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Perpetua EM, Palmer R, Le VT, Al-Khatib SM, Beavers CJ, Beckman JA, Bozkurt B, Coylewright M, Lloyd Doherty C, Guibone KA, Hawkey M, Keegan PA, Kirkpatrick JN, Laperle J, Lauck SB, Levine G, Lindman BR, Mack MJ, Price AL, Strong S, Wyman JF, Youmans QR, Gulati M. JACC: Advances Expert Panel Perspective: Shared Decision-Making in Multidisciplinary Team-Based Cardiovascular Care. JACC. ADVANCES 2024; 3:100981. [PMID: 39130036 PMCID: PMC11312306 DOI: 10.1016/j.jacadv.2024.100981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/25/2024] [Accepted: 02/28/2024] [Indexed: 08/13/2024]
Abstract
Shared decision-making (SDM) and multidisciplinary team-based care delivery are recommended across several cardiology clinical practice guidelines. However, evidence for benefit and guidance on implementation are limited. Informed consent, the use of patient decision aids, or the documentation of these elements for governmental or societal agencies may be conflated as SDM. SDM is a bidirectional exchange between experts: patients are the experts on their goals, values, and preferences, and clinicians provide their expertise on clinical factors. In this Expert Panel perspective, we review the current state of SDM in team-based cardiovascular care and propose best practice recommendations for multidisciplinary team implementation of SDM.
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Affiliation(s)
- Elizabeth M. Perpetua
- Empath Health Services, Seattle, Washington, USA
- School of Nursing, Department of Biobehavioral Nursing and Informatics, University of Washington, Seattle, Washington, USA
| | - Roseanne Palmer
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Viet T. Le
- Intermountain Health, Salt Lake City, Utah, USA
| | - Sana M. Al-Khatib
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Craig J. Beavers
- University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Joshua A. Beckman
- Southwestern Medical Center, University of Texas, Dallas, Texas, USA
| | | | | | | | | | - Marian Hawkey
- Hackensack University Medical Center, Heart and Vascular Hospital, Hackensack, New Jersey, USA
| | - Patricia A. Keegan
- Columbia University Irving Medical Center, Center of Interventional Therapy, New York, New York, USA
| | - James N. Kirkpatrick
- Emory Healthcare, Heart and Vascular, Atlanta, Georgia, USA
- Departments of Medicine and Bioethics and Humanities, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Jessica Laperle
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Sandra B. Lauck
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Brian R. Lindman
- Vanderbilt University Medical Center, Division of Cardiovascular Medicine, Nashville, Tennessee, USA
| | | | | | | | - Janet F. Wyman
- Department of Structural Heart, Division of Cardiovascular Medicine, Henry Ford health System, Detroit, Michigan, USA
| | - Quentin R. Youmans
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Martha Gulati
- Preventive Cardiology, Barbra Streisand Women's Heart Center, Preventive and Cardiac Rehabilitation Center, Women's Cardiovascular Medicine & Research, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California, USA
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2
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Billy MJ, Brennan Z, Ahmad T, Conte JV, Wallen TJ. Time From First Contact With Heart Team to Transcatheter Aortic Valve Replacement in the COVID-19 Era. Cureus 2023; 15:e41837. [PMID: 37575844 PMCID: PMC10423063 DOI: 10.7759/cureus.41837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
OBJECTIVE Transcatheter aortic valve replacement (TAVR) has become the dominant form of aortic valve replacement in the United States. During the Coronavirus disease 2019 (COVID-19) pandemic, access to elective surgical care was decreased, particularly for TAVR patients. In this study, we examine the impact of each COVID-19 "wave," on our patient's access to TAVR procedures and their associated outcomes. Methods: After institutional review board approval, we conducted a retrospective review of a prospectively maintained database and a review of our own center's database to assess time to TAVR pre-COVID-19 and during internally defined COVID-19 "waves." Statistical analysis was conducted via a t-test. RESULTS We measured the time from first contact to TAVR and compared each COVID-19 wave to our institution's pre-COVID-19 data. During Wave 1 and 2 of COVID-19, our mean time to TAVR increased significantly to 68.44 ± 48.66 days (p = 0.05) and 68.94 ± 53.16 days (p = 0.02), respectively. All three COVID-19 waves demonstrated a statistically significant increase in all-cause mortality post-operatively (PO) with mean PO mortality of 2.5 (p = 0.0035), 1.33 (p = 0.0009), and 0.67 (p = 0.006), respectively, compared to pre-COVID-19 data. Conclusions: Multiple studies have shown that increased time from first contact to TAVR results in increased morbidity and mortality. COVID-19 increased our institution's time to TAVR significantly across two waves with an increase in all-cause mortality in each wave. This study highlights the importance that institutions should develop mechanisms to ensure access to care during crises so that patients do not face potentially avoidable harm.
