrillation improves disease knowledge, enabling a shared decision with low decisional conflict. Further studies are needed to confirm if this finding can be translated into clinical benefit. (Arq Bras Cardiol. 2018; 110(1):7-15) Keywords: Anticoagulants / therapeutic use; Atrial Fibrillation; Stroke; Hemorrhage;MedicationAdherence; Telemedicine. Introduction Atrial fibrillation (AF) affects 33.5 million people in the world 1 and is the cause of 28% of strokes. 2 Prophylaxis with oral anticoagulants (OACs) can reduce the risk of stroke by 60-70%, 3-6 with a variable risk of bleeding. AF guidelines recommend the use of the CHA 2 DS 2 ‑VASc (for stroke) and HAS-BLED (for bleeding) risk scores to recognize those patients who will benefit the most from anticoagulants. 7-10 More recently, the SAMe-TT 2 R 2 score 11 was validated to predict a poor anticoagulation control with coumarins, contributing to the selection of the anticoagulant type. Although many scores are available, 12 their use should be done with caution. The current European guideline, 8 for example, recommends the use of bleeding scores to identify modifiable risk factors for major bleeding rather than to contraindicate anticoagulation. Besides, these scores do not take into account patients’ worries, objectives and values, and do not evaluate costs, posology, and frequency of visits to physician and exams, which influence adherence to treatment. 13 The complexity of such decision process is reflected in the suboptimal number of patients who receive an OAC prescription, maintain target coagulation and adhere to drug treatment. 13-15 New approaches for the management of chronic diseases have been patient-centered, in which the patient practices shared treatment decision making, leading to improved outcomes and efficacy of the health system. 16,17 Patients with AF are likely to benefit from these strategies, due to the importance of patient ownership of decisions that require patient action, such as taking the medication and monitoring of treatment. 18 Mobile health technology, or just mobile health (mHealth) – seems promising in expanding healthcare coverage, facilitating the decision-making process and improving the management of chronic diseases. 17-20 In 2015, more than 3 billion health app downloads were made worldwide. 21 It is important that this new technology includes other specific groups, such as the elderly and low-income adults with limited access to mobile communication. 18.22 In this article, we describe the development of a mHealth application to be used during medical visits, aiming to facilitate the shared decision-making on thromboembolic prophylaxis in AF. The app was tested in low-income patients with low educational attainment by the measurement of disease knowledge before and after its use. 7