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Tobita K, Sakamoto H, Inami T, Fujisawa D, Takeuchi K, Kikuchi H, Ito J, Goda A, Soejima K, Kohno T. Understanding Patient Perspectives Toward Shared Decision-Making in Patients With Pulmonary Hypertension. Am J Cardiol 2024; 212:23-29. [PMID: 37984635 DOI: 10.1016/j.amjcard.2023.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/15/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023]
Abstract
Clinical guidelines for pulmonary hypertension (PH) recommend shared decision-making and individualized treatment. However, patient perspectives on PH treatment goals, preference toward a decision-making style of treatment, and adoption of shared decision-making remain unclear. This cross-sectional questionnaire-based study assessed the patients' preferred and actual participation role in treatment decision-making, rated on 5 scales (ranging from passive [patients leave all decisions to physicians] to active [patients make the decision after physicians show patients several options]) and evaluated the concordance between preferred and actual participation roles. The important factors underlying patients' perspectives in treatment decision-making (i.e., prognosis; symptom, financial, family, and social burdens; patient values; and physician recommendation) were evaluated. Univariate logistic regression analysis was performed to determine the patients with a positive preference toward "physician recommendation" in treatment decision-making. Among 130 patients with PH (median age: 58 years; mean pulmonary arterial pressure: 23 mm Hg; 27.7% were males), 59.2% preferred that "physicians make the decision regarding treatment after showing patients therapeutic options (i.e., intermediate between passive and active roles)." The patient-preferred and actual participation roles in decision-making had moderate agreement (Cohen's kappa = 0.46). The most important factor in treatment decisions was "symptom burden reduction" (93.8%). Although 85.0% of patients chose "physician recommendation" as an important factor, 49.6% chose "alignment with my values." The determinants of patients who chose "physician recommendation" were less severe hemodynamics and better functional capacity. In conclusion, patients with PH preferred that the "physicians make the decision after showing patients therapeutic options" and prioritized physician recommendation over their values.
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Affiliation(s)
- Kazuki Tobita
- Department of Physical Therapy, Saitama Medical University Faculty of Health and Medical Care, Saitama, Japan; Departments of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Hayato Sakamoto
- Department of Rehabilitation, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Takumi Inami
- Departments of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Daisuke Fujisawa
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Kaori Takeuchi
- Departments of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Hanako Kikuchi
- Departments of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Junnosuke Ito
- Departments of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Ayumi Goda
- Departments of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Kyoko Soejima
- Departments of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Departments of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan.
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Montembeau SC, Merchant FM, Speight C, Kramer DB, Matlock DD, Horný M, Dickert NW, Rao BR. Patients' Perspectives Regarding Generator Exchanges of Implantable Cardioverter Defibrillators. Circ Cardiovasc Qual Outcomes 2023; 16:509-518. [PMID: 37492959 PMCID: PMC10524607 DOI: 10.1161/circoutcomes.122.009827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/25/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Shared decision-making is mandated for patients receiving primary prevention implantable cardioverter defibrillators (ICDs). Less attention has been paid to generator exchange decisions, although at the time of generator exchange, patients' risk of sudden cardiac death, risk of procedural complications, quality of life, or prognosis may have changed. This study was designed to explore how patients make ICD generator exchange decisions. METHODS Emory Healthcare patients with primary prevention ICDs implanted from 2013 to 2021 were recruited to complete in-depth interviews exploring perspectives regarding generator exchanges. Interviews were conducted in 2021. Transcribed interviews were qualitatively coded using multilevel template analytic methods. To investigate benefit thresholds for pursuing generator exchanges, patients were presented standard-gamble type hypothetical scenarios where their ICD battery was depleted but their 5-year risk of sudden cardiac death at that time varied (10%, 5%, and 1%). RESULTS Fifty patients were interviewed; 18 had a prior generator exchange, 16 had received ICD therapy, and 17 had improved left ventricular ejection fraction. As sudden cardiac death risk decreased from 10% to 5% to 1%, the number of participants willing to undergo a generator exchange decreased from 48 to 42 to 33, respectively. Responses suggest that doctor's recommendations are likely to substantially impact patients' decision-making. Other drivers of decision-making included past experiences with ICD therapy and device implantation, as well as risk aversion. Therapeutic inertia and misconceptions about ICD therapy were common and represent substantive barriers to effective shared decision-making in this context. CONCLUSIONS Strong defaults may exist to continue therapy and exchange ICD generators. Updated risk stratification may facilitate shared decision-making and reduce generator exchanges in very low-risk patients, especially if these interventions are directed toward clinicians. Interventions targeting phenomena such as therapeutic inertia may be more impactful and warrant exploration in randomized trials.
