Incorporating the patient perspective: a critical review of clinical practice guidelines for implantable cardioverter defibrillator therapy

Exploring approaches to identify, incorporate and report patient preferences in clinical guidelines: Qualitative interviews with guideline developers

BACKGROUND

Clinical guidelines informed by patient preferences are more likely to be used and widely advocated, yet research shows that few guidelines reflect patient preferences.

OBJECTIVE

Explore how developers generate guidelines informed by patient preferences.

PATIENT INVOLVEMENT

Seventeen patients were involved as interview participants.

METHODS

Using a basic descriptive approach, we conducted and analyzed semi-structured telephone interviews with 50 participants who were involved in developing guidelines on various topics. The sample included 17 patients, 16 clinicians and 17 managers from a total of 7 countries.

RESULTS

Participants used one or more approaches to identify preferences, patient panelists, focus groups, surveys and review of published research, despite acknowledging they identified similar preferences. Participants said they incorporated preferences in all guideline development steps, but provided little detail of specific processes. Few participants said their guidelines explicitly reported how patients were engaged, preferences identified, or how preferences influenced development processes or the guideline. Enablers were patient and clinician training, supportive coordinators and chairs, involving experienced patients, and assistance from qualitative and review experts. Barriers were finding and preparing patients, clinician skepticism about benefits, and token patient involvement. Participants recommended research on how to generate preference-informed guidelines.

DISCUSSION

Ideal approaches to identify, incorporate and report patient preferences in guidelines are unclear and unproven.

PRACTICAL VALUE

Findings revealed specific ways that developers can enhance their processes (e.g. patient training, supportive coordinators and chairs, involve experts in qualitative researcher and systematic reviews) and key issues that warrant ongoing research (e.g. how best to incorporate and report preferences).

How to identify, incorporate and report patient preferences in clinical guidelines: A scoping review

BACKGROUND

Clinical guidelines optimize care delivery and outcomes. Guidelines support patient engagement and adherence if they reflect patient preferences for treatment options, risks and benefits. Many guidelines do not address patient preferences. Developers require insight on how to develop such guidelines.

OBJECTIVE

To conduct a scoping review on how to identify, incorporate and report patient preferences in guidelines.

SEARCH

We searched MEDLINE, EMBASE, Scopus, CINAHL, OpenGrey and GreyLit from 2010 to November 2019.

ELIGIBILITY

We included English language studies describing patient preferences and guidelines.

DATA EXTRACTION AND SYNTHESIS

We reported approaches for and determinants and impacts of identifying patient preferences using summary statistics and text, and interpreted findings using a conceptual framework of patient engagement in guideline development.

RESULTS

Sixteen studies were included: 2 consulted patients and providers about patient engagement approaches, and 14 identified patient preferences (42.9%) or methods for doing so (71.4%). Studies employed single (57.1%) or multiple (42.9%) methods for identifying preferences. Eight (57.1%) incorporated preferences in one aspect of guideline development, while 6 (42.9%) incorporated preferences in multiple ways, most commonly to identify questions, benefits or harms, and generate recommendations. Studies did not address patient engagement in many guideline development steps. Included studies were too few to establish the best approaches for identifying or incorporating preferences. Fewer than half of the studies (7, 43.8%) explored barriers. None examined reporting preferences in guidelines.

CONCLUSIONS

Research is needed to establish the single or multiple approaches that result in incorporating and reporting preferences in all guideline development steps.

How do guideline developers identify, incorporate and report patient preferences? An international cross-sectional survey

Background

Guidelines based on patient preferences differ from those developed solely by clinicians and may promote patient adherence to guideline recommendations. There is scant evidence on how to develop patient-informed guidelines. This study aimed to describe how guideline developers identify, incorporate and report patient preferences.

Methods

We employed a descriptive cross-sectional survey design. Eligible organizations were non-profit agencies who developed at least one guideline in the past five years and had considered patient preferences in guideline development. We identified developers through the Guidelines International Network and publicly-available guideline repositories, administered the survey online, and used summary statistics to report results.

Results

The response rate was 18.3% (52/284). Respondents included professional societies, and government, academic, charitable and healthcare delivery organizations from 18 countries with at least 1 to ≥6 years of experience generating patient-informed guidelines. Organizations most frequently identified preferences through patient panelists (86.5%) and published research (84.6%). Most organizations (48, 92.3%) used multiple approaches to identify preferences (median 3, range 1 to 5). Most often, organizations used preferences to generate recommendations (82.7%) or establish guideline questions (73.1%). Few organizations explicitly reported preferences; instead, they implicitly embedded preferences in guideline recommendations (82.7%), questions (73.1%), or point-of-care communication tools (61.5%). Most developers had little capacity to generate patient-informed guidelines. Few offered training to patients (30.8%), or had dedicated funding (28.9%), managers (9.6%) or staff (9.6%). Respondents identified numerous barriers to identifying preferences. They also identified processes, resources and clinician- and patient-strategies that can facilitate the development of patient-informed guidelines. In contrast to identifying preferences, developers noted few approaches for, or barriers or facilitators of incorporating or reporting preferences.

