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Nicmanis M, Holmes J, Oxlad M, Chur-Hansen A. Patient Information Needs and Decision-Making Before a Cardiac Implantable Electronic Device: A Qualitative Study Utilizing Social Media Data. J Clin Psychol Med Settings 2024:10.1007/s10880-024-10024-6. [PMID: 38773048 DOI: 10.1007/s10880-024-10024-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2024] [Indexed: 05/23/2024]
Abstract
The decision to receive a cardiac implantable electronic device (CIED) represents a challenging experience for patients. However, the majority of previous research has only considered retrospective accounts of patient experiences. This study aimed to use social media data to characterize the information sought by people anticipating or considering CIED implantation and factors that influence their decision-making experiences. A Python-based script was used to collect posts made to a community intended for discussions concerning CIEDs on the social media platform Reddit. Reflexive content analysis was used to analyze the collected data. From 799 posts collected, 101 made by 86 participants were analyzed. The reported median (range) age of participants was 34 (16-67), and most were anticipating or considering a pacemaker. Three overarching categories classified the data: "Use of social media to meet informational and other needs"; "Factors influencing acceptance of the need for implantation"; and "Specific concerns considered during decision-making." Participants anticipating or considering a CIED predominantly sought experiential information. Among asymptomatic participants, doubts were prevalent, with acceptance being an influential factor in decision-making. Healthcare professionals should recognize the informational and emotional needs of prospective CIED patients and tailor support mechanisms to better facilitate their decision-making.
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Affiliation(s)
- Mitchell Nicmanis
- School of Psychology, Faculty of Health and Medical Sciences, The University of Adelaide, Level 5, Hughes Building North Terrace Campus, Adelaide, SA, 5000, Australia.
| | - Joshua Holmes
- School of Computer and Mathematical Sciences, Faculty of Sciences, Engineering and Technology, The University of Adelaide, Adelaide, SA, Australia
| | - Melissa Oxlad
- School of Psychology, Faculty of Health and Medical Sciences, The University of Adelaide, Level 5, Hughes Building North Terrace Campus, Adelaide, SA, 5000, Australia
| | - Anna Chur-Hansen
- School of Psychology, Faculty of Health and Medical Sciences, The University of Adelaide, Level 5, Hughes Building North Terrace Campus, Adelaide, SA, 5000, Australia
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2
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Shaffer JA, Matlock DD, Boylan JM, Vagnini KM, Rush CL, Martin R, Masters KS. Linking Cardiac Psychology and Cardiovascular Medicine via Self-Determination Theory and Shared Decision-Making. J Clin Psychol Med Settings 2024:10.1007/s10880-024-10014-8. [PMID: 38678122 DOI: 10.1007/s10880-024-10014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/29/2024]
Abstract
Despite considerable progress in recent years, research in cardiac psychology is not widely translated into routine practice by clinical cardiologists or clinical health psychologists. Self-determination theory (SDT), which addresses how basic psychological needs of autonomy, competence, and relatedness contribute to the internalization of motivation, may help bridge this research-practice gap through its application to shared decision-making (SDM). This narrative review discusses the following: (a) brief background information on SDT and SDM, (b) the application of SDT to health behavior change and cardiology interventions, and (c) how SDT and SDM may be merged using a dissemination and implementation (D&I) framework. We address barriers to implementing SDM in cardiology, how SDM and SDT address the need for respect of patient autonomy, and how SDT can enhance D&I of SDM interventions through its focus on autonomy, competence, and relatedness and its consideration of other constructs that facilitate the internalization of motivation.
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Affiliation(s)
- Jonathan A Shaffer
- Department of Psychology, University of Colorado Denver, Campus Box 173, PO Box 173364, Denver, CO, 80217, USA.
| | - Daniel D Matlock
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, USA
| | | | - Katilyn M Vagnini
- Department of Psychology, University of Colorado Denver, Campus Box 173, PO Box 173364, Denver, CO, 80217, USA
| | - Christina L Rush
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, USA
| | - Rebecca Martin
- Department of Psychology, University of Colorado Denver, Campus Box 173, PO Box 173364, Denver, CO, 80217, USA
| | - Kevin S Masters
- Department of Psychology, University of Colorado Denver, Campus Box 173, PO Box 173364, Denver, CO, 80217, USA
- Anschutz Health and Wellness Center, University of Colorado Anschutz Medical Campus, Aurora, USA
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3
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Kuo YT, Jenq CC, Li US, Lin YP. Evaluating shared decision making for dialysis initiation: A qualitative study on patient refusal of long-term dialysis in Taiwan. J Eval Clin Pract 2024; 30:174-183. [PMID: 37723854 DOI: 10.1111/jep.13922] [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: 04/01/2023] [Revised: 07/26/2023] [Accepted: 08/15/2023] [Indexed: 09/20/2023]
Abstract
RATIONALE Previous studies have explored shared decision making (SDM) implementation to determine the renal replacement therapy modality; however, the SDM approach for dialysis initiation, especially when patients refuse physician suggestions for long-term dialysis, remains unclear. AIMS AND OBJECTIVES This study aimed to explore physicians' responses towards patients' refusal of long-term dialysis during the SDM process and the thinking processes of both physicians and patients regarding dialysis refusal. METHOD We conducted in-depth semi-structured interviews with 10 patients diagnosed with end-stage renal disease, each of whom refused long-term dialysis after physicians employed the SDM framework, and nine nephrologists at the Chang Gung Memorial Hospital, Taiwan, from March to May 2020. Interviews were audio-recorded, transcribed, and translated from Mandarin to English. They were then thematically analysed. RESULTS Three main themes on dialysis initiation SDM implementation and the differences between physician and patient perceptions on patient treatment refusal were yielded. While the SDM approach for dialysis initiation developed by nephrologists in Taiwan respects patient decisions, physicians often actively persuade patients to undergo dialysis in case of treatment refusal. The motivation behind this approach is to promote the patient's best medical interests, particularly post-dialysis life quality, and to ensure a 'rational' medical decision is made. However, patients' perceptions of treatment refusal differ significantly from those of physicians, and their decision-making process is often iterative and based on comprehensive evaluation of immediate concerns beyond biomedical factors. CONCLUSIONS Findings suggest that the current physician-led SDM approach for dialysis initiation characterises active persuasion with physicians' perspectives predominating the clinical encounter. To improve SDM implementation, we propose that physicians should acknowledge and understand patients' reasoning for dialysis refusal and the distinction between objective health and subjective well-being during the decision-making process.
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Affiliation(s)
- Yi-Ting Kuo
- Department of medical education, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chang-Chyi Jenq
- Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Uen Shuen Li
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Ya-Ping Lin
- Department of Medical Humanities and Education, School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei City, Taiwan
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Anderson CB, Kittelson AJ, Wurdeman SR, Miller MJ, Stoneback JW, Christiansen CL, Magnusson DM. Understanding decision-making in prosthetic rehabilitation by prosthetists and people with lower limb amputation: a qualitative study. Disabil Rehabil 2023; 45:723-732. [PMID: 35389313 PMCID: PMC9537359 DOI: 10.1080/09638288.2022.2037745] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 01/27/2022] [Accepted: 01/30/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE Little has been published about the process of decision-making between prosthetists and people with lower limb amputation (LLA). The purpose of this study is to identify decisions and factors influencing decision-making in prosthetic rehabilitation from the perspectives of prosthetists and prosthesis users, to identify barriers and opportunities for shared decision-making (SDM). METHODS Qualitative semi-structured individual interviews were conducted with 13 prosthetists and 14 prosthesis users from three clinics in three states of the Rocky Mountain and Southwest regions of the United States. Transcripts were analyzed using thematic analysis. RESULTS Four main themes were identified: perceived decision points, importance of relationship, balancing competing priorities, and experience. Contrasts between perceptions of prosthetists and prosthesis users were related to prosthesis design decisions, and the purpose of communication (e.g., goals for a prosthesis vs. goals informing prosthesis design). Both prosthetists and prosthesis users described balancing priorities that contribute to prosthetic rehabilitation decisions, and the role of experience for informing realistic expectations and preferences necessary for participating in decision-making. CONCLUSION Opportunities for improving SDM between prosthetists and prosthesis users include (1) clarifying key rehabilitation decisions, (2) identifying the purpose of initial communications, (3) support for balancing priorities, and (4) utilizing experience to achieve informed preferences.IMPLICATIONS FOR REHABILITATIONMany people with lower limb amputation experience poor physical function and psychosocial outcomes, which may be further compounded by under informed prosthesis-user expectations for function with a prosthesis.Shared decision-making offers an opportunity for improving realistic prosthesis-user expectations, reducing healthcare costs, and improving prosthesis-user satisfaction and adherence to care plans.Opportunities for improving shared decision-making between prosthetists and prosthesis-users include (1) clarifying key rehabilitation decisions, (2) identifying the purpose of initial communications, (3) support for balancing priorities, and (4) utilizing experience to achieve informed preferences.
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Affiliation(s)
- Chelsey B. Anderson
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, CO, USA
| | - Andrew J. Kittelson
- Department of Physical Therapy and Rehabilitation Science, University of Montana, Missoula, MT, USA
| | - Shane R. Wurdeman
- Department of Clinical and Scientific Affairs, Hanger Clinic, Austin, TX, USA
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE, USA
| | - Matthew J. Miller
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
| | | | - Cory L. Christiansen
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, CO, USA
- Department of Geriatrics, Geriatric Research, Education, and Clinical Center, VA Eastern Colorado Healthcare System, Aurora, CO, USA
| | - Dawn M. Magnusson
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, CO, USA
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Callaghan EM, Diamandis-Nikoletatos E, van Leeuwen PP, Higgins JB, Somerville CE, Brown LJ, Schumacher TL. Communication regarding the deactivation of implantable cardioverter-defibrillators: A scoping review and narrative summary of current interventions. PATIENT EDUCATION AND COUNSELING 2022; 105:3431-3445. [PMID: 36055906 DOI: 10.1016/j.pec.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Communication about deactivation of implantable cardioverter-defibrillator (ICD) therapy at end-of-life (EoL) is a recognised issue within clinical practice. The aim of this scoping review was to explore and map the current literature in this field, with a focus on papers which implemented interventional studies. METHODS Systematic searches of six major databases were conducted. Citations were included by four researchers according to selection criteria. Key demographic data and prespecified themes in relation to communication of ICD deactivation at EoL were extracted. RESULTS The search found 6197 texts of which 63 were included: 39 quantitative, 14 qualitative and 10 mixed-methods. Surveys were predominantly used to gather data (n = 34), followed by interviews (n = 18) and retrospective reviews of patient records (n = 18). CONCLUSIONS Several key gaps in the literature warrant further research. These include who is responsible for initiating ICD deactivation discussions, how clinicians should initiate and conduct these discussions, when ICD deactivations should be occurring, and family perspectives. Adequately explored themes include patient and clinician knowledge and attitudes regarding ICD deactivation at EoL. PRACTICAL IMPLICATIONS Facilities treating patients with ICDs at EoL should consider ongoing quality improvement projects aimed at clinician education and protocol changes to improve communication surrounding EoL ICD deactivation.