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Affiliation(s)
- Matthew J Billy
- General Surgery, Geisinger Commonwealth School of Medicine, Scranton, USA
| | - Zachary Brennan
- Surgery, Michigan State University College of Osteopathic Medicine, East Lansing, USA
| | - Tariq Ahmad
- Interventional Cardiology, Geisinger Commonwealth School of Medicine, Wilkes-Barre, USA
| | - John V Conte
- Cardiothoracic Surgery, Geisinger Commonwealth School of Medicine, Wilkes-Barre, USA
| | - Tyler J Wallen
- Cardiovascular Surgery, Geisinger Commonwealth School of Medicine, Wilkes-Barre, USA
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3
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Col NF, Otero D, Lindman BR, Horne A, Levack MM, Ngo L, Goodloe K, Strong S, Kaplan E, Beaudry M, Coylewright M. What matters most to patients with severe aortic stenosis when choosing treatment? Framing the conversation for shared decision making. PLoS One 2022; 17:e0270209. [PMID: 35951553 PMCID: PMC9371337 DOI: 10.1371/journal.pone.0270209] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Guidelines recommend including the patient’s values and preferences when choosing treatment for severe aortic stenosis (sAS). However, little is known about what matters most to patients as they develop treatment preferences. Our objective was to identify, prioritize, and organize patient-reported goals and features of treatment for sAS.
Methods
This multi-center mixed-methods study conducted structured focus groups using the nominal group technique to identify patients’ most important treatment goals and features. Patients separately rated and grouped those items using card sorting techniques. Multidimensional scaling and hierarchical cluster analyses generated a cognitive map and clusters.
Results
51 adults with sAS and 3 caregivers with experience choosing treatment (age 36–92 years) were included. Participants were referred from multiple health centers across the U.S. and online. Eight nominal group meetings generated 32 unique treatment goals and 46 treatment features, which were grouped into 10 clusters of goals and 11 clusters of features. The most important clusters were: 1) trust in the healthcare team, 2) having good information about options, and 3) long-term outlook. Other clusters addressed the need for and urgency of treatment, being independent and active, overall health, quality of life, family and friends, recovery, homecare, and the process of decision-making.
Conclusions
These patient-reported items addressed the impact of the treatment decision on the lives of patients and their families from the time of decision-making through recovery, homecare, and beyond. Many attributes had not been previously reported for sAS. The goals and features that patients’ value, and the relative importance that they attach to them, differ from those reported in clinical trials and vary substantially from one individual to another. These findings are being used to design a shared decision-making tool to help patients and their clinicians choose a treatment that aligns with the patients’ priorities.
Trial registration
ClinicalTrials.gov, Trial ID: NCT04755426, Trial URL https://clinicaltrials.gov/ct2/show/NCT04755426.