Conclusions

Developers emphasized the need for knowledge on how to identify, incorporate and report patient preferences in guidelines. In particular, how to use patient preferences to formulate recommendations, and transparently report patient preferences and the influence of preferences on guidelines is unknown. Still, insights from responding developers may help others who may be struggling to generate guidelines informed by patient preferences.

Incorporating patients' preference diagnosis in implantable cardioverter defibrillator decision-making: a review of recent literature

PURPOSE OF REVIEW

Strong recommendations exist for implantable cardioverter defibrillators (ICD) in appropriately selected patients. Yet, patient preferences are not often incorporated when decisions about ICD therapy are made. Literature published since 2016 was reviewed aiming to discuss current advances and ongoing challenges with ICD decision-making in adults, discuss shared decision-making (SDM) as a strategy to incorporate preference diagnoses, summarize current evidence on effective interventions to facilitate SDM, and identify opportunities for research and practice.

RECENT FINDINGS

Advances in risk stratification can identify patients who will most and least likely benefit from the ICD. Interventions to support SDM are emerging. These interventions present options, the risks, and the benefits of each option, and elicit patients' values and preferences regarding possible outcomes.

SUMMARY

Appropriate patient selection for initial or continued ICD therapy is multifactorial. It requires accurate clinical diagnosis using careful risk stratification and accurate preference diagnosis based upon the patient's preferences. SDM aims to unite the elements that constitute these two equally important diagnoses. High-quality decision-making will be difficult to achieve if patients lack or misunderstand information, and if evolving patient preferences are not incorporated when making decisions.

A qualitative study of decision-making about the implantation of cardioverter defibrillators and deactivation during end-of-life care

Background

Implantable cardioverter defibrillators (ICDs) are recommended for patients at high risk of sudden cardiac death or for survivors of cardiac arrest. All ICDs combine a shock function with a pacing function to treat fast and slow heart rhythms, respectively. The pacing function may be very sophisticated and can provide so-called cardiac resynchronisation therapy for the treatment of heart failure using a pacemaker (cardiac resynchronisation therapy with pacemaker) or combined with an ICD [cardiac resynchronisation therapy with defibrillator (CRT-D)]. Decision-making about these devices involves considering the benefit (averting sudden cardiac death), possible risks (inappropriate shocks and psychological problems) and the potential need for deactivation towards the end of life.

Objectives

To explore patients’/relatives’ and clinicians’ views/experiences of decision-making about ICD and CRT-D implantation and deactivation, to establish how and when ICD risks, benefits and consequences are communicated to patients, to identify individual and organisational facilitators and barriers to discussions about implantation and deactivation and to determine information and decision-support needs for shared decision-making (SDM).

Data sources

Observations of clinical encounters, in-depth interviews and interactive group workshops with clinicians, patients and their relatives.

Methods

Observations of consultations with patients being considered for ICD or CRT-D implantation were undertaken to become familiar with the clinical environment and to optimise the sampling strategy. In-depth interviews were conducted with patients, relatives and clinicians to gain detailed insights into their views and experiences. Data collection and analysis occurred concurrently. Interactive workshops with clinicians and patients/relatives were used to validate our findings and to explore how these could be used to support better SDM.

Results

We conducted 38 observations of clinical encounters, 80 interviews (44 patients/relatives, seven bereaved relatives and 29 clinicians) and two workshops with 11 clinicians and 11 patients/relatives. Patients had variable knowledge about their conditions, the risk of sudden cardiac death and the clinical rationale for ICDs, which sometimes resulted in confusion about the potential benefits. Clinicians used various metaphors, verbal descriptors and numerical risk methods, including variable disclosure of the potential negative impact of ICDs on body image and the risk of psychological problems, to convey information to patients/relatives. Patients/relatives wanted more information about, and more involvement in, deactivation decisions, and expressed a preference that these decisions be addressed at the time of implantation. There was no consensus among clinicians about the initiation or timing of such discussions, or who should take responsibility for them. Introducing deactivation discussions prior to implantation was thus contentious; however, trigger points for deactivation discussions embedded within the pathway were suggested to ensure timely discussions.

Limitations

Only two patients who were prospectively considering deactivation and seven bereaved relatives were recruited. The study also lacks the perspectives of primary care clinicians.

Conclusions

There is discordance between patients and clinicians on information requirements, in particular the potential consequences of implantation on psychological well-being and quality of life in the short and long term (deactivation). There were no agreed points across the care pathway at which to discuss deactivation. Codesigned information tools that present balanced information on the benefits, risks and consequences, and SDM skills training for patients/relative and clinicians, would support better SDM about ICDs.