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Affiliation(s)
- Ellen M Callaghan
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | - Elly Diamandis-Nikoletatos
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | - Paul P van Leeuwen
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | - Jack B Higgins
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | | | - Leanne J Brown
- Department of Rural Health, College of Health, Medicine and Wellbeing, University of Newcastle, Tamworth, NSW 2340, Australia; Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Tracy L Schumacher
- Department of Rural Health, College of Health, Medicine and Wellbeing, University of Newcastle, Tamworth, NSW 2340, Australia; Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
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6
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Zakeri MA, Sedri N, Bazmandegan G, Zakeri M, Safariyan M, Dehghan M. Patients' knowledge and concerns about using the implantable cardioverter defibrillator for the primary prevention of sudden cardiac death and its correlates: A cross-sectional study. Health Sci Rep 2022; 5:e698. [PMID: 35734342 PMCID: PMC9193961 DOI: 10.1002/hsr2.698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Aims Sudden cardiac death (SCD) is one of the most common causes of mortality in heart failure (HF) patients with reduced ejection fraction. Patients have concerns about the disease and use the implantable cardioverter defibrillator (ICD) to reduce the effects of HF disease. The current study aims to evaluate the barriers and factors affecting the implantation of the ICD for primary prevention. Methods One hundred-forty-seven patients with HF were studied in public hospitals in southern Iran by using a cross-sectional design from April 2018 to June 2019. Demographic, researcher-made questionnaire, World Health Organization Quality of life-BREF (WHOQOL-BREF), general self-efficacy questionnaires, and Multidimensional Scale of Perceived Social Support (MSPSS) were measured for investigating the barriers and impact factors in patent HF. Results Most participants were male (56.5%), married (88.4%), illiterate (54.1%), and unemployed (72.6%). 62.6% (n = 92) of the participants did not know about HF and ICD. The total score of patients' concerns about using ICD was 47.11 ± 11.26, which showed a moderate level. The scores of knowledge about HF and ICD had a significant positive poor correlation with self-efficacy, perceived social support and QoL. Also, the score of concerns about the ICD had a significant negative poor correlation with perceived social support. Conclusion Understanding HF patients' issues and obstacles can help us prevent sudden death. Doctors' advice has a significant impact on patients' acceptance. Poor knowledge is the most important reason for nonparticipation. Intervention is necessary to inform patients to understand the advantages and disadvantages.
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Affiliation(s)
- Mohammad A. Zakeri
- Social Determinants of Health Research CentreRafsanjan University of Medical SciencesRafsanjanIran
- Non‐Communicable Diseases Research CenterRafsanjan University of Medical SciencesRafsanjanIran
| | - Nadia Sedri
- Critical Care Nursing, Zarand Nursing FacultyKerman University of Medical SciencesKermanIran
| | - Golamreza Bazmandegan
- Clinical Research Development Unit, Ali‐Ibn Abi‐Talib HospitalRafsanjan University of Medical SciencesRafsanjanIran
- Department of Family Medicine, Ali‐Ibn Abi‐Talib Hospital, School of MedicineRafsanjan University of Medical SciencesRafsanjanIran
| | - Maryam Zakeri
- Physiology‐Pharmacology Research Center, Research Institute of Basic Medical SciencesRafsanjan University of Medical SciencesRafsanjanIran
| | - Mohammad Safariyan
- Department of Cardiology, Faculty of MedicineRafsanjan University of Medical SciencesRafsanjanIran
| | - Mahlagha Dehghan
- Department of Critical Care Nursing, Razi Faculty of Nursing and MidwiferyKerman University of Medical SciencesKermanIran
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7
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Stafford R, Pourshams I, Lin B, Wang P. Decision-making experiences and decisional regret in patients receiving implanted cardioverter-defibrillators. HEART AND MIND 2022. [DOI: 10.4103/hm.hm_51_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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8
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OUP accepted manuscript. Eur J Cardiovasc Nurs 2022; 21:677-686. [DOI: 10.1093/eurjcn/zvab135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/24/2021] [Accepted: 12/22/2021] [Indexed: 11/13/2022]
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9
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Reed SD, Yang JC, Rickert T, Johnson FR, Gonzalez JM, Mentz RJ, Krucoff MW, Vemulapalli S, Adamson PB, Gebben DJ, Rincon-Gonzalez L, Saha A, Schaber D, Stein KM, Tarver ME, Bruhn-Ding D. Quantifying Benefit-Risk Preferences for Heart Failure Devices: A Stated-Preference Study. Circ Heart Fail 2021; 15:e008797. [PMID: 34937393 PMCID: PMC8763248 DOI: 10.1161/circheartfailure.121.008797] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Regulatory and clinical decisions involving health technologies require judgements about relative importance of their expected benefits and risks. We sought to quantify heart-failure patients’ acceptance of therapeutic risks in exchange for improved effectiveness with implantable devices. Methods: Individuals with heart failure recruited from a national web panel or academic medical center completed a web-based discrete-choice experiment survey in which they were randomized to one of 40 blocks of 8 experimentally controlled choice questions comprised of 2 device scenarios and a no-device scenario. Device scenarios offered an additional year of physical functioning equivalent to New York Heart Association class III or a year with improved (ie, class II) symptoms, or both, with 30-day mortality risks ranging from 0% to 15%, in-hospital complication risks ranging from 0% to 40%, and a remote adjustment device feature. Logit-based regression models fit participants’ choices as a function of health outcomes, risks and remote adjustment. Results: Latent-class analysis of 613 participants (mean age, 65; 49% female) revealed that two-thirds were best represented by a pro-device, more risk-tolerant class, accepting up to 9% (95% CI, 7%–11%) absolute risk of device-associated mortality for a one-year gain in improved functioning (New York Heart Association class II). Approximately 20% were best represented by a less risk-tolerant class, accepting a maximum device-associated mortality risk of 3% (95% CI, 1%–4%) for the same benefit. The remaining class had strong antidevice preferences, thus maximum-acceptable risk was not calculated. Conclusions: Quantitative evidence on benefit-risk tradeoffs for implantable heart-failure device profiles may facilitate incorporating patients’ views during product development, regulatory decision-making, and clinical practice.
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Affiliation(s)
- Shelby D Reed
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC. (S.D.R., F.R.J., J.M.G.).,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.)
| | - Jui-Chen Yang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.)
| | - Timothy Rickert
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.)
| | - F Reed Johnson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC. (S.D.R., F.R.J., J.M.G.).,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.)
| | - Juan Marcos Gonzalez
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC. (S.D.R., F.R.J., J.M.G.).,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.)
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.).,Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC. (R.J.M., M.W.K., S.V.)
| | - Mitchell W Krucoff
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.).,Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC. (R.J.M., M.W.K., S.V.)
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.).,Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC. (R.J.M., M.W.K., S.V.)
| | | | - David J Gebben
- Food and Drug Administration, Center for Devices and Radiological Health, Silver Spring, MD (D.J.G., A.S., M.E.T.)
| | | | - Anindita Saha
- Food and Drug Administration, Center for Devices and Radiological Health, Silver Spring, MD (D.J.G., A.S., M.E.T.)
| | | | | | - Michelle E Tarver
- Food and Drug Administration, Center for Devices and Radiological Health, Silver Spring, MD (D.J.G., A.S., M.E.T.)
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Wallace BC, Jones J, Masoudi FA, Nowels CT, Varosy P, Thomson R, Elwyn G, Brega AG, Vermilye T, Knoepke CE, Sandhu A, Allen LA, Matlock DD. Development and piloting of four decision aids for implantable cardioverter-defibrillators in different media formats. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1842-1852. [PMID: 34528271 DOI: 10.1111/pace.14365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/28/2021] [Accepted: 09/12/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Using DAs for preference-sensitive decisions is an evidence-based way to improve patient-centered decisions. Reimbursement mandates have increased the need for DAs in ICD care, although none have been formally evaluated. The objectives were to develop and pilot implantable cardioverter-defibrillator (ICD) decision aids (DAs) for patients considering primary prevention ICDs. METHODS Development Phase: An expert panel, including patients and physicians, iteratively developed four DAs: a one-page Option GridTM conversation aid, a four-page in-depth paper tool, a 17-minute video, and an interactive website. Trial Phase: At three sites, patients with heart failure who were eligible for primary prevention ICDs were randomly assigned 2:1 to intervention (received DAs) or control (usual care). We conducted a mixed-methods evaluation exploring acceptability and feasibility. RESULTS Twenty-one eligible patients enrolled (15 intervention). Most intervention participants found the DAs to be unbiased (67%), helpful (89%), and would recommend them to others (100%). The pilot was feasible at all sites; however, using clinic staff to identify eligible patients was more efficient than chart review. Although the main goals were to measure acceptability and feasibility, intervention participants trended towards increased concordance between longevity values and ICD decisions (71% concordant vs. 29%, p = .06). Participants preferred the in-depth paper tool and video DAs. Access to a nurse during the decision-making window encouraged questions and improved participant-perceived confidence. CONCLUSIONS Participants felt the DAs provided helpful, balanced information that they would recommend to other patients. Further exploration of this larger context of DA use and strategies to promote independent use related to electrophysiology (EP) visits are needed.