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Affiliation(s)
- Nananda F. Col
- Shared Decision Making Resources, Georgetown, ME and University of New England, Biddeford, Maine, United States of America
- * E-mail:
| | - Diana Otero
- Department of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States of America
| | - Brian R. Lindman
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Aaron Horne
- HeartCare Specialists, Medical City North Hills, North Richland Hills, Texas, United States of America
| | - Melissa M. Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Long Ngo
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kimberly Goodloe
- American Heart Association Ambassador, Atlanta, Georgia, United States of America
| | - Susan Strong
- Heart Valve Voice US, Washington DC, United States of America
| | - Elvin Kaplan
- Patient Collaborator, Brownsville, Vermont, United States of America
| | - Melissa Beaudry
- Central Vermont Medical Center, Berlin, Vermont, United States of America
| | - Megan Coylewright
- Department of Cardiovascular Medicine, The Erlanger Heart and Lung Institute, Chattanooga, Tennessee, United States of America
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Bohmann K, Burgdorf C, Zeus T, Joner M, Alvarez H, Berning KL, Schikowski M, Kasel AM, van Mark G, Deutsch C, Kurucova J, Thoenes M, Frank D, Wundram S, Bramlage P, Miller B, Veulemans V. The COORDINATE Pilot Study: Impact of a Transcatheter Aortic Valve Coordinator Program on Hospital and Patient Outcomes. J Clin Med 2022; 11:jcm11051205. [PMID: 35268296 PMCID: PMC8910867 DOI: 10.3390/jcm11051205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 12/03/2022] Open
Abstract
The transcatheter aortic valve implantation (TAVI) treatment pathway is complex, leading to procedure-related delays. Dedicated TAVI coordinators can improve pathway efficiency. COORDINATE was a pilot observational prospective registry at three German centers that enrolled consecutive elective patients with severe aortic stenosis undergoing TAVI to investigate the impact a TAVI coordinator program. Pathway parameters and clinical outcomes were assessed before (control group) and after TAVI coordinator program implementation (intervention phase). The number of repeated diagnostics remained unchanged after implementation. Patients with separate hospitalizations for screening and TAVI had long delays, which increased after implementation (65 days pre- vs. 103 days post-implementation); hospitalizations combining these were more efficient. The mean time between TAVI and hospital discharge remained constant. Nurse (p = 0.001) and medical technician (p = 0.008) working hours decreased. Patient satisfaction increased, and more consistent/intensive contact between patients and staff was reported. TAVI coordinators provided more post-TAVI support, including discharge management. No adverse effects on post-procedure or 30-day outcomes were seen. This pilot suggests that TAVI coordinator programs may improve aspects of the TAVI pathway, including post-TAVI care and patient satisfaction, without compromising safety. These findings will be further investigated in the BENCHMARK registry.
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Affiliation(s)
- Katja Bohmann
- Cardiothoracic Surgery Department, Heart and Vessel Center Bad Bevensen, 29549 Bad Bevensen, Germany; (K.B.); (M.S.)
| | - Christof Burgdorf
- Cardiology Department, Heart and Vessel Center Bad Bevensen, 29549 Bad Bevensen, Germany;
| | - Tobias Zeus
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, 40225 Düsseldorf, Germany; (T.Z.); (K.L.B.); (V.V.)
| | - Michael Joner
- German Heart Center Munich, 80636 Munich, Germany; (M.J.); (H.A.); (A.M.K.)
| | - Héctor Alvarez
- German Heart Center Munich, 80636 Munich, Germany; (M.J.); (H.A.); (A.M.K.)
| | - Kira Lisanne Berning
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, 40225 Düsseldorf, Germany; (T.Z.); (K.L.B.); (V.V.)
| | - Maren Schikowski
- Cardiothoracic Surgery Department, Heart and Vessel Center Bad Bevensen, 29549 Bad Bevensen, Germany; (K.B.); (M.S.)
| | - Albert Markus Kasel
- German Heart Center Munich, 80636 Munich, Germany; (M.J.); (H.A.); (A.M.K.)
- Cardiology Department, University Heart Centre, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Gesine van Mark
- Institute for Pharmacology and Preventive Medicine, 49661 Cloppenburg, Germany; (G.v.M.); (C.D.); (P.B.)
| | - Cornelia Deutsch
- Institute for Pharmacology and Preventive Medicine, 49661 Cloppenburg, Germany; (G.v.M.); (C.D.); (P.B.)
| | | | | | - Derk Frank
- Internal Medicine III (Cardiology, Angiology and Intensive Care Medicine) Department, UKSH University Clinical Center Schleswig-Holstein, 24105 Kiel, Germany;
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, 24105 Kiel, Germany
- Correspondence: ; Tel.: +49-431-5002-2801
| | - Steffen Wundram
- Internal Medicine III (Cardiology, Angiology and Intensive Care Medicine) Department, UKSH University Clinical Center Schleswig-Holstein, 24105 Kiel, Germany;
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, 24105 Kiel, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, 49661 Cloppenburg, Germany; (G.v.M.); (C.D.); (P.B.)
| | | | - Verena Veulemans
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, 40225 Düsseldorf, Germany; (T.Z.); (K.L.B.); (V.V.)
