Decision-Making Experiences of Patients with Implantable Cardioverter Defibrillators

Engaging women in decision-making about their heart health: a literature review with patients' perspective

Cardiovascular disease (CVD) remains the leading cause of death globally. Although the burden of CVD risk factors tends to be lower in women, they remain at higher risk of developing complications when affected by these risk factors. There is still a lack of awareness surrounding CVD in women, both from a patient's and a clinician's perspective, especially among visible minorities. However, women who are informed about their heart health and who engage in decision-making with their healthcare providers are more likely to modify their lifestyle, and improve their CVD risk. A patient-centered care approach benefits patients' physical and mental health, and is now considered gold-standard for efficient patient care. Engaging women in their heart health will contribute in closing the gap of healthcare disparities between men and women, arising from sociocultural, socioeconomic, and political factors. This comprehensive review of the literature discusses the importance of engaging women in decision-making surrounding their heart health and offers tools for an effective and culturally sensitive patient-provider relationship.

Patient Information Needs and Decision-Making Before a Cardiac Implantable Electronic Device: A Qualitative Study Utilizing Social Media Data

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.

Development and piloting of four decision aids for implantable cardioverter-defibrillators in different media formats

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 Grid^TM 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.

Patient and Cardiologist Perspectives on Shared Decision Making in the Treatment of Older Adults Hospitalized for Acute Myocardial Infarction

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.

Device Adjustment and Recovery in Patients With Heart Failure Undergoing a Cardiac Resynchronization Therapy Implantation: A Longitudinal Study

BACKGROUND

Little is known about risk factors for poor adjustment to the device after cardiac resynchronization therapy (CRT) implantation in patients with heart failure.

PURPOSE

The aim of this study was to explore device adjustment and the postoperative recovery of patients with heart failure undergoing elective CRT device implantation.

METHODS

In this prospective multicenter longitudinal study, data were collected before implantation and after 2 weeks, 6 months, and 1 year, using validated self-reported instruments and investigator-designed, CRT-specific questions.

RESULTS

A total of 133 patients, 79% male, with a mean age of 70 ± 10 years, were included. Patients adjusted to the device over time (P < .001), but 20% of patients had difficulties after 2 weeks, and 11% had difficulties at the 1-year follow-up. Fatigue was the most common health problem before surgery (87%), which was reduced to 65% after 1 year, P < .001. Patients' recovery improved over time (P < .001). Device-specific problems with hiccups (7% vs 14%), pulsation around the device (29% vs 24%), tachycardia (28% vs 29%), appearance of the scar (21% vs 17%), and the device bulging out (65% vs 61%) remained unchanged over time, whereas stiffness in the shoulder (64% vs 28%, P < .001) and wound healing (9% vs 2%, P < .05) improved.

CONCLUSIONS

Most patients with heart failure recover and adjust early after their CRT implantation and improve even more during follow-up. However, recovery and adjustment are problematic for some patients, and many experience bodily discomforts because of the device. Early screening for poor adjustment and psychological distress can lead to appropriate interventions and timely referrals. This is important in the era of remote monitoring with less face-to-face contact.

A Qualitative Analysis of Patient-Related Factors Associated With Implantable Cardioverter Defibrillator Acceptance

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.

Enhancing Success of Medicare's Shared Decision Making Mandates Using Implementation Science: Examples Applying the Pragmatic Robust Implementation and Sustainability Model (PRISM)

The Centers for Medicare and Medicaid Services (CMS) has mandated shared decision making (SDM) using patient decision aids for three conditions (lung cancer screening, atrial fibrillation, and implantable defibrillators). These forward-thinking approaches are in response to a wealth of efficacy data demonstrating that decision aids can improve patient decision making. However, there has been little focus on how to implement these approaches in real-world practice. This article demonstrates how using an implementation science framework may help programs understand multilevel challenges and opportunities to improve adherence to the CMS mandates. Using the PRISM (Pragmatic Robust Implementation and Sustainability Model) framework, we discuss general challenges to implementation of SDM, issues specific to each mandate, and how to plan for, enhance, and assess SDM implementation outcomes. Notably, a theme of this discussion is that successful implementation is context-specific and to truly have successful and sustainable changes in practice, context variability, and adaptation to context must be considered and addressed.