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Affiliation(s)
- Sarah C. Montembeau
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Faisal M. Merchant
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Candace Speight
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Daniel B. Kramer
- The Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Daniel D. Matlock
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO
| | - Michal Horný
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
- Department of Health Policy and Management Rollins School of Public Health, Atlanta, GA
| | - Neal W. Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Birju R. Rao
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
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Hasan MR, Tabassum T, Tabassum T, Tanbir MA, Kibria M, Chowduary M, Nambiar R. Navigating Cultural Diversity in the Selection of Cardiovascular Device Treatments: A Comprehensive Review. Cureus 2023; 15:e38934. [PMID: 37313070 PMCID: PMC10259755 DOI: 10.7759/cureus.38934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/15/2023] Open
Abstract
In cardiology, patients' cultural beliefs, linguistic differences, lack of knowledge, and socioeconomic status can create barriers to choosing device treatment. To address this issue, we conducted a thorough literature review using online databases such as PubMed, Google Scholar, and Texas Tech University Health Sciences Center's research portal. Our review found that cultural, religious, and linguistic barriers can contribute to patients' apprehension and reservations about device placement. These barriers can also impact patients' adherence to treatment and clinical outcomes. Patients from lower socioeconomic backgrounds may have difficulty accessing and affording device-based treatments. Additionally, fear and inadequate understanding of surgical procedures can deter patients from accepting device treatment in cardiology. To overcome these cultural barriers, healthcare providers must raise awareness about the benefits of device treatment and provide better training to overcome these challenges. It is crucial to address the unique needs of patients from different cultural backgrounds and socioeconomic statuses to ensure they receive the care they need.
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Affiliation(s)
- Md Rockyb Hasan
- Department of Internal Medicine, Amarillo Campus, Texas Tech University Health Sciences Center, Amarillo, USA
| | - Tahsin Tabassum
- Department of Public Health, School of Community Health and Policy, Morgan State University, Baltimore, USA
| | - Tanzin Tabassum
- Department of General Surgery, West Suffolk Hospital, Bury St Edmunds, GBR
| | - Mohammed A Tanbir
- Department of Internal Medicine, Amarillo Campus, Texas Tech University Health Sciences Center, Amarillo, USA
| | - Mahzabin Kibria
- Department of Medicine, Sir Salimullah Medical College, Dhaka, BGD
| | - Mahidul Chowduary
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, USA
| | - Rajesh Nambiar
- Department of Cardiology, Amarillo Campus, Texas Tech University Health Sciences Center, Amarillo, USA
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Knoepke CE, Wallace BC, Allen LA, Lewis CL, Gupta SK, Peterson PN, Kramer DB, Brancato SC, Varosy PD, Mandrola JM, Tzou WS, Matlock DD. Experiences Implementing a Suite of Decision Aids for Implantable Cardioverter Defibrillators: Qualitative Insights From the DECIDE-ICD Trial. Circ Cardiovasc Qual Outcomes 2022; 15:e009352. [PMID: 36378770 PMCID: PMC9680003 DOI: 10.1161/circoutcomes.122.009352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/05/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Shared decision making (SDM) is gaining importance in cardiology, including Centers for Medicare & Medicaid Services (CMS) reimbursement policies requiring documented SDM for patients considering primary prevention implantable cardioverter defibrillators. The DECIDE-ICD Trial (Decision Support Intervention for Patients offered implantable Cardioverter-Defibrillators) assessed the implementation and effectiveness of patient decision aids (DAs) using a stepped-wedge design at 7 sites. The purpose of this subanalysis was to qualitatively describe electrophysiology clinicians' experience implementing and using the DAs. METHODS This included semi-structured individual interviews with electrophysiology clinicians at participating sites across the US, at least 6 months following conversion into the implementation phase of the trial (from June 2020 through February 2022). The interview guide was structured according to the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance [implementation evaluation model]) framework, assessing clinician experiences, which can impact implementation domains, and was qualitatively assessed using a mixed inductive/deductive method. RESULTS We completed 22 interviews post-implementation across all 7 sites. Participants included both physicians (n=16) and other clinicians who counsel patients regarding treatment options (n=6). While perception of SDM and the DA were positive, participants highlighted reasons for uneven delivery of DAs to appropriate patients. The CMS mandate for SDM was not universally viewed as associating with patients receiving DA's, but rather (1) logistics of DA delivery, (2) perceived effectiveness in improving patient decision-making, and (3) match of DA content to current patient populations. Remaining tensions include the specific trial data used in DAs and reconciling timing of delivery with when patients are actively making decisions. CONCLUSIONS Clinicians charged with delivering DAs to patients considering primary prevention implantable cardioverter defibrillators were generally supportive of the tenets of SDM, and of the DA tools themselves, but noted several opportunities to improve the reach and continued use of them in routine care. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique Identifier: NCT03374891.