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5
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Heen AF, Lytvyn L, Shapiro M, Guyatt GH, Siemieniuk RAC, Zhang Y, Manja V, Vandvik PO, Agoritsas T. Patient values and preferences on valve replacement for aortic stenosis: a systematic review. Heart 2021; 107:1289-1295. [PMID: 33563630 PMCID: PMC8327404 DOI: 10.1136/heartjnl-2020-318334] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 12/14/2022] Open
Abstract
The review aims to summarise evidence addressing patients’ values, preferences and practical issues on deciding between transcatheter aortic valve insertion (TAVI) and surgical aortic valve replacement (SAVR) for aortic stenosis. We searched databases and grey literature until June 2020. We included studies of adults with aortic stenosis eliciting values and preferences about treatment, excluding medical management or palliative care. Qualitative findings were synthesised using thematic analysis, and quantitative findings were narratively described. Evidence certainty was assessed using CERQual (Confidence in the Evidence from Reviews of Qualitative Research) and GRADE (Grading of Recommendations Assessment, Development and Evaluation). We included eight studies. Findings ranged from low to very low certainty. Most studies only addressed TAVI. Studies addressing both TAVI and SAVR reported on factors affecting patients’ decision-making along with treatment effectiveness, instead of trade-offs between procedures. Willingness to accept risk varied considerably. To improve their health status, participants were willing to accept higher mortality risk than current evidence suggests for either procedure. No study explicitly addressed valve reintervention, and one study reported variability in willingness to accept shorter duration of known effectiveness of TAVI compared with SAVR. The most common themes were desire for symptom relief and improved function. Participants preferred minimally invasive procedures with shorter hospital stay and recovery. The current body of evidence on patients’ values, preferences and practical issues related to aortic stenosis management is of suboptimal rigour and reports widely disparate results regarding patients’ perceptions. These findings emphasise the need for higher quality studies to inform clinical practice guidelines and the central importance of shared decision-making to individualise care fitted to each patient.
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Affiliation(s)
- Anja Fog Heen
- Department of Medicine, Innlandet Hospital Trust Gjøvik Hospital, Brumunddal, Norway
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | | | - Gordon Henry Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | | | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Veena Manja
- Department of Surgery, University of California Davis, Sacramento, California, USA.,Department of Medicine, Veterans Affairs Northern California Health Care System, Mather, California, USA
| | - Per Olav Vandvik
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.,Division of General Internal Medicine, Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
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6
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Lysell E, Wolf A. Patients' experiences of everyday living before and after transcatheter aortic valve implantation. Scand J Caring Sci 2020; 35:788-795. [PMID: 32781491 DOI: 10.1111/scs.12893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/21/2020] [Accepted: 07/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aortic stenosis (AS) is the most common valvular disease in western countries. Unless treated, it is associated with a poor prognosis. Surgical aortic valve replacement, the gold-standard approach, aims to increase survival and improve quality of life. In recent years, though, transcatheter aortic valve implantation (TAVI) has become the treatment of choice in elderly, high-risk patients who are denied open surgery. To date, however, little is known about their personal psychological experience after undergoing TAVI. AIM This study aimed to explore patients' experiences during everyday life before and after TAVI. METHOD Altogether, 14 elderly Swedish patients (9 women, 5 men), treated with TAVI, were interviewed between 2 and 6 months after the implantation. The interviews were analysed using qualitative content analysis. RESULTS Analysis of the participants' experiences was divided into two domains: before and after, that is, life with AS vs. life after TAVI. From these domains, four categories were derived: (1) adapting to the deteriorating self; (2) feeling disconnected; (3) reconstruction of self; and (4) processing disappointment. CONCLUSIONS Transcatheter aortic valve implantation involves not only adding years to life but also adding life to years. The urge to live an autonomous life in a social context with others is an important argument for undergoing a TAVI procedure. Despite severe illness and demanding rehabilitation, elderly TAVI patients have the ability to regain independence and rebuild their lives when they base their decision to undergo TAVI on personal goals. These findings might be helpful when implementing person-centred care.