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Affiliation(s)
- Bryan C Wallace
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, Colorado, USA
| | - Jacqueline Jones
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Frederick A Masoudi
- Ascension Health, St Louis MO.,Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Carolyn T Nowels
- Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Paul Varosy
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado, USA.,Cardiology Section, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Richard Thomson
- Population Health Sciences Institute, Newcastle University, UK
| | - Glyn Elwyn
- Coproduction Laboratory, Dartmouth Institute, Lebanon, New Hampshire, USA
| | - Angela G Brega
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Travis Vermilye
- Department of Visual Arts, University of Colorado Denver, Denver, Colorado, USA
| | - Christopher E Knoepke
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, Colorado, USA.,Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amneet Sandhu
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado, USA
| | - Larry A Allen
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, Colorado, USA.,Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado, USA.,Advanced Heart Failure and Transplantation, Division of Cardiology, and Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Daniel D Matlock
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, Colorado, USA.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado, USA.,Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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11
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Berkowitz J, Martinez-Camblor P, Stevens G, Elwyn G. The development of incorpoRATE: A measure of physicians' willingness to incorporate shared decision making into practice. PATIENT EDUCATION AND COUNSELING 2021; 104:2327-2337. [PMID: 33744056 DOI: 10.1016/j.pec.2021.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To develop 'incorpoRATE', a brief and broadly applicable measure of physicians' willingness to incorporate shared decision making (SDM) into practice. METHODS incorpoRATE was developed across three phases: 1) A review of relevant literature to inform candidate domain and item development, 2) Cognitive interviews with US physicians to iteratively refine the measure, and 3) Pilot testing of the measure across a larger sample of US physicians to explore item and measure performance. RESULTS The final measure consists of seven items that assess physician perspectives on various components of SDM use that may present as barriers in practice. During pilot testing, the majority of physicians expressed positive opinions about the overall concept of SDM, yet were less comfortable acting on informed patient choices when there was known incongruence with their own recommendations. CONCLUSIONS incorpoRATE is a novel physician-reported measure that assesses physicians' willingness to incorporate SDM in practice. PRACTICE IMPLICATIONS incorpoRATE has the potential to help us further understand the limited adoption of SDM and areas of focus for improving the use of SDM in the future. We recommend that incorpoRATE be subject to further psychometric, real-world testing, in order to explore its performance across different samples of physicians and organizations.
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Affiliation(s)
- Julia Berkowitz
- The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Pablo Martinez-Camblor
- The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Gabrielle Stevens
- The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, 1 Medical Center Drive, Lebanon, NH 03756, USA.
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12
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Christie M, Coyne E, Mitchell M. The educational experiences and needs of patients with an internal cardiac defibrillator: An interpretive phenomenological study. Collegian 2021. [DOI: 10.1016/j.colegn.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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13
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Benjamin IJ, Valentine CM, Oetgen WJ, Sheehan KA, Brindis RG, Roach WH, Harrington RA, Levine GN, Redberg RF, Broccolo BM, Hernandez AF, Douglas PS, Piña IL, Benjamin EJ, Coylewright MJ, Saucedo JF, Ferdinand KC, Hayes SN, Poppas A, Furie KL, Mehta LS, Erwin JP, Mieres JH, Murphy DJ, Weissman G, West CP, Lawrence WE, Masoudi FA, Jones CP, Matlock DD, Miller JE, Spertus JA, Todman L, Biga C, Chazal RA, Creager MA, Fry ET, Mack MJ, Yancy CW, Anderson RE. 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report. Circulation 2021; 143:e1035-e1087. [PMID: 33974449 DOI: 10.1161/cir.0000000000000963] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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14
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Benjamin IJ, Valentine CM, Oetgen WJ, Sheehan KA, Brindis RG, Roach WH, Harrington RA, Levine GN, Redberg RF, Broccolo BM, Hernandez AF, Douglas PS, Piña IL, Benjamin EJ, Coylewright MJ, Saucedo JF, Ferdinand KC, Hayes SN, Poppas A, Furie KL, Mehta LS, Erwin JP, Mieres JH, Murphy DJ, Weissman G, West CP, Lawrence WE, Masoudi FA, Jones CP, Matlock DD, Miller JE, Spertus JA, Todman L, Biga C, Chazal RA, Creager MA, Fry ET, Mack MJ, Yancy CW, Anderson RE. 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report. J Am Coll Cardiol 2021; 77:3079-3133. [PMID: 33994057 DOI: 10.1016/j.jacc.2021.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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15
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Grant EV, Summapund J, Matlock DD, Vaughan Dickson V, Iqbal S, Patel S, Katz SD, Chaudhry SI, Dodson JA. Patient and Cardiologist Perspectives on Shared Decision Making in the Treatment of Older Adults Hospitalized for Acute Myocardial Infarction. Med Decis Making 2021; 40:279-288. [PMID: 32428431 DOI: 10.1177/0272989x20912293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Medical and interventional therapies for older adults with acute myocardial infarction (AMI) reduce mortality and improve outcomes in selected patients, but there are also risks associated with treatments. Shared decision making (SDM) may be useful in the management of such patients, but to date, patients' and cardiologists' perspectives on SDM in the setting of AMI remain poorly understood. Accordingly, we performed a qualitative study eliciting patients' and cardiologists' perceptions of SDM in this scenario. Methods. We conducted 20 in-depth, semistructured interviews with older patients (age ≥70) post-AMI and 20 interviews with cardiologists. The interviews were transcribed and analyzed using ATLAS.ti. Two investigators independently coded transcripts using the constant comparative method, and an integrative, team-based process was used to identify themes. Results. Six major themes emerged: 1) patients felt their only choice was to undergo an invasive procedure; 2) patients placed a high level of trust and gratitude toward physicians; 3) patients wanted to be more informed about the procedures they underwent; 4) for cardiologists, patients' age was not a major contraindication to intervention, while cognitive impairment and functional limitation were; 5) while cardiologists intuitively understood the concept of SDM, interpretations varied; and 6) cardiologists considered SDM to be useful in the setting of non-ST elevated myocardial infarction (NSTEMI) but not ST-elevated myocardial infarction (STEMI). Conclusions. Patients viewed intervention as "the only choice," whereas cardiologists saw a need for balancing risks and benefits in treating older adults post-NSTEMI. This discrepancy implies there is room to improve communication of risks and benefits to older patients. A decision aid informed by the needs of older adults could help to better convey patient-specific risk and increase choice awareness.
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Affiliation(s)
- Eleonore V Grant
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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16
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Stacey D, Légaré F, Boland L, Lewis KB, Loiselle MC, Hoefel L, Garvelink M, O'Connor A. 20th Anniversary Ottawa Decision Support Framework: Part 3 Overview of Systematic Reviews and Updated Framework. Med Decis Making 2021; 40:379-398. [PMID: 32428429 DOI: 10.1177/0272989x20911870] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction. The Ottawa Decision Support Framework (ODSF) has guided practitioners and patients facing difficult decisions for 20 years. It asserts that decision support interventions that address patients' decisional needs improve decision quality. Purpose. To update the ODSF based on a synthesis of evidence. Methods. We conducted an overview of systematic reviews, searching 9 electronic databases. Eligible reviews included decisional needs assessments, decision support interventions, and decisional outcome measures guided by the ODSF. We extracted data and synthesized results narratively. Eight ODSF developers/expert users from 4 disciplines revised the ODSF. Results. Of 4656 citations, we identified 4 eligible reviews (>250 studies, >100 different decisions, >50,000 patients, 18 countries, 5 continents). They reported current ODSF decisional needs and their most frequent manifestations in the areas of inadequate knowledge/information, unclear values, decisional conflict/uncertainty, and inadequate support. They uncovered 11 new manifestations of 6 decisional needs. Using the Decisional Conflict Scale (DCS) to assess decisional needs, average scores were elevated at baseline and declined shortly after decision making, even without information interventions. Patient decision aids were superior to usual care in reducing total DCS scores and improving decision quality. We revised the ODSF by refining definitions of 6 decisional needs and adding new interventions to address 4 needs. We added a decision process outcome and eliminated secondary outcomes unlikely to improve across a range of decisions, retaining the implementation/continuance of the chosen option and appropriate use/costs of health services. Conclusions. We updated the ODSF to reflect the current evidence and identified implications for practice and further research.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec, Canada.,Canada Research Chair in Shared Decision Making and Knowledge Translation, and Population Health and Practice-Changing Research Group, Université Laval Primary Care Research Centre (CERSSPL-UL), Quebec, Canada
| | - Laura Boland
- Western University, School of Health Studies, London, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Marie-Chantal Loiselle
- School of Nursing, Faculty of Medicine and Health Sciences, University of Sherbrooke, Quebec, Canada
| | - Lauren Hoefel
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Mirjam Garvelink
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, the Netherlands
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17
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Sahl S, Pontoriero MI, Hill C, Knoepke CE. Stakeholder perspectives on the implementation of shared decision making to empower youth who have experienced commercial sexual exploitation. CHILDREN AND YOUTH SERVICES REVIEW 2021; 122:105894. [PMID: 34446975 PMCID: PMC8386426 DOI: 10.1016/j.childyouth.2020.105894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Shared decision making (SDM) has been proposed as a method to improve treatment adherence, placement stability, and other youth-centric outcomes for children who have been victims of commercial sexual exploitation (CSEC). This project seeks to characterize service providers' perspectives on the adoption and implementation of SDM into treatment and placement planning decisions. METHOD Sixteen key stakeholders who provide services for youth who have experienced CSEC in a Southern city, as well as adults who survived exploitation as children, were individually interviewed. These interviews focused on stakeholders' perspective on the appropriateness and contextual considerations regarding implementing this model to engage youth in decision-making conversations. Interview transcripts were qualitatively analyzed using group-based inductive content analysis. RESULT While all participants acknowledged the philosophical importance of including youth in decision-making, perspectives varied on how this philosophy could be operationalized. Trauma-bonds to offenders, distrust in service systems, and policy and time constraints were discussed as potential barriers to implementation. Perceived benefits to applying this model included encouraging youth empowerment, helping youth develop decision-making skills, and strengthening relationships between youth and providers. Implementation considerations mirrored those seen in other medical and behavioral health settings, including extensive training, fidelity monitoring, enforcement through policy and legislation, and ultimately resetting the culture of services to be maximally youth inclusive. CONCLUSION Participants supported the use of SDM to standardize the inclusion of youth in treatment and placement planning decisions. However, there exist challenges in defining exactly how to adopt this approach, and how to implement broad-scale cultural change within the service-providing community.