Decision regret in implantable cardioverter-defibrillator recipients : A cross-sectional analysis on patients that regret their decision after ICD implantation

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) are designed to deliver therapy in the event of malignant ventricular arrhythmias. Despite their benefits, some ICD recipients regret their decision on device implantation.

OBJECTIVES

The aim of this study was to evaluate the incidence, predictors, and consequences of recipients that regretted their decision after implantation.

METHODS

A questionnaire-based cross-sectional survey of consecutive ICD recipients examined during a routine outpatient follow-up visit was conducted. Their level of depression and anxiety was assessed with the hospital anxiety and depression scale (HADS). Quality of life (QOL) was assessed using the Minnesota living with heart failure questionnaire.

RESULTS

Of 434 ICD recipients invited to the study, 423 (97.5%) agreed and completed the survey, 349 (83%) had a primary prevention indication, and 339 (80%) ischemic cardiomyopathy. A total of 41 recipients (9.7%) regretted their decision to undergo ICD implantation. These patients were: (1) younger (63 versus 69 years), (2) more frequently in New York Heart Association (NYHA) ≥2 functional class (63% versus 22%), (3) had higher education levels (more than high-school: 76% versus 60%), (4) felt that preoperative information was lacking (22% versus 4%), (5) had more complications in the perioperative period (15% versus 3%), (6) felt less safe after ICD implantation (54% versus 5%), and (7) considered more frequently ICD deactivation during near end-of-life situations (54% versus 29%). Mean QOL and HADS scores were significantly worse in these patients (36 versus 30 and 12 versus 8.8 points, respectively; p < 0.01 for all).

CONCLUSION

Almost 10% of ICD recipients regretted their decision after implantation. Predictors included younger age, higher education levels, complicated perioperative period, and lack of preoperative information.

Health-related preferences of older patients with multimorbidity: an evidence map

OBJECTIVES

To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence.

DESIGN

Evidence map (systematic review variant).

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018.

STUDY SELECTION

Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions).

DATA EXTRACTION

Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software.

RESULTS

The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9-9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies.

CONCLUSION

Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences.

TRIAL REGISTRATION NUMBER

Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.

Exploring the experiences of individuals with an insertable cardiac monitor: Making the decision for device insertion

BACKGROUND

Little is known about the decision-making process for insertable cardiac monitors (ICM) in those with suspected arrhythmias.

OBJECTIVE

The purpose of this qualitative study was to describe how individuals make a decision to insert an ICM.

METHODS

A qualitative descriptive design was used. Data were analyzed using content analysis and constant comparison. NVivo 10 was used for data grouping and patterns.

RESULTS

Participants (N = 12) ranged in age from 41to 95. Most (n = 7) had the device inserted because of syncope or atrial fibrillation (AF), and others (n = 5) for cryptogenic stroke. Three categories emerged: pre-decision, definitive decision, and deliberated decision. Event symptoms, including physical, cognitive and emotional, and trust emerged as factors in decision-making.

CONCLUSIONS

Those who perceived their experience as life-threatening, trusted the healthcare provider and assented to the ICM insertion. Conversely, those who perceived symptoms as episodic, used other strategies to resolve symptoms prior to making the decision for insertion.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

"I don't know exactly what you're referring to": the challenge of values elicitation in decision making for implantable cardioverter-defibrillators

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".

Patient and provider perspectives on shared decision making: a systematic review of the peer-reviewed literature

For comparative effectiveness research to be effective, patients and providers must collaborate in shared decision making (SDM) to make evidence-based clinical decisions that align with patient preferences. We conducted a systematic review to examine patient and provider attitudes toward and engagement in SDM in the USA. Searches in PubMed and PsycINFO identified 1585 articles published between July 2006 and December 2016, of which 290 were screened in for coding and analysis. We found that patients and providers have generally positive attitudes toward SDM, but actual engagement in SDM behavior is lagging. Translation of positive attitudes into behavior could be achieved through policies that support key SDM processes of sharing evidence, considering patient preferences and discussing the relative advantages of different clinical options.