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Affiliation(s)
- Eva Lysell
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Region VästraGötaland, Gothenburg, Sweden
| | - Axel Wolf
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital/Östra, Region VästraGötaland, Gothenburg, Sweden.,Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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7
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van Beek-Peeters JJAM, van Noort EHM, Faes MC, de Vos AJBM, van Geldorp MWA, Minkman MMN, van der Meer NJM. Shared decision making in older patients with symptomatic severe aortic stenosis: a systematic review. Heart 2020; 106:647-655. [PMID: 32001621 DOI: 10.1136/heartjnl-2019-316055] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/24/2019] [Accepted: 12/19/2019] [Indexed: 12/18/2022] Open
Abstract
This review provides an overview of the status of shared decision making (SDM) in older patients regarding treatment of symptomatic severe aortic stenosis (SSAS). The databases Embase, Medline Ovid, Cinahl and Cochrane Dare were searched for relevant studies from January 2002 to May 2018 regarding perspectives of professionals, patients and caregivers; aspects of decision making; type of decision making; application of the six domains of SDM; barriers to and facilitators of SDM. The systematic search yielded 1842 articles, 15 studies were included. Experiences of professionals and informal caregivers with SDM were scarcely found. Patient refusal was a frequently reported result of decision making, but often no insight was given into the decision process. Most studies investigated the 'decision' and 'option' domains of SDM, yet no study took all six domains into account. Problem analysis, personalised treatment aims, use of decision aids and integrating patient goals in decisions lacked in all studies. Barriers to and facilitators of SDM were 'individualised formal and informal information support' and 'patients' opportunity to use their own knowledge about their health condition and preferences for SDM'. In conclusion, SDM is not yet common practice in the decision making process of older patients with SSAS. Moreover, the six domains of SDM are not often applied in this process. More knowledge is needed about the implementation of SDM in the context of SSAS treatment and how to involve patients, professionals and informal caregivers.
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Affiliation(s)
| | | | - Miriam C Faes
- Department of Geriatrics, Amphia Hospital, Breda, The Netherlands
| | | | | | - Mirella M N Minkman
- TIAS, School for Business and Society, Tilburg University, Tilburg, The Netherlands.,Vilans, Centre of Expertise for Long-term Care, Utrecht, The Netherlands
| | - Nardo J M van der Meer
- TIAS, School for Business and Society, Tilburg University, Tilburg, The Netherlands.,Department of Anesthesiology, Amphia Hospital, Breda, The Netherlands
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8
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Abstract
Background Rapid growth in transcatheter aortic valve replacement (TAVR) demand has translated to inadequate access, reflected by prolonged wait times. Increasing wait times are associated with important adverse outcomes while on the wait‐list; however, it is unknown if prolonged wait times influence postprocedural outcomes. Our objective was to determine the association between TAVR wait times and postprocedural outcomes. Methods and Results In this population‐based study in Ontario, Canada, we identified all TAVR procedures between April 1, 2010, and March 31, 2016. Wait time was defined as the number of days between initial referral and the procedure. Primary outcomes of interest were 30‐day all‐cause mortality and all‐cause readmission. Multivariable regression models incorporated wait time as a nonlinear variable, using cubic splines. The study cohort included 2170 TAVR procedures, of which 1741 cases were elective and 429 were urgent. There was a significant, nonlinear relationship between TAVR wait time and post‐TAVR 30‐day mortality, as well as 30‐day readmission. We observed an increased hazard associated with shorter wait times that diminished as wait times increased. This statistically significant nonlinear relationship was seen in the unadjusted model as well as after adjusting for clinical variables. However, after adjusting for case urgency status, there was no relationship between wait times and postprocedural outcomes. In sensitivity analyses restricted to either only elective or only urgent cases, there was no relationship between wait times and postprocedural outcomes. Conclusions Wait time has a complex relationship with postprocedural outcomes that is mediated entirely by urgency status. This suggests that further research should elucidate factors that predict hospitalization requiring urgent TAVR while on the wait list.
