Evaluating a digital decision aid for atrial fibrillation rhythm control in a hybrid implementation-effectiveness trial

Digital decision aids significantly improve shared decision-making outcomes, but barriers to implementation in clinical settings remain. We conducted a Hybrid Type 2 implementation-effectiveness trial of an atrial fibrillation rhythm control decision aid (clinicaltrials.gov NCT04993807; registered 08/06/2021) among 75 older adults across two sites. Guided by the RE-AIM framework, we assessed decision quality and implementation outcomes. While the decision aid was highly acceptable and broadly adopted, changes in decisional conflict and self-efficacy varied widely, with no significant average improvement across the cohort. Subgroup and qualitative analyses revealed that the decision aid was most effective when delivered to the right patient, at the right time, and in the right clinical context. Barriers included variability in health literacy, digital access, and timing of delivery relative to the clinical decision-making process. Findings underscore the challenges of deploying digital interventions within real-world workflows and highlight the importance of targeting decision support tools based on patient readiness, literacy, and care context.