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Affiliation(s)
- Samantha Sahl
- National Center for Missing and Exploited Children, Alexandria, VA, USA
- USC Dworak-Peck School of Social Work, CA, USA
| | - Maria Isabella Pontoriero
- Children’s Hospital New Orleans, New Orleans, LA, USA
- Tulane University School of Social Work, New Orleans, LA, USA
| | - Chloe Hill
- Tulane University School of Social Work, New Orleans, LA, USA
| | - Christopher E. Knoepke
- Division of Cardiology, University of Colorado School of Medicine, Denver, CO, USA
- Adult & Child Consortium for Outcomes Research & Delivery Science (ACCORDS), University of Colorado School of Medicine, Denver, CO, USA
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18
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Knoepke CE, Allen LA, Sepucha K, Masoudi FA, Kutner J, Varosy P, Magid D, Matlock DD. Development of a measure of decision quality for implantable defibrillators. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:677-684. [PMID: 33555044 DOI: 10.1111/pace.14189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/20/2021] [Accepted: 01/31/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND CMS reimbursement guidelines for implantable cardioverter-defibrillators (ICDs) include mandated shared decision making (SDM), but without any manner of assessing the quality of decisions made. We developed and tested a scale meant to assess patients' knowledge of and preferences specific to ICDs. Such a tool would assess these constructs in the clinical environment, targeting resources and support for patients considering a primary prevention ICD. METHODS Development of the ICD decision quality (ICD-DQ) scale included (1) item creation, (2) content validation using surveys of patients (n = 23) and clinicians (n = 31), and (3) examination of validity and reliability using a survey of patients who previously received an ICD (n = 295, response rate = 72%). RESULTS The final scale consists of 12 knowledge and 8 preference items. With respect to content validity, clinician and patient respondents agreed on the importance of 19 of 24 candidate knowledge items (79%), and 9 of 11 treatment preference items (81%). Knowledge items exhibited moderate internal validity (α = 0.62, 1 factor), strong test-retest reliability (mean % correct at first administration = 59%, 62% at follow-up, P > .1) and discriminant validity (59% correct for patients, 93% among cardiologists). Short versions of the ICD-DQ were developed for clinical settings, the scores from both of which correlated with the long version in this cohort (11-item (r = 0.90) and a 5-item (r = 0.75)). CONCLUSIONS The ICD-DQ fills a critical gap in measuring the quality of patients' ICD decisions. They may be used to evaluate the effectiveness of patient decision aids or the quality of SDM in clinical practice.
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Affiliation(s)
- Christopher E Knoepke
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Larry A Allen
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Karen Sepucha
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Frederick A Masoudi
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jean Kutner
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Paul Varosy
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA.,VA Eastern Colorado Health Care System, Denver, Colorado, USA
| | - David Magid
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Daniel D Matlock
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Medicine, Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado, USA
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19
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Johnson AE, Bell YK, Hamm ME, Saba SF, Myaskovsky L. A Qualitative Analysis of Patient-Related Factors Associated With Implantable Cardioverter Defibrillator Acceptance. Cardiol Ther 2020; 9:421-432. [PMID: 32476091 PMCID: PMC7584700 DOI: 10.1007/s40119-020-00180-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Patient-related factors determining implantable cardioverter-defibrillator (ICD) use for primary prevention of sudden cardiac death in patients with cardiomyopathy have not been well explored. To assess race and sex differences regarding ICD preferences in this patient population, we sought to analyze a diverse cohort of patients with heart failure (HF) with reduced ejection fraction. METHODS We conducted qualitative interviews of 28 adults with severe HF and either (1) an ICD or (2) no ICD. Interviews were recorded, transcribed, and coded using an inductively developed codebook by independent investigators. Coding was fully adjudicated and transcripts were reviewed to identify themes. RESULTS We recruited patients between 12/2015 and 06/2017, primarily from the outpatient cardiology clinic (24/28 = 86%). Half were women (50%) and 13/28 (46%) were black. Eight did not have an ICD. Neither race nor sex was associated with ICD. Four themes emerged: (1) HF requiring an ICD is profoundly disruptive to patients' lives; (2) patients had positive, yet unrealistic opinions of ICDs; or (3) Patients had negative/ambivalent opinions of ICDs; (4) medical decision-making included aspects of shared decision-making and informed consent. CONCLUSIONS Patients without ICDs perceived less benefit from ICDs and had less decision support. Participants viewed conversations with providers as insufficient. Needed interventions include the development and validation of processes for informed decisions about ICDs.
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Affiliation(s)
- Amber E Johnson
- Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Yamira K Bell
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Megan E Hamm
- Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Samir F Saba
- Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Larissa Myaskovsky
- Internal Medicine and Psychiatry, University of Pittsburgh, and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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20
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"Why Would I Choose Death?": A Qualitative Study of Patient Understanding of the Role and Limitations of Cardiac Devices. J Cardiovasc Nurs 2020; 34:275-282. [PMID: 30789490 DOI: 10.1097/jcn.0000000000000565] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Although cardiology organizations recommend early introduction of palliative care for patients with heart failure (HF), integration has remained challenging, particularly in patients with cardiac devices such as cardiac implantable electronic devices and left ventricular assist devices. Study authors suggest that patients often have limited and erroneous understanding of these devices and their implications for future care. OBJECTIVE The aim of this study was to assess perceptions of cardiac devices in patients with HF and how these perceptions impacted advance care planning and future expectations. METHODS This study used qualitative semistructured interviews with 18 community-dwelling patients with New York Heart Association stage II to IV HF. RESULTS We interviewed 18 patients (mean ejection fraction, 38%; mean age, 64 years; 33% female; 83% white; 39% New York Heart Association class II, 39% class III, and 22% class IV). All had a cardiac implantable electronic device (6% permanent pacemaker, 56% implantable cardioverter-defibrillator, 28% biventricular implantable cardioverter-defibrillator); 11% had left ventricular assist devices. Patients with devices frequently misunderstood the impact of their device on cardiac function. A majority expressed the belief that the device would forestall further deterioration, regardless of whether this was the case. This anticipation of stability was often accompanied by the expectation that emerging technologies would continue to preempt decline. Citing this faith in technology, these patients frequently saw limited value in advance care planning. CONCLUSIONS In our sample, patients with cardiac devices overestimated the impact of their devices on preventing disease progression and death and deprioritized advance care planning as a result.
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21
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Ingles J. Psychological Issues in Managing Families with Inherited Cardiovascular Diseases. Cold Spring Harb Perspect Med 2020; 10:cshperspect.a036558. [PMID: 31548222 DOI: 10.1101/cshperspect.a036558] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The field of cardiovascular genetic counseling has evolved dramatically in recent years largely to manage the unique psychological needs of the inherited cardiovascular disease patient population. For many, there can be difficulty in coming to terms with a diagnosis, whether it be adjusting to lifestyle recommendations such as exclusion from competitive sports or living with a small but remarkable risk of sudden cardiac death. For those considered at risk of life-threatening ventricular arrhythmias, the decision to have an implantable cardioverter defibrillator can be difficult. Living with the device, especially for those who are young and those who receive multiple shocks, can precipitate psychological distress and poor adaptation to the device. Family members who experience a sudden cardiac death of a young relative have a significant risk of poor psychological outcomes. The roles of the cardiac genetic counselor in facilitating patients' adaptation to their diagnoses and management and recognizing when additional support from a clinical psychologist is needed are key to ensuring families receive the best possible care.
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Affiliation(s)
- Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Newtown, New South Wales NSW 2042, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales NSW 2000, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales NSW 2050, Australia
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22
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Wallace BC, Allen LA, Knoepke CE, Glasgow RE, Lewis CL, Fairclough DL, Helmkamp LJ, Fitzgerald MD, Tzou WS, Kramer DB, Varosy PD, Gupta SK, Mandrola JM, Brancato SC, Peterson PN, Matlock DD. A multicenter trial of a shared DECision Support Intervention for Patients offered implantable Cardioverter-DEfibrillators: DECIDE-ICD rationale, design, Medicare changes, and pilot data. Am Heart J 2020; 226:161-173. [PMID: 32599257 DOI: 10.1016/j.ahj.2020.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 04/15/2020] [Indexed: 01/15/2023]
Abstract
Shared decision making (SDM) facilitates delivery of medical therapies that are in alignment with patients' goals and values. Medicare national coverage decision for several interventions now includes SDM mandates, but few have been evaluated in nationwide studies. Based upon a detailed needs assessment with diverse stakeholders, we developed pamphlet and video patient decision aids (PtDAs) for implantable cardioverter/defibrillator (ICD) implantation, ICD replacement, and cardiac resynchronization therapy with defibrillation to help patients contemplate, forecast, and deliberate their options. These PtDAs are the foundation of the Multicenter Trial of a Shared Decision Support Intervention for Patients Offered Implantable Cardioverter-Defibrillators (DECIDE-ICD), a multicenter, randomized trial sponsored by the National Heart, Lung, and Blood Institute aimed at understanding the effectiveness and implementation of an SDM support intervention for patients considering ICDs. Finalization of a Medicare coverage decision mandating the inclusion of SDM for new ICD implantation occurred shortly after trial initiation, raising novel practical and statistical considerations for evaluating study end points. METHODS/DESIGN: A stepped-wedge randomized controlled trial was designed, guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) planning and evaluation framework using an effectiveness-implementation hybrid type II design. Six electrophysiology programs from across the United States will participate. The primary effectiveness outcome is decision quality (defined by knowledge and values-treatment concordance). Patients with heart failure who are clinically eligible for an ICD are eligible for the study. Target enrollment is 900 participants. DISCUSSION: Study findings will provide a foundation for implementing decision support interventions, including PtDAs, with patients who have chronic progressive illness and are facing decisions involving invasive, preference-sensitive therapy options.