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Affiliation(s)
- Christopher E. Knoepke
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bryan C. Wallace
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Larry A. Allen
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carmen L. Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | - Pamela N. Peterson
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health Medical Center, Denver, CO, USA
| | - Daniel B. Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Paul D. Varosy
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
- Cardiology Section, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | | | - Wendy S. Tzou
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel D. Matlock
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
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Eckhardt LL, Kalscheur MM. Machine Learning in CRT Outcomes: Implementing the Right Tool for the Right Outcome. JACC Clin Electrophysiol 2021; 7:1516-1518. [PMID: 34949420 DOI: 10.1016/j.jacep.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/01/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Lee L Eckhardt
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA; Cellular and Molecular Arrhythmia Research Program, University of Wisconsin-Madison, Madison, Wisconsin, USA.
| | - Matthew M Kalscheur
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA; Section of Cardiovascular Medicine, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
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Chaussee EL, Dickinson LM, Fairclough DL. Evaluation of a covariate-constrained randomization procedure in stepped wedge cluster randomized trials. Contemp Clin Trials 2021; 105:106409. [PMID: 33894362 DOI: 10.1016/j.cct.2021.106409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 01/11/2023]
Abstract
In stepped wedge (SW) designs, differing cluster-level characteristics or individual-level covariate distributions that differ by cluster can lead to imbalance by treatment arm and potential confounding of the treatment effect. Adapting a method used in cluster-randomized trials, we propose a covariate-constrained randomization method to be used in SW designs. First, we define a balance metric to be calculated for all possible randomizations of cluster order for a given SW design. The resulting distribution of this balance metric across all possible randomizations is used to select a candidate set of randomizations with acceptable covariate balance. One cluster order is selected at random from this candidate set to be used as the cluster order for treatment implementation. In a simulation study, we implement the covariate-constrained randomization procedure and compare treatment effect estimation, type I error, and power under varying SW design and confounding settings, and using multiple analysis methods. We observed optimal statistical properties when the balance metric was used to exclude a small set of potential randomizations with the highest level of imbalance, and when analysis methods were adjusted for the potential confounders. The covariate-constrained randomization was most beneficial in settings with a small number of clusters and in the presence of cluster-level confounding.
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Affiliation(s)
- Erin Leister Chaussee
- Adult & Child Consortium for Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Biostatistics & Informatics, Colorado School of Public Health, Aurora, CO, United States of America.
| | - L Miriam Dickinson
- Adult & Child Consortium for Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Biostatistics & Informatics, Colorado School of Public Health, Aurora, CO, United States of America; Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Diane L Fairclough
- Adult & Child Consortium for Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Biostatistics & Informatics, Colorado School of Public Health, Aurora, CO, United States of America
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Kramer DB. Mandates for Shared Decisions: Means to which Ends? THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2021; 49:630-632. [PMID: 35006044 PMCID: PMC9749894 DOI: 10.1017/jme.2021.86] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
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