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9
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Olsson K, Näslund U, Nilsson J, Hörnsten Å. Hope and despair: patients' experiences of being ineligible for transcatheter aortic valve implantation. Eur J Cardiovasc Nurs 2019; 18:593-600. [PMID: 31113221 DOI: 10.1177/1474515119852209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation may be indicated for patients with aortic stenosis and high risk of postoperative mortality. The assessment of suitability for transcatheter aortic valve implantation requires consensus agreement of a team of cardiologists and cardiac surgeons. The burden of comorbidities, frailty and cognitive impairment are factors included when risks for transcatheter aortic valve implantation are balanced against the expected benefits. Although transcatheter aortic valve implantation is a possibility for many, there are still ineligible patients. Knowledge of their experiences of being deemed ineligible are lacking. AIM The aim of this study was to explore patients' experiences of being considered for transcatheter aortic valve implantation but judged ineligible. METHODS Individual in-depth interviews were performed with eight persons, and qualitative content analysis was used for the analysis. RESULTS Being ineligible for transcatheter aortic valve implantation may induce both hope and despair. Hope was linked to experiences of acceptance, relief of symptoms, support and control; despair was associated with feelings of being missed and abandoned, and of grief and insecurity. Some expressed great anxiety, since their incurable heart disease meant an imminent death. Others were more concerned over practical problems that affected everyday life. CONCLUSION Being ineligible for transcatheter aortic valve implantation does not necessarily lead to despair. Hope is built through relationships, continuity and support. A combination of person-centred care and palliative care during the end-of-life phase should be offered to patients in order to help clients re-conceptualise hope during this stage of their illness. Cardiovascular nurses in the transcatheter aortic valve implantation team are suitable to facilitate continued care based on the patient's needs, desires and local conditions.
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Affiliation(s)
- Karin Olsson
- Heart Centre, Umeå University, Sweden.,Department of Public Health and Clinical Medicine, Umeå University, Sweden.,Department of Nursing, Umeå University, Sweden
| | - Ulf Näslund
- Heart Centre, Umeå University, Sweden.,Department of Public Health and Clinical Medicine, Umeå University, Sweden
| | - Johan Nilsson
- Heart Centre, Umeå University, Sweden.,Department of Public Health and Clinical Medicine, Umeå University, Sweden
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10
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Faridi KF, Yeh RW, Poulin M. Treating Symptomatic Aortic Stenosis With Transcatheter Aortic Valve Replacement: Is There Time to Wait? J Am Heart Assoc 2019; 8:e011527. [PMID: 30612523 PMCID: PMC6405731 DOI: 10.1161/jaha.118.011527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kamil F. Faridi
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA
| | - Marie‐France Poulin
- Division of CardiologyDepartment of MedicineRush University Medical CenterChicagoIL
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11
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Olsson K, Näslund U, Nilsson J, Hörnsten Å. Patients' experiences of the transcatheter aortic valve implantation trajectory: A grounded theory study. Nurs Open 2018; 5:149-157. [PMID: 29599990 PMCID: PMC5867280 DOI: 10.1002/nop2.124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 12/29/2017] [Indexed: 12/14/2022] Open
Abstract
Aim The aim of this study was to explore how patients experienced the recovery process from transcatheter aortic valve implantation. Design A qualitative approach where in-depth interviews were used. Method Eleven men and eight women undergoing transcatheter aortic valve implantation were individually interviewed 6 months after transcatheter aortic valve implantation. Grounded theory was used for the analysis. Results The analysis generated the core concept "A journey of balancing between life-struggle and hope" connected to descriptive, bipolar categories. Before transcatheter aortic valve implantation patients not only felt threatened but also experienced hope. The rehabilitation phase was described as demanding or surprisingly simple. At the 6 months follow-up patients were pleased to return to life, however, still struggling with limitations. To feel hope is essential for transcatheter aortic valve implantation patients' well-being, both before and during the recovery process. It is important that healthcare professionals not only support hopeful thinking but also take time to discuss and prepare patients, talk about concerns and build confidence. Individual plans for rehabilitation should be designed.