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23
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Hoefel L, O’Connor AM, Lewis KB, Boland L, Sikora L, Hu J, Stacey D. 20th Anniversary Update of the Ottawa Decision Support Framework Part 1: A Systematic Review of the Decisional Needs of People Making Health or Social Decisions. Med Decis Making 2020; 40:555-581. [DOI: 10.1177/0272989x20936209] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background. The Ottawa Decision Support Framework (ODSF) has been used for 20 years to assess and address people’s decisional needs. The evidence regarding ODSF decisional needs has not been synthesized. Objectives. To synthesize evidence from ODSF-based decisional needs studies, identify new decisional needs, and validate current ODSF decisional needs. Methods. A mixed-studies systematic review. Nine electronic databases were searched. Inclusion criteria: studies of people’s decisional needs when making health or social decisions for themselves, a child, or a mentally incapable person, as reported by themselves, families, or practitioners. Two independent authors screened eligibility, extracted data, and quality appraised studies using the Mixed Methods Appraisal Tool. Data were analyzed using narrative synthesis. Results. Of 4532 citations, 45 studies from 7 countries were eligible. People’s needs for 101 unique decisions (85 health, 16 social) were reported by 2857 patient decision makers ( n = 36 studies), 92 parent decision makers ( n = 6), 81 family members ( n = 5), and 523 practitioners ( n = 21). Current ODSF decisional needs were reported in 2 to 40 studies. For 6 decisional needs, there were 11 new (manifestations): 1) information (overload, inadequacy regarding others’ experiences with options), 2) difficult decisional roles (practitioner, family involvement, or deliberations), 3) unrealistic expectations (difficulty believing outcome probabilities apply to them), 4) personal needs (religion/spirituality), 5) difficult decision timing (unpredictable), and 6) unreceptive decisional stage (difficulty accepting condition/need for treatment, powerful emotions limiting information processing, lacking motivation to consider delayed/unpredictable decisions). Limitations. Possible publication bias (only peer-reviewed journals included). Possible missed needs (non-ODSF studies, patient decision aid development studies, 3 ODSF needs added in 2006). Conclusion. We validated current decisional needs, identified 11 new manifestations of 6 decisional needs, and recommended ODSF revisions.
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Affiliation(s)
- Lauren Hoefel
- School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Laura Boland
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Health Studies, Western University, London, Ontario, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Jiale Hu
- School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | - Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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24
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Stoevelaar R, Brinkman-Stoppelenburg A, van Bruchem-Visser RL, van Driel AG, Bhagwandien RE, Theuns DAMJ, Rietjens JAC, van der Heide A. Implantable cardioverter defibrillators at the end of life: future perspectives on clinical practice. Neth Heart J 2020; 28:565-570. [PMID: 32548800 PMCID: PMC7596123 DOI: 10.1007/s12471-020-01438-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The implantable cardioverter defibrillator (ICD) is effective in terminating life-threatening arrhythmias. However, in the last phase of life, ICD shocks may no longer be appropriate. Guidelines recommend timely discussion with the patient regarding deactivation of the shock function of the ICD. However, research shows that such conversations are scarce, and some patients experience avoidable and distressful shocks in the final days of life. Barriers such as physicians’ lack of time, difficulties in finding the right time to discuss ICD deactivation, patients’ reluctance to discuss the topic, and the fragmentation of care, which obscures responsibilities, prevent healthcare professionals from discussing this topic with the patient. In this point-of-view article, we argue that healthcare professionals who are involved in the care for ICD patients should be better educated on how to communicate with patients about ICD deactivation and the end of life. Optimal communication is needed to reduce the number of patients experiencing inappropriate and painful shocks in the terminal stage of their lives.
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Affiliation(s)
- R Stoevelaar
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - A Brinkman-Stoppelenburg
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - R L van Bruchem-Visser
- Department of Internal Medicine, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A G van Driel
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
- Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - R E Bhagwandien
- Department of Cardiology, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - D A M J Theuns
- Department of Cardiology, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J A C Rietjens
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
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25
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Alameddine M, AlGurg R, Otaki F, Alsheikh-Ali AA. Physicians' perspective on shared decision-making in Dubai: a cross-sectional study. HUMAN RESOURCES FOR HEALTH 2020; 18:33. [PMID: 32381007 PMCID: PMC7206665 DOI: 10.1186/s12960-020-00475-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 04/24/2020] [Indexed: 05/04/2023]
Abstract
BACKGROUND Shared decision-making (SDM) is an integral part of patient-centered delivery of care. Maximizing the opportunity of patients to participate in decisions related to their health is an expectation in care delivery nowadays. The purpose of this study is to explore the perceptions of physicians in regard to SDM in a large private hospital network in Dubai, United Arab Emirates. METHODS This study utilized a cross-sectional design, where a survey questionnaire was assembled to capture quantitative and qualitative data on the perception of physicians in relation to SDM. The survey instrument included three sections: the first solicited physicians' personal and professional information, the second entailed a 9-item SDM Questionnaire (SDM-Q-9), and the third included an open-ended section. Statistical analysis assessed whether the average SDM-Q-9 score differed significantly by gender, age, years of experience, professional status-generalist versus specialist, and work location-hospitals versus polyclinics. Non-parametric analysis (two independent variables) with the Mann-Whitney test was utilized. The qualitative data was thematically analyzed. RESULTS Fifty physicians from various specialties participated in this study (25 of each gender-85% response rate). Although the quantitative data analysis revealed that most physicians (80%) rated themselves quite highly when it comes to SDM, qualitative analysis underscored a number of barriers that limited the opportunity for SDM. Analysis identified four themes that influence the acceptability of SDM, namely physician-specific (where the physicians' extent of adopting SDM is related to their own belief system and their perception that the presence of evidence negates the need for SDM), patient-related (e.g., patients' unwillingness to be involved in decisions concerning their health), contextual/environmental (e.g., sociocultural impediments), and relational (the information asymmetry and the power gradient that influence how the physician and patient relate to one another). CONCLUSIONS SDM and evidence-based management (EBM) are not mutually exclusive. Professional learning and development programs targeting caregivers should focus on the consolidation of the two perspectives. We encourage healthcare managers and leaders to translate declared policies into actionable initiatives supporting patient-centered care. This could be achieved through the dedication of the necessary resources that would enable SDM, and the development of interventions that are designed both to improve health literacy and to educate patients on their rights.
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Affiliation(s)
- Mohamad Alameddine
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, P.O. Box 505055, Dubai, United Arab Emirates
| | - Reem AlGurg
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, P.O. Box 505055, Dubai, United Arab Emirates.
| | - Farah Otaki
- Strategy and Institutional Excellence, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Alawi A Alsheikh-Ali
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, P.O. Box 505055, Dubai, United Arab Emirates
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McIlvennan CK, Morris MA, Guetterman TC, Matlock DD, Curry L. Qualitative Methodology in Cardiovascular Outcomes Research: A Contemporary Look. Circ Cardiovasc Qual Outcomes 2019; 12:e005828. [PMID: 31510771 DOI: 10.1161/circoutcomes.119.005828] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Qualitative research offers unique opportunities to contribute to cardiovascular outcomes research. Despite the growth in qualitative research over the last decade, outcomes investigators in cardiology still have relatively little guidance on when and how best to implement these methods in their investigations, leaving the full potential of these methods unrealized. We offer a contemporary look at qualitative methods, including publication trends of qualitative studies in cardiology journals from 1998 to 2018, novel emerging data collection and analytic methods, and current use and examples of cardiovascular outcomes research that apply qualitative methods such as user-centered design, preimplementation evaluation, implementation evaluation, effectiveness evaluation, and policy analysis.
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Affiliation(s)
- Colleen K McIlvennan
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (C.K.M., M.A.M., D.D.M.), University of Colorado School of Medicine, Aurora.,Division of Cardiology (C.K.M.), University of Colorado School of Medicine, Aurora
| | - Megan A Morris
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (C.K.M., M.A.M., D.D.M.), University of Colorado School of Medicine, Aurora
| | | | - Daniel D Matlock
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (C.K.M., M.A.M., D.D.M.), University of Colorado School of Medicine, Aurora.,Veteran Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO (D.D.M.)
| | - Leslie Curry
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (L.C.).,Yale Global Health Leadership Institute, Yale University, New Haven, CT (L.C.)
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Lohmueller LC, Naik A, Breitfeller L, McIlvennan CK, Kanwar M, Murali S, Rosé C, Antaki JF. Factors Affecting Health Care Engagement of Patients With End-Stage Heart Failure: An Exploratory Survey Study. MDM Policy Pract 2019; 4:2381468319865515. [PMID: 31453361 PMCID: PMC6699010 DOI: 10.1177/2381468319865515] [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: 12/07/2017] [Accepted: 05/24/2019] [Indexed: 11/16/2022] Open
Abstract
Background. The decision to receive a permanent left ventricular assist device (LVAD) to treat end-stage heart failure (HF) involves understanding and weighing the risks and benefits of a highly invasive treatment. The goal of this study was to characterize end-stage HF patients across parameters that may affect their decision making and to inform the development of an LVAD decision support tool. Methods. A survey of 35 end-stage HF patients at an LVAD implant hospital was performed to characterize their information-seeking habits, interaction with physicians, technology use, numeracy, and concerns about their health. Survey responses were analyzed using descriptive statistics, grounded theory method, and Bayesian network learning. Results. Most patients indicated an interest in using some type of decision support tool (roadmap of health progression: 46%, n = 16; personal prognosis: 51%, n = 18; short videos of patients telling stories of their experiences with an LVAD: 57%, n = 20). Information patients desired in a hypothetical decision support tool fell into the following topics: prognoses for health outcomes, technical information seeking, expressing emotions, and treatment decisions. Desire for understanding their condition was closely related to whether they had difficult interpreting their electronic medical record in the past. Conclusions. Most patients reported interest in engaging in their health care decision making and seeing their prognosis and electronic health record information. Patients who were less interested in their own treatment decisions were characterized by having less success understanding their health information. Design of a decision support tool for potential LVAD patients should consider a spectrum of health literacy and include information beyond the technical specifications of LVAD support.
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Affiliation(s)
- Lisa Carey Lohmueller
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Aakanksha Naik
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Luke Breitfeller
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Colleen K McIlvennan
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Srinivas Murali
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Carolyn Rosé
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - James F Antaki
- Biomedical Engineering, Cornell University, Ithaca, New York
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Sandhu A, Levy A, Varosy PD, Matlock D. Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy in Older Adults With Heart Failure. J Am Geriatr Soc 2019; 67:2193-2199. [PMID: 31403714 DOI: 10.1111/jgs.16099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/04/2019] [Accepted: 06/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) are cardiac implantable electronic devices that may improve morbidity and mortality in select patients with heart failure. Although the benefits of these devices have been well defined, competing mortality risks, comorbid conditions, and frailty pose difficulty in determining risk-benefit trade-offs when these options are considered for older adults. CONCLUSION In this review, we focus on the benefit, risk, and use of ICD and CRT in older adults, particularly because the goals of care for many older adults include a shift away from life-prolonging interventions. Additionally, we discuss periprocedural risk, cost, and maintenance in older populations. Finally, we introduce a framework for helping clinicians and older adults make these challenging decisions collectively. J Am Geriatr Soc 67:2193-2199, 2019.