Future work

Multifaceted SDM interventions that focus on skills development for SDM combined with decision-support tools are warranted, and there is a potential central role for heart failure nurses and physiologists in supporting and preparing patients/relatives for such discussions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The gap between policy and practice: a systematic review of patient-centred care interventions in chronic heart failure

Patient-centred care (PCC) is recommended in policy documents for chronic heart failure (CHF) service provision, yet it lacks an agreed definition. A systematic review was conducted to identify PCC interventions in CHF and to describe the PCC domains and outcomes. Medline, Embase, CINAHL, PsycINFO, ASSIA, the Cochrane database, clinicaltrials.gov, key journals and citations were searched for original studies on patients with CHF staged II–IV using the New York Heart Association (NYHA) classification. Included interventions actively supported patients to play informed, active roles in decision-making about their goals of care. Search terms included ‘patient-centred care’, ‘quality of life’ and ‘shared decision making’. Of 13,944 screened citations, 15 articles regarding 10 studies were included involving 2540 CHF patients. Three studies were randomised controlled trials, and seven were non-randomised studies. PCC interventions focused on collaborative goal setting between patients and healthcare professionals regarding immediate clinical choices and future care. Core domains included healthcare professional-patient collaboration, identification of patient preferences, patient-identified goals and patient motivation. While the strength of evidence is poor, PCC has been shown to reduce symptom burden, improve health-related quality of life, reduce readmission rates and enhance patient engagement for patients with CHF. There is a small but growing body of evidence, which demonstrates the benefits of a PCC approach to care for CHF patients. Research is needed to identify the key components of effective PCC interventions before being able to deliver on policy recommendations.

Communicating risk using absolute risk reduction or prolongation of life formats: cluster-randomised trial in general practice

BACKGROUND

It is important that patients are well-informed about risks and benefits of therapies to help them decide whether to accept medical therapy. Different numerical formats can be used in risk communication but It remains unclear how the different formats affect decisions made by real-life patients.

AIM

To compare the impact of using Prolongation Of Life (POL) and Absolute Risk Reduction (ARR) information formats to express effectiveness of cholesterol-lowering therapy on patients' redemptions of statin prescriptions, and on patients' confidence in their decision and satisfaction with the risk communication.

DESIGN AND SETTING

Cluster-randomised clinical trial in general practices. Thirty-four Danish GPs from 23 practices participated in a primary care-based clinical trial concerning use of quantitative effectiveness formats for risk communication in health prevention consultations.

METHOD

GPs were cluster-randomised (treating practices as clusters) to inform patients about cardiovascular mortality risk and the effectiveness of statin treatment using either POL or ARR formats. Patients' redemptions of statin prescriptions were obtained from a regional prescription database. The COMRADE questionnaire was used to measure patients' confidence in their decision and satisfaction with the risk communication.

RESULTS

Of the 240 patients included for analyses, 112 were allocated to POL information and 128 to ARR. Patients redeeming a statin prescription totalled six (5.4%) when informed using POL, and 32 (25.0%) when using ARR. The level of confidence in decision and satisfaction with risk communication did not differ between the risk formats.

CONCLUSION

Patients redeemed statin prescriptions less often when their GP communicated treatment effectiveness using POL compared with ARR.

Refusing Implantable Cardioverter Defibrillator (ICD) Replacement in Elderly Persons-The Same as Giving Up Life: A Qualitative Study

BACKGROUND

More than 20% of implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices are implanted in the elderly population aged 80 years or older. In recent scientific literature it is suggested to consider termination of ICD therapy, rather than ICD replacement, in this patient group. The aim of this study was to explore the experiences of persons above 80 years of age concerning replacement of the ICD battery, and the shared communication and decision making with healthcare professionals.

METHODS

We performed a qualitative, explorative study, inspired by Ricoeur's narrative, with a phenomenological-hermeneutic approach, involving 11 ICD patients older than 80 years. The study period was 2011-2012.

RESULTS

The meaning of the patients' experiences of living with an ICD was formulated into two themes: (1) "Feeling safe with the ICD" with the subthemes: "The ICD-a life keeper," "The battery level is important," "ICD shock-no problem." (2) "The physician is an authority" with the subthemes: "Being trustful," "Feeling fine knowing nothing," "Criminal act to deactivate the ICD."

CONCLUSION

The elderly ICD recipients tended not to be aware of the option of declining replacement of their ICD. They tended to expect to have their ICD replaced and not to be involved actively in decision making concerning this. Healthcare professionals have an obligation to discuss options and ensure that every patient understands these. More research is needed to change practices and create more realistic, person-centered, ethically acceptable, and constructive healthcare for elderly persons with an ICD.