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Affiliation(s)
- Karin Olsson
- Cardiology, Heart CentreDepartment of Public Health and Clinical MedicineUmeå UniversityUmeaSweden
- Department of NursingUmeå UniversityUmeaSweden
| | - Ulf Näslund
- Cardiology, Heart CentreDepartment of Public Health and Clinical MedicineUmeå UniversityUmeaSweden
| | - Johan Nilsson
- Cardiology, Heart CentreDepartment of Public Health and Clinical MedicineUmeå UniversityUmeaSweden
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12
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Baumbusch J, Lauck SB, Achtem L, O'Shea T, Wu S, Banner D. Understanding experiences of undergoing transcatheter aortic valve implantation: one-year follow-up. Eur J Cardiovasc Nurs 2017; 17:280-288. [PMID: 29087216 DOI: 10.1177/1474515117738991] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is the treatment of choice for frail, older adults with severe symptomatic aortic stenosis. Although research about long-term clinical outcomes is emerging, there is limited evidence from the perspectives of patients and family caregivers on their perceived benefits and challenges after TAVI. AIMS The aim of this study was to describe older adults and family caregivers' perspectives on undergoing TAVI at one year post-procedure. METHODS Qualitative description was the method of inquiry. A purposive sample of 31 patients and 15 family caregivers was recruited from a TAVI programme in western Canada. Semi-structured interviews were conducted with participants one year after TAVI. Data were analysed thematically. RESULTS All participants were satisfied with the decision to undergo TAVI. There were three central themes. First, recovery was experienced in the context of aging and comorbidities, which was shaped by patients' limited options for care and post-procedure symptom burden. Second, reconciling expectations with reality meant that, for some patients, symptom burden remained prevalent and was also influenced by others' expectations. Third, recommendations for recovery related to having information needs met, keeping informed of evolving care processes, and addressing individualised needs for support. CONCLUSIONS The perspectives of participants provide a valuable contribution to the literature about undergoing TAVI. Clinicians need to be attentive to patients' expectations of benefit and temper these with consideration of the individual's broader health situation to provide treatment decision support. Patients and family caregivers also need adequate teaching and support to facilitate safe transition home given the shift towards early discharge after TAVI.
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Affiliation(s)
| | | | | | - Tamar O'Shea
- 1 School of Nursing, University of British Columbia, Canada
| | - Sarah Wu
- 3 Department of Kinesiology, University of Waterloo, Canada
| | - Davina Banner
- 4 School of Nursing, University of Northern British Columbia, Canada
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13
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Astin F, Horrocks J, McLenachan J, Blackman DJ, Stephenson J, Closs SJ. The impact of transcatheter aortic valve implantation on quality of life: A mixed methods study. Heart Lung 2017; 46:432-438. [PMID: 28985898 DOI: 10.1016/j.hrtlng.2017.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 08/14/2017] [Accepted: 08/15/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To provide an in-depth understanding of patients' views about the impact of transcatheter aortic valve implantation on self-reported quality of life. BACKGROUND Transcatheter aortic valve implantation is considered to be the gold standard of care for inoperable patients diagnosed with severe symptomatic aortic stenosis. Mid- to long-term clinical outcomes are favourable and questionnaire data indicates improvements in quality of life but an in-depth understanding of how quality of life is altered by the intervention is missing. METHODS A mixed methods study design with a total of 89 in-depth qualitative interviews conducted with participants (39% male; mean age 81.7 years), 1 and 3 months post TAVI, recruited from a regional centre in England. Data were triangulated with questionnaire data (SF-36 and EQ5D-VAS) collected, pre, 1 and 3 months post implantation. RESULTS Participants' accounts were characterised by four key themes; shortened life, extended life, limited life and changed life. Quality of life was changed through two mechanisms. Most participants reported a reduced symptom burden and all explained that their life expectancy was improved. Questionnaire data supported interview data with gradual improvements in mean EQ-5D scores and SF-36 physical and mental domain scores at 1 and 3 months compared to baseline. CONCLUSION Findings suggest that TAVI was of variable benefit, producing considerable improvements in either mental or physical health in many participants, while a smaller proportion continued to deteriorate.
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Affiliation(s)
- Felicity Astin
- Centre for Applied Health Research, School of Human and Health Sciences, University of Huddersfield, UK; Research and Development, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK.