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Affiliation(s)
- Amneet Sandhu
- Section of Electrophysiology, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado.,Section of Electrophysiology, University of Colorado School of Medicine, Aurora, Colorado.,Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Andrew Levy
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Paul D Varosy
- Section of Electrophysiology, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado.,Section of Electrophysiology, University of Colorado School of Medicine, Aurora, Colorado.,Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Veterans Affairs (VA) Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado.,Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, Colorado
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Fisher KA, Tan ASL, Matlock DD, Saver B, Mazor KM, Pieterse AH. Keeping the patient in the center: Common challenges in the practice of shared decision making. PATIENT EDUCATION AND COUNSELING 2018; 101:2195-2201. [PMID: 30144968 PMCID: PMC6376968 DOI: 10.1016/j.pec.2018.08.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/03/2018] [Accepted: 08/05/2018] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To examine situations where shared decision making (SDM) in practice does not achieve the goal of a patient-centered decision. METHODS We explore circumstances in which elements necessary to realize SDM - patient readiness to participate and understanding of the decision - are not present. We consider the influence of contextual factors on decision making. RESULTS Patients' preference and readiness for participation in SDM are influenced by multiple interacting factors including the patient's comprehension of the decision, their emotional state, the strength of their relationship with the clinician, and the nature of the decision. Uncertainty often inherent in information can lead to misconceptions and ill-formed opinions that impair patients' understanding. In combination with cognitive biases, these factors may result in decisions that are incongruent with patients' preferences. The impact of suboptimal understanding on decision making may be augmented by the context. CONCLUSIONS There are circumstances in which basic elements required for SDM are not present and therefore the clinician may not achieve the goal of a patient-centered decision. PRACTICE IMPLICATIONS A flexible and tailored approach that draws on the full continuum of decision making models and communication strategies is required to achieve the goal of a patient-centered decision.
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Affiliation(s)
- Kimberly A Fisher
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA; Meyers Primary Care Institute, A joint Endeavor Between the University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA.
| | - Andy S L Tan
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
| | - Barry Saver
- Swedish Family Medicine Residency Cherry Hill, Seattle, WA, USA; Department of Family and Community Medicine, University of Massachusetts, Worcester, MA, USA
| | - Kathleen M Mazor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA; Meyers Primary Care Institute, A joint Endeavor Between the University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Arwen H Pieterse
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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30
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2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Heart Rhythm 2018; 15:e73-e189. [DOI: 10.1016/j.hrthm.2017.10.036] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Indexed: 02/07/2023]
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31
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Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2018; 138:e272-e391. [PMID: 29084731 DOI: 10.1161/cir.0000000000000549] [Citation(s) in RCA: 264] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - William G Stevenson
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Michael J Ackerman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - William J Bryant
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - David J Callans
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Anne B Curtis
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Barbara J Deal
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Timm Dickfeld
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Michael E Field
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Gregg C Fonarow
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Anne M Gillis
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Christopher B Granger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Stephen C Hammill
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Mark A Hlatky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - José A Joglar
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - G Neal Kay
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Daniel D Matlock
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Robert J Myerburg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Richard L Page
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
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Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2018; 72:e91-e220. [PMID: 29097296 DOI: 10.1016/j.jacc.2017.10.054] [Citation(s) in RCA: 717] [Impact Index Per Article: 119.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Johnson AE, Adhikari S, Althouse AD, Thoma F, Marroquin OC, Koscumb S, Hausmann LRM, Myaskovsky L, Saba SF. Persistent sex disparities in implantable cardioverter-defibrillator therapy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1150-1157. [PMID: 29959781 DOI: 10.1111/pace.13435] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/17/2018] [Accepted: 06/10/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical guidelines recommend cardioverter defibrillator implantation for patients with heart failure and reduced ejection fraction. Despite this, women and minorities have been less likely to receive implantable cardioverter-defibrillator (ICD) therapy than white men. We examined race and sex differences in ICD implantation in a recent cohort. METHODS Using cross-sectional, retrospective analyses, we mined our health system's outpatient electronic medical records to assess age, race, sex, medications, and comorbidities for patients aged ≥18 years with ejection fraction ≤ 35% during 2014. While adjusting for confounding variables such as medications, age, and comorbidities, we conducted a multivariable logistic regression assessing whether racial and sex differences in ICD therapy persist. RESULTS Among 5,156 outpatients with ejection fraction ≤35%, 1,681 (32.6%) patients had an ICD present at the time of their index outpatient visit in 2014. Women were less likely to have an ICD than men (25.0% vs 36.3%, P < 0.01), and black patients were less likely to have an ICD than white patients (28.0% vs 33.2%, P = 0.02). In adjusted multivariable analyses, women were less like to have ICDs (adjusted odds ratio [OR] = 0.68, 95% confidence interval [CI], 0.58-0.79, P < 0.01) but the race difference dissipated (adjusted OR for black race = 0.86, 95% CI, 0.68-1.08, P = 0.18). CONCLUSIONS In this large, outpatient cohort, we have shown that sex differences in ICD therapy continue to exist, but the difference in ICD prevalence by race was attenuated. Dedicated studies are required to fully understand the causes of persistent sex differences in ICD therapy.
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Affiliation(s)
- Amber E Johnson
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Floyd Thoma
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Oscar C Marroquin
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,UPMC's Department of Clinical Analytics, Pittsburgh, PA, USA
| | - Stephen Koscumb
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,UPMC's Department of Clinical Analytics, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- University of Pittsburgh Department of Medicine, Pittsburgh, PA, USA.,Veterans Affairs Pittsburgh Healthcare System Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease and Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Samir F Saba
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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35
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Carroll SL, Embuldeniya G, Pannag J, Lewis KB, Healey JS, McGillion M, Thabane L, Stacey D. "I don't know exactly what you're referring to": the challenge of values elicitation in decision making for implantable cardioverter-defibrillators. Patient Prefer Adherence 2018; 12:1947-1954. [PMID: 30319244 PMCID: PMC6168006 DOI: 10.2147/ppa.s173705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Patients' values are a key component of patient-centered care and shared decision making in health care organizations. There is limited understanding on how patients' values guide their health related decision making or how patients understand the concept of values during these processes. This study investigated patients' understanding of their values in the context of considering the risks/benefits of receiving an implantable cardioverter-defibrillator (ICD). PATIENTS AND METHODS A qualitative substudy was conducted within a feasibility trial with first-time ICD candidates randomized to receive a patient decision aid or usual care prior to specialist consultation. Semi-structured interviews were conducted with participants post-implantation or post-specialist consultation. RESULTS Sixteen patients (ten male) aged 47-87 years participated. Of these, ten (62.5%) received the patient decision aid prior to specialist consultation. Findings revealed patients were confused by the word "values" and had difficulty expressing values related to risks/benefits during ICD decision making. When probed, values were conceptualized broadly capturing other factors such as desire to live, good quality of life, family's views, ICD information, control over decision, and medical authority. CONCLUSION This study revealed the difficulty patients considering an ICD had with articulating their values in the context of an ICD health decision and highlighted the challenge to effectively elicit patients' values within health decisions overall. It is suggested that there should be a shift away from the use of the word "values" when speaking directly to patients toward language such as "what matters to you the most" or "what is most important to you".
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Affiliation(s)
- Sandra L Carroll
- School of Nursing, McMaster University, Hamilton, ON, Canada,
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada,
- Hamilton Health Sciences, Hamilton, ON, Canada,
| | | | - Jasprit Pannag
- School of Nursing, McMaster University, Hamilton, ON, Canada,
| | | | - Jeff S Healey
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada,
- Hamilton Health Sciences, Hamilton, ON, Canada,
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Michael McGillion
- School of Nursing, McMaster University, Hamilton, ON, Canada,
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada,
| | - Lehana Thabane
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada,
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Baskar S, Jefferies JL, Salberg L, Khoury PR, Spar DS, Knilans TK, Czosek RJ. Patient understanding of disease and the use and outcome of implantable cardioverter defibrillators in hypertrophic cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 41:57-64. [PMID: 29154461 DOI: 10.1111/pace.13234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/18/2017] [Accepted: 10/29/2017] [Indexed: 11/29/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiac death (SCD) in young individuals. Implantable cardioverter defibrillators (ICD) are the primary therapy for sudden death prevention; however, are associated with both physical and psychological complications. We sought to determine factors associated with ICD understanding and patient satisfaction. This was a cross-sectional study, using patient/parent answered questionnaires distributed to patients enrolled in the Hypertrophic Cardiomyopathy Association. Patient characteristics and satisfaction data were obtained via questionnaire. Patients were compared based on age at diagnosis and presence of ICD. ICD patients with high satisfaction were compared to those with low satisfaction to determine factors associated with poor satisfaction. A total of 538 responses were obtained (53 ± 16 years); 46% were females. Seventy patients (13%) were diagnosed with HCM < 18 years of age and 356 (66%) had an ICD. Compared to those without an ICD, patients with ICDs were younger at age of diagnosis (P = 0.001) and time of study (P = 0.008). Patients with ICDs were more likely to have presented with syncope and have family history of ICD, SCD, or HCM-related death. Nineteen patients (5%) felt that issues surrounding their ICD outweighed its benefit. Compared to patients with a favorable satisfaction, the only significant difference was the preimplant ICD discussion (P < 0.001) and history of lead replacement (P = 0.01). In conclusion, the majority of HCM patients with ICDs are satisfied with their ICD management and feel the benefits of ICDs outweigh issues associated with ICDs. Additionally, these data highlight the importance of the preimplant patient-physician discussion around the need for ICD prior to implantation.
