The Learning Curve for Shared Decision-making in Symptomatic Aortic Stenosis

Abstract

IMPORTANCE Shared decision-making (SDM) is widely advocated for patients with valvular heart disease yet is not integrated into the heart team model for patients with symptomatic aortic stenosis. Decision aids (DAs) have been shown to improve patient-centered outcomes and may facilitate SDM.OBJECTIVE To determine whether the repeated use of a DA by heart teams is associated with greater SDM, along with improved patient-centered outcomes and clinician attitudes about DAs. DESIGN, SETTING, AND PARTICIPANTSThis mixed-methods study included a nonrandomized pre-post intervention and clinician interviews. It was conducted between April 30, 2015, and December 7, 2017, with quantitative analysis performed between January 12, 2017, and May 26, 2017, within 2 academic medical centers in northern New England among 35 patients with symptomatic aortic stenosis who were at high to prohibitive risk for surgery. The qualitative analysis was performed between August 6, 2018, and May 7, 2019. The Severe Aortic Stenosis Decision Aid was delivered by 6 clinicians, with patients choosing between transcatheter aortic valve replacement and medical management.MAIN OUTCOMES AND MEASURES Clinician SDM performance was measured using the Observer OPTION 5 scale with dual-independent coding of audiotaped clinic visits. Previsit and postvisit surveys measured the patient's knowledge, satisfaction, and decisional conflict. Audiotaped clinician interviews were coded, and qualitative thematic analysis was performed.RESULTS Six male clinicians and 35 patients (19 of 34 women [55.9%; 1 survey was missing]; mean [SD] age, 85.8 [7.8] years) participated in the study. Shared decision-making increased stepwise with repeated use of the DA (mean [SD] Observer OPTION 5 scores: usual care, 17.9 [7.6]; first use of a DA, 60.5 [30.9]; fifth use of a DA, 79.0 [8.4]; P < .001 for comparison between usual care and fifth use of DA). Multiple uses of the DA were associated with increased patient knowledge (mean difference, 18.0%; 95% CI, 1.2%-34.8%; P = .04) and satisfaction (mean difference, 6.7%; 95% CI, 2.5%-10.8%; P = .01) but not decisional conflict (mean [SD]: usual care, 96.0% [9.4%]; first use of DA, 93.8% [12.5%]; fifth use of DA, 95.0% [11.2%]; P = .60). Qualitative analysis of clinicians' interviews revealed that clinicians perceived that they used an SDM approach without DAs and that the DA was not well understood by elderly patients. There was infrequent values clarification or discussion of stroke risk. CONCLUSION AND RELEVANCEIn a mixed-methods pilot study, use of a DA for severe aortic stenosis by heart team clinicians was associated with improved SDM and patient-centered outcomes. However, in qualitative interviews, heart team clinicians did not perceive a significant benefit of the DA, and therefore sustained implementation is unlikely. This pilot study of SDM clarifies new research directions for heart teams.

“What Is the Right Decision for Me?” Integrating Patient Perspectives Through Shared Decision-Making for Valvular Heart Disease Therapy

“…The recently revised United States Centers for Medicare and Medicaid Services National Coverage Determination for TAVR that drives health policy and funding models, used the strongest endorsement to date, but stressing that they "support patient SDM in AVR, but there is not a fully developed tool at this time". 2 The availability of evidence-based tools and other strategies to facilitate the integration of SDM in clinical care is of the highest priority to capitalize on this momentum, and gain credibility and adoption among multiple stakeholders. Patient-decision aids (PDAs) are designed to support the process of SDM, and help guide the conversation between patients and clinicians.…”

Shared Decision Making in the Heart Team: Current Team Attitudes and Review

“…These types of decisions are ideally driven by an approach termed shared decision making (SDM): a bidirectional exchange of information between physicians and patients, distinct from the one-way stream of information in patient education or informed consent. 1 However, this approach has not received wide application, perhaps due to a lack of understanding and/or support by Heart Team members. In this article we explore Heart Team attitudes to shared decision making by Heart Team members, review the current status of SDM for HVD, and consider the requirements for implementation of a SDM approach in clinical practice.…”

“…15 A recent study of SDM in patient with severe aortic stenosis found that Heart Team physicians perceive that patients have poor understanding of DAs despite patients' reports that SDM with DAs improved their knowledge and the quality of clinical encounters. 1 Taken together, it appears that physicians' attitudes towards SDM and DAs remain limited, which would render implementation unlikely. 1 Barriers and facilitators to SDM have been mainly identified from patients' perspectives.…”

“…1 Taken together, it appears that physicians' attitudes towards SDM and DAs remain limited, which would render implementation unlikely. 1 Barriers and facilitators to SDM have been mainly identified from patients' perspectives. 15,16 The most frequently identified barrier for patients is insufficient information support ("too little" or "unimportant").…”

“…Prior studies in cardiovascular care have emphasized the importance of DAs to promote SDM and demonstrated multiple benefits 24,25 , but implementation barriers at the clinician level are an important cause of underuse of DAs. 1 Recent studies support that in-consultation tools are often better in facilitating discussions between patient and clinician than those used outside the consultation. Currently, there are 3 publicly available DAs for patients with HVD.…”