| | | | - Jim McLenachan
- Department of Cardiology, Leeds Teaching Hospitals, Leeds, UK
| | | | - John Stephenson
- Centre for Applied Health Research, School of Human and Health Sciences, University of Huddersfield, UK
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14
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Olsson K, Nilsson J, Hörnsten Å, Näslund U. Patients' self-reported function, symptoms and health-related quality of life before and 6 months after transcatheter aortic valve implantation and surgical aortic valve replacement. Eur J Cardiovasc Nurs 2016; 16:213-221. [PMID: 27169460 DOI: 10.1177/1474515116650342] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Aortic stenosis is the most common valve disease in western countries and has poor prognosis without treatment. Surgical aortic valve replacement (SAVR) is the gold standard, and transcatheter aortic valve implantation (TAVI) is a new method that is used in high-risk patients who are denied surgery. The purpose of treatment is not only to save life, but also to reduce symptoms and increase health-related quality of life (HRQoL). OBJECTIVE The aim of this study was to describe patients' self-reported outcomes in terms of physical function, symptoms, dependence, HRQoL, and cognitive function after TAVI and SAVR. METHODS All patients treated with TAVI during 1 year ( n = 24) and age-matched patients treated with SAVR ( n = 24) were included. Data were collected on the day before and at 6 months after treatment using structural questionnaires. RESULTS Self-rated function was low before treatment and increased at follow-up. A quarter of all patients reported syncope at baseline, and none reported this at follow-up. Breathlessness was reported by all patients to be the most limiting cardiac symptom, but the TAVI patients reported more severe symptoms. At 6 months' follow-up, symptoms were reduced, but breathlessness and fatigue were still common, especially in the TAVI group. HRQoL, which was very low in the TAVI group at baseline, increased in all dimensions except social function. CONCLUSION We found no change in cognitive function or dependence at follow-up. There was no difference in the size of improvement between groups. The results could be helpful when informing future patients in order to give them realistic expectations.
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Affiliation(s)
- Karin Olsson
- 1 Cardiology, Heart Centre, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.,2 Department of Nursing, Umeå University, Umeå, Sweden
| | - Johan Nilsson
- 1 Cardiology, Heart Centre, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Åsa Hörnsten
- 2 Department of Nursing, Umeå University, Umeå, Sweden
| | - Ulf Näslund
- 1 Cardiology, Heart Centre, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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15
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Lauck SB, Baumbusch J, Achtem L, Forman JM, Carroll SL, Cheung A, Ye J, Wood DA, Webb JG. Factors influencing the decision of older adults to be assessed for transcatheter aortic valve implantation: An exploratory study. Eur J Cardiovasc Nurs 2015; 15:486-494. [PMID: 26498908 DOI: 10.1177/1474515115612927] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 09/15/2015] [Accepted: 09/29/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is the recommended therapy for patients with severe symptomatic aortic stenosis at increased surgical risk and likely to derive benefit. Multimodality and multidisciplinary assessment is required for the heart team to determine eligibility for TAVI in a primarily older population. Little is known about patients' motivation and perspectives on making the decision to undergo the complex assessment. AIMS To explore factors influencing patients' decision making to undergo TAVI eligibility assessment to inform practice, programme development, health policy and future research. METHODS An exploratory qualitative approach was used. Semistructured interviews were conducted with 15 patients at the time of their referral for assessment to a quaternary cardiac and high volume TAVI centre. RESULTS Multiple, intersecting factors that included biomedical, functional, social and environmental considerations influenced patients' decision. The six distinct factors were symptom burden, participants' perception as 'experienced' patients, expectations of benefit and risks, healthcare system and informal support, logistical barriers and facilitators, and obligations and responsibilities. CONCLUSIONS The decision to undergo TAVI eligibility assessment is multifaceted and complex. Programmatic processes of care must be in place to facilitate appropriate and patient-centered decision making and access to TAVI. Strategies are required to mitigate the risks associated with the rapid deterioration of severe aortic stenosis, address patient and referring physicians' education needs, and provide individualised care and equitable access. Future research must focus on patients' experiences throughout the trajectory of TAVI care.
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Affiliation(s)
- Sandra B Lauck
- Centre for Heart Valve Innovation, St Paul's Hospital, Canada .,University of British Columbia, Canada
| | | | - Leslie Achtem
- Centre for Heart Valve Innovation, St Paul's Hospital, Canada
| | | | | | - Anson Cheung
- Centre for Heart Valve Innovation, St Paul's Hospital, Canada.,University of British Columbia, Canada
| | - Jian Ye
- Centre for Heart Valve Innovation, St Paul's Hospital, Canada.,University of British Columbia, Canada
| | - David A Wood
- Centre for Heart Valve Innovation, St Paul's Hospital, Canada.,University of British Columbia, Canada
| | - John G Webb
- Centre for Heart Valve Innovation, St Paul's Hospital, Canada.,University of British Columbia, Canada
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