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Affiliation(s)
- Shankar Baskar
- Division of Pediatric Cardiology, Department of Pediatrics, The Heart Institute at Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John L Jefferies
- Division of Pediatric Cardiology, Department of Pediatrics, The Heart Institute at Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lisa Salberg
- Hypertrophic Cardiomyopathy Association, Denville, NJ, USA
| | - Philip R Khoury
- Division of Pediatric Cardiology, Department of Pediatrics, The Heart Institute at Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David S Spar
- Division of Pediatric Cardiology, Department of Pediatrics, The Heart Institute at Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Timothy K Knilans
- Division of Pediatric Cardiology, Department of Pediatrics, The Heart Institute at Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Richard J Czosek
- Division of Pediatric Cardiology, Department of Pediatrics, The Heart Institute at Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Gagliardi AR, Lehoux P, Ducey A, Easty A, Ross S, Bell CM, Trbovich P, Takata J, Urbach DR. Factors constraining patient engagement in implantable medical device discussions and decisions: interviews with physicians. Int J Qual Health Care 2017; 29:276-282. [PMID: 28453827 PMCID: PMC5412024 DOI: 10.1093/intqhc/mzx013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 01/20/2017] [Indexed: 01/03/2023] Open
Abstract
Objective Patient engagement (PE) is warranted when treatment risks and outcomes are uncertain, as is the case for higher risk medical devices. Previous research found that patients were not engaged in discussions or decisions about implantable medical devices. This study explored physician views about engaging patients in such discussions. Design Qualitative interviews using a basic descriptive approach. Setting Canada. Participants Practicing cardiovascular and orthopaedic physicians. Main outcome measures Level, processes and determinants of PE in medical device discussions and decisions. Results Views were largely similar among 10 cardiovascular and 12 orthopaedic physicians interviewed. Most said that it was feasible to inform and sometimes involve patients in discussions, but not to partner with them in medical device decision-making. PE was constrained by patient (comfort with PE, technical understanding, physiologic/demographic characteristics, prognosis), physician (device preferences, time), health system (purchasing contracts) and device factors (number of devices on market, comparative advantage). A framework was generated to help physicians engage patients in discussions about medical devices, even when decisions may not be preference sensitive due to multiple constraints on choice. Conclusions This study identified that patients are not engaged in discussions or decisions about implantable medical devices. This may be due to multiple constraints. Further research should establish the legitimacy, prevalence and impact of constraining factors, and examine whether and how different levels and forms of PE are needed and feasible.
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Affiliation(s)
- Anna R Gagliardi
- Toronto General Hospital Research Institute, University Health Network, 200 Elizabeth Street, Toronto, M5G2C4, Canada
| | - Pascale Lehoux
- Department of Public Health Administration, University of Montreal, C.P. 6128, succ. Centre-ville Montréal, H3C 3J7, Canada
| | - Ariel Ducey
- Department of Sociology, University of Calgary, Social Sciences Building, Room 956618 Campus Place N.W., 2500 University Drive NW, Calgary, T2N2N4, Canada
| | - Anthony Easty
- Institute of Biomaterial & Biomedical Engineering, University of Toronto
| | - Sue Ross
- Women & Children's Health Research Institute, University of Alberta, 11405 87 Avenue NW, Edmonton, T6G1C9, Canada
| | - Chaim M Bell
- Department of General Internal Medicine, Mount Sinai Hospital, 600 University Avenue, Toronto, M5G1X5, Canada
| | - Patricia Trbovich
- Toronto General Hospital Research Institute, University Health Network, 200 Elizabeth Street, Toronto, M5G2C4, Canada
| | - Julie Takata
- Toronto General Hospital Research Institute, University Health Network, 200 Elizabeth Street, Toronto, M5G2C4, Canada
| | - David R Urbach
- Toronto General Hospital Research Institute, University Health Network, 200 Elizabeth Street, Toronto, M5G2C4, Canada
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38
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Kusumoto F, Austin C. Brugada Syndrome. J Am Coll Cardiol 2017; 70:2003-2005. [DOI: 10.1016/j.jacc.2017.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/08/2017] [Indexed: 10/18/2022]
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Makdisi T, Makdisi G. Ethical challenges and terminal deactivation of left ventricular assist device. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:331. [PMID: 28861428 DOI: 10.21037/atm.2017.04.39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tony Makdisi
- Palliative Care Division, University of Massachusetts Medical School, Berkshire Medical Center, Pittsfield, MA, USA
| | - George Makdisi
- Division of Cardiothoracic Surgery, University of South Florida, Tampa General Hospital, Tampa, FL, USA
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Bakshi N, Sinha CB, Ross D, Khemani K, Loewenstein G, Krishnamurti L. Proponent or collaborative: Physician perspectives and approaches to disease modifying therapies in sickle cell disease. PLoS One 2017; 12:e0178413. [PMID: 28727801 PMCID: PMC5518995 DOI: 10.1371/journal.pone.0178413] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/13/2017] [Indexed: 11/18/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited blood disorder that primarily affects African-American and other ethnic minority populations. There are three available disease-modifying therapies for sickle cell disease: hydroxyurea (HU), bone marrow transplantation (BMT), and chronic blood transfusion (CBT). Since these treatments vary in their therapeutic intent, efficacy in preventing progression of the disease, short and long-term adverse effects, costs and patient burden, the decision-making process regarding these therapies is complicated for both the patient and healthcare provider. While previous research has focused on the patient perspective of treatment-related decision making, there is a paucity of research investigating the physician perspective of treatment-related decision making. We conducted a qualitative study with physicians who were experts in the field of SCD. Interviews focused on physician perceptions of patient decisional needs as well as physicians' approach to decision making regarding disease-modifying therapies in SCD. Thirty-six physician interviews were analyzed, with a focus on their perspectives regarding available treatment options and on how they approach decision making with patients. We identified two narrative approaches. The Collaborative approach (CA) was characterized by emphasizing the need to discuss all possible treatment options to ensure that the patient and/or family was equipped to make an informed decision. The Proponent approach (PA) was characterized by strongly advocating a pre-determined treatment plan and providing patients/families with information, with the objective of convincing them to accept the treatment. An interplay of patient-related and disease-related factors, decision type and physician-related factors, as well as institutional frameworks, influenced physician perspectives on treatment options and decision making regarding these therapies. These findings point to the potential value of developing systems to foster patient engagement as a way of facilitating shared decision making.
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Affiliation(s)
- Nitya Bakshi
- Division of Pediatric Hematology-Oncology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Aflac Cancer and Blood Disorders, Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America.,Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University, Atlanta, Georgia, United States of America
| | - Cynthia B Sinha
- Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University, Atlanta, Georgia, United States of America
| | - Diana Ross
- Division of Pediatric Hematology-Oncology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University, Atlanta, Georgia, United States of America
| | - Kirshma Khemani
- Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University, Atlanta, Georgia, United States of America
| | - George Loewenstein
- Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Lakshmanan Krishnamurti
- Division of Pediatric Hematology-Oncology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Aflac Cancer and Blood Disorders, Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America.,Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University, Atlanta, Georgia, United States of America
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Randolph TC, Hellkamp AS, Zeitler EP, Fonarow GC, Hernandez AF, Thomas KL, Peterson ED, Yancy CW, Al-Khatib SM. Utilization of cardiac resynchronization therapy in eligible patients hospitalized for heart failure and its association with patient outcomes. Am Heart J 2017. [PMID: 28625381 DOI: 10.1016/j.ahj.2017.04.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We examined trends in CRT utilization overall and by sex and race and to assess whether CRT use is associated with a reduction in HF hospitalization and mortality. BACKGROUND It is unknown whether underutilization and race/sex-based differences in cardiac resynchronization therapy (CRT) use have persisted. The association between CRT and heart failure (HF) hospitalization and mortality in real-world practice remains unclear. METHODS We linked 72,008 HF patients from 388 hospitals participating in Get With The Guidelines HF eligible for CRT with Centers for Medicare & Medicaid Services data to assess CRT utilization trends, HF hospitalization rates, and all-cause mortality. RESULTS From 2005-2014, 18,935 (26.3%) eligible patients had CRT in place, implanted, or prescribed. The majority were male (60.0%) and white (61.9%). CRT utilization increased during the study period (P = .0002) especially in the early period. Women were less likely to receive CRT, and this difference increased over time (interaction P = .0037) despite greater mortality risk reduction (interaction P = .0043). Black patients were less likely than white patients to have CRT throughout the study period (adjusted hazard ratio (HR) 0.79; 95% CI 0.74-0.85). Patients with CRT implanted during the index hospitalization had lower mortality (adjusted HR 0.65; 95% CI 0.59-0.71) and were less likely to be readmitted for HF than patients without CRT (adjusted HR 0.64; 95% CI 0.58-0.71). CONCLUSIONS/RELEVANCE CRT use has increased in all populations, but it remains underutilized. CRT remains more common among white than black HF patients, and women were less likely than men to receive CRT despite deriving greater benefit.
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Malecki-Ketchell A, Marshall P, Maclean J. Adult patient decision-making regarding implantation of complex cardiac devices: a scoping review. Eur J Cardiovasc Nurs 2017. [DOI: 10.1177/1474515117715730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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43
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Maddox TM, Albert NM, Borden WB, Curtis LH, Ferguson TB, Kao DP, Marcus GM, Peterson ED, Redberg R, Rumsfeld JS, Shah ND, Tcheng JE. The Learning Healthcare System and Cardiovascular Care: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e826-e857. [DOI: 10.1161/cir.0000000000000480] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The learning healthcare system uses health information technology and the health data infrastructure to apply scientific evidence at the point of clinical care while simultaneously collecting insights from that care to promote innovation in optimal healthcare delivery and to fuel new scientific discovery. To achieve these goals, the learning healthcare system requires systematic redesign of the current healthcare system, focusing on 4 major domains: science and informatics, patient-clinician partnerships, incentives, and development of a continuous learning culture. This scientific statement provides an overview of how these learning healthcare system domains can be realized in cardiovascular disease care. Current cardiovascular disease care innovations in informatics, data uses, patient engagement, continuous learning culture, and incentives are profiled. In addition, recommendations for next steps for the development of a learning healthcare system in cardiovascular care are presented.
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Evidence of Cognitive Bias in Decision Making Around Implantable-Cardioverter Defibrillators: A Qualitative Framework Analysis. J Card Fail 2017; 23:794-799. [PMID: 28363805 DOI: 10.1016/j.cardfail.2017.03.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 02/05/2017] [Accepted: 03/24/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Studies have demonstrated that patients with primary prevention implantable cardioverter-defibrillators (ICDs) often misunderstand the ICD. Advances in behavioral economics demonstrate that some misunderstandings may be due to cognitive biases. We aimed to explore the influence of cognitive bias on ICD decision making. METHODS AND RESULTS We used a qualitative framework analysis including 9 cognitive biases: affect heuristic, affective forecasting, anchoring, availability, default effects, halo effects, optimism bias, framing effects, and state dependence. We interviewed 48 patients from 4 settings in Denver. The majority were male (n = 32). Overall median age was 61 years. We found frequent evidence for framing, default, and halo effects; some evidence of optimism bias, affect heuristic, state dependence, anchoring and availability bias; and little or no evidence of affective forecasting. Framing effects were apparent in overestimation of benefits and downplaying or omitting potential harms. CONCLUSIONS We found evidence of cognitive bias in decision making for ICD implantation. The majority of these biases appeared to encourage ICD treatment.
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Standing H, Exley C, Flynn D, Hughes J, Joyce K, Lobban T, Lord S, Matlock D, McComb JM, Paes P, Thomson RG. A qualitative study of decision-making about the implantation of cardioverter defibrillators and deactivation during end-of-life care. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04320] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Holly Standing
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Julian Hughes
- Policy, Ethics and Life Sciences Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Kerry Joyce
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Trudie Lobban
- Arrhythmia Alliance: The Heart Rhythm Charity, Stratford-upon-Avon, UK
| | - Stephen Lord
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Daniel Matlock
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Janet M McComb
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Paul Paes
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Green AR, Jenkins A, Masoudi FA, Magid DJ, Kutner JS, Leff B, Matlock DD. Decision-Making Experiences of Patients with Implantable Cardioverter Defibrillators. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:1061-1069. [PMID: 27566614 DOI: 10.1111/pace.12943] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 08/03/2016] [Accepted: 08/18/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND When patients are not adequately engaged in decision making, they may be at risk of decision regret. Our objective was to explore patients' perceptions of their decision-making experiences related to implantable cardioverter defibrillators (ICDs). METHODS Cross-sectional, mailed survey of 412 patients who received an ICD without cardiac resynchronization therapy for any indication between 2006 and 2009. Patients were asked about decision participation and decision regret. RESULTS A total of 295 patients with ICDs responded (72% response rate). Overall, 79% reported that they were as involved in the decision as they wanted. However, 28% reported that they were not told of the option of not getting an ICD and 37% did not remember being asked if they wanted an ICD. In total, 19% reported not wanting their ICD at the time of implantation. Those who did not want the ICD were younger (<65 years; 74% vs 43%, P < 0.001), had higher decision regret (31/100 vs 11/100, P < 0.001), and reported less participation in decision making (the doctor "totally" made the decision, 9% vs 3%; P < 0.001). CONCLUSIONS A considerable number of ICD recipients recalled not wanting their ICD at the time of implantation. While these findings may be prone to recall bias, they likely identify opportunities to improve ICD decision making.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Amy Jenkins
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Frederick A Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado
| | - David J Magid
- Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Jean S Kutner
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Bruce Leff
- Division of Geriatric Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.,Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Daniel D Matlock
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado
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North F, Fox S, Chaudhry R. Clinician time used for decision making: a best case workflow study using cardiovascular risk assessments and Ask Mayo Expert algorithmic care process models. BMC Med Inform Decis Mak 2016; 16:96. [PMID: 27439359 PMCID: PMC4955236 DOI: 10.1186/s12911-016-0334-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 07/09/2016] [Indexed: 11/18/2022] Open
Abstract
Background Risk calculation is increasingly used in lipid management, congestive heart failure, and atrial fibrillation. The risk scores are then used for decisions about statin use, anticoagulation, and implantable defibrillator use. Calculating risks for patients and making decisions based on these risks is often done at the point of care and is an additional time burden for clinicians that can be decreased by automating the tasks and using clinical decision-making support. Methods Using Morae Recorder software, we timed 30 healthcare providers tasked with calculating the overall risk of cardiovascular events, sudden death in heart failure, and thrombotic event risk in atrial fibrillation. Risk calculators used were the American College of Cardiology Atherosclerotic Cardiovascular Disease risk calculator (AHA-ASCVD risk), Seattle Heart Failure Model (SHFM risk), and CHA2DS2VASc. We also timed the 30 providers using Ask Mayo Expert care process models for lipid management, heart failure management, and atrial fibrillation management based on the calculated risk scores. We used the Mayo Clinic primary care panel to estimate time for calculating an entire panel risk. Results Mean provider times to complete the CHA2DS2VASc, AHA-ASCVD risk, and SHFM were 36, 45, and 171 s respectively. For decision making about atrial fibrillation, lipids, and heart failure, the mean times (including risk calculations) were 85, 110, and 347 s respectively. Conclusion Even under best case circumstances, providers take a significant amount of time to complete risk assessments. For a complete panel of patients this can lead to hours of time required to make decisions about prescribing statins, use of anticoagulation, and medications for heart failure. Informatics solutions are needed to capture data in the medical record and serve up automatically calculated risk assessments to physicians and other providers at the point of care.
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Affiliation(s)
- Frederick North
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Samuel Fox
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, USA
| | - Rajeev Chaudhry
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, USA
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Elston Lafata J, Brown RF, Pignone MP, Ratliff S, Shay LA. Primary Care Physicians' Support of Shared Decision Making for Different Cancer Screening Decisions. Med Decis Making 2016; 37:70-78. [PMID: 27430237 DOI: 10.1177/0272989x16660547] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/18/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite its widespread advocacy, shared decision making (SDM) is not routinely used for cancer screening. To better understand the implementation barriers, we describe primary care physicians' (PCPs') support for SDM across diverse cancer screening contexts. METHODS Surveys were mailed to a random sample of USA-based PCPs. Using multivariable logistic regression analyses, we tested for associations of PCPs' support of SDM with the US Preventive Service Task Force (USPSTF) assigned recommendation grade, assessed whether the decision pertained to not screening older patients, and the PCPs' autonomous v. controlled motivation-orientation for using SDM. RESULTS PCPs (n = 278) were, on average, aged 52 years, 38% female, and 69% white. Of these, 79% endorsed discussing screening benefits as very important to SDM; 64% for discussing risks; and 31% for agreeing with patient's opinion. PCPs were most likely to rate SDM as very important for colorectal cancer screening in adults aged 50-75 years (69%), and least likely for colorectal cancer screening in adults aged >85 years (34%). Regression results indicated the importance of PCPs' having autonomous or self-determined reasons for engaging in SDM (e.g., believing in the benefits of SDM) (OR = 2.29, 95% CI, 1.87 to 2.79). PCPs' support for SDM varied by USPSTF recommendation grade (overall contrast, X2 = 14.7; P = 0.0054), with support greatest for A-Grade recommendations. Support for SDM was lower in contexts where decisions pertained to not screening older patients (OR = 0.45, 95% CI, 0.35 to 0.56). LIMITATIONS It is unknown whether PCPs' perceptions of the importance of SDM behaviors differs with specific screening decisions or the potential limited ability to generalize findings. CONCLUSIONS Our results highlight the need to document SDM benefits and consider the specific contextual challenges, such as the level of uncertainty or whether evidence supports recommending/not recommending screening, when implementing SDM across an array of cancer screening contexts.
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Affiliation(s)
- Jennifer Elston Lafata
- Massey Cancer Center and Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA (JEL, RFB)
| | - Richard F Brown
- Massey Cancer Center and Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA (JEL, RFB)
| | - Michael P Pignone
- Division of General Medicine and UNC Institute for Healthcare Quality Improvement, School of Medicine, University of North Carolina, Chapel Hill, NC, USA (MPP)
| | - Scott Ratliff
- Family Medicine and Population Health, Virginia Commonwealth University, Richmond VA, USA (SR)
| | - L Aubree Shay
- Department of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, San Antonio, TX, USA (LAS)
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LEWIS KRYSTINAB, STACEY DAWN, CARROLL SANDRAL, BOLAND LAURA, SIKORA LINDSEY, BIRNIE DAVID. Estimating the Risks and Benefits of Implantable Cardioverter Defibrillator Generator Replacement: A Systematic Review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:709-22. [DOI: 10.1111/pace.12850] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 02/25/2016] [Accepted: 03/06/2016] [Indexed: 11/28/2022]
Affiliation(s)
- KRYSTINA B. LEWIS
- School of Nursing; University of Ottawa; Ottawa Canada
- University of Ottawa Heart Institute; Ottawa Canada
| | - DAWN STACEY
- School of Nursing; University of Ottawa; Ottawa Canada
- Ottawa Hospital Research Institute; Ottawa Canada
| | | | - LAURA BOLAND
- Interdisciplinary School of Health Sciences; University of Ottawa; Ottawa Canada
| | - LINDSEY SIKORA
- Health Sciences Library; University of Ottawa; Ottawa Canada
| | - DAVID BIRNIE
- University of Ottawa Heart Institute; Ottawa Canada
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Green AR, Boyd CM, Rickard J, Gomon R, Leff B. Attitudes of older adults with serious competing health risks toward their implantable cardioverter-defibrillators: a pilot study. BMC Geriatr 2015; 15:173. [PMID: 26700296 PMCID: PMC4690308 DOI: 10.1186/s12877-015-0173-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/16/2015] [Indexed: 11/23/2022] Open
Abstract
Background In elderly heart failure patients, the survival benefit of implantable cardioverter-defibrillators (ICDs) may be attenuated due to competing health risks, and the risk of adverse outcomes magnified. Our objective was to examine older adults’ attitudes towards ICD implantation in the context of competing health risks, exploring the determinants of ICD decision-making among a group of patients who had faced the decision in the past. Methods Telephone survey with a qualitative component. Patients were age ≥70 with single- or dual-chamber ICDs from a single academic cardiac device clinic. Health status was assessed with the Vulnerable Elders Survey (VES-13). Responses to open-ended questions were transcribed verbatim; an “editing analysis” approach was used to extract themes. Results Forty-four ICD recipients participated (mean age 77.5 years). Nineteen participants (43 %) had VES-13 scores ≥3, indicating a 50 % likelihood of death or functional decline within 2 years. Twenty-one participants (48 %) had received prior ICD shocks. Forty participants (91 %) said they would “definitely” choose to get an ICD again in their current health. By and large, patients revealed a strong desire to extend life, expressed complete confidence in the lifesaving capabilities of their ICDs, and did not describe consideration of competing health risks. Conclusions In this pilot telephone survey with a qualitative component, nearly all older adults with ICDs would still choose to get an ICD despite high short-term risk of death or health deterioration. These findings suggest the need to partner more effectively with patients and families to decide how best to use medical technologies, particularly for older adults with competing risks.
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Affiliation(s)
- Ariel R Green
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, 7th floor, Baltimore, MD, 21224, USA.
| | - Cynthia M Boyd
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, 7th floor, Baltimore, MD, 21224, USA.
| | - John Rickard
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 301 building, Baltimore, MD, 21224, USA.
| | - Robert Gomon
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 301 building, Baltimore, MD, 21224, USA.
| | - Bruce Leff
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, 7th floor, Baltimore, MD, 21224, USA. .,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA. .,Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, USA.
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