A LEARNING CURVE FOR SHARED DECISION MAKING: THE IMPACT OF PHYSICIAN EXPERIENCE ON DECISION AID EFFICACY IN SEVERE AORTIC STENOSIS

Background: Decision aids frequently focus on decisions that are preference-sensitive due to an absence of superior medical option or qualitative differences in treatments. Out of pocket cost can also make decisions preference-sensitive. However, cost is infrequently discussed with patients, and cost has not typically been considered in developing approaches to shared decision-making or decision aids. Determining a therapy’s value to a patient requires an individualized assessment of both benefits and cost. A decision aid addressing cost for sacubitril-valsartan in heart failure with reduced ejection fraction (HFrEF) was developed because this medication has clear medical benefits but can entail appreciable out-of-pocket cost. Objective: To explore patients’ perspectives on a decision aid for sacubitril-valsartan in HFrEF. Methods: Twenty adults, ages 32-73, with HFrEF who met general eligibility for sacubitril-valsartan were recruited from outpatient HF clinics and inpatient services at 2 geographically-distinct academic health systems. In-depth interviews were conducted by trained interviewers using a semi-structured guide after patients reviewed the decision aid. Interviews were audio-recorded and transcribed; qualitative descriptive analysis was conducted using a template analytic method. Results: Participants confirmed that cost was relevant to this decision and that cost discussions with clinicians are infrequent but welcomed. Participants cited multiple ways that this decision aid could be helpful beyond informing a choice; these included serving as a conversation starter, helping inform questions, and serving as a reference later. The decision aid seemed balanced; several participants felt that it was promotional, while others wanted a more “positive” presentation. Participants valued the display of benefits of sacubitril-valsartan but had variable views about how to apply data to themselves and heterogenous interpretations of a 3% absolute reduction in mortality over 2 years. None felt this benefit was overwhelming; about half felt it was very small. The decision aid incorporated a novel “gist statement” to contextualize benefits and counter tendencies to dismiss this mortality reduction as trivial. Several participants liked this statement; few had strong impressions. Conclusion: Out of pocket cost should be part of shared decision-making. These data suggest patients are receptive to inclusion of cost in decision aids and that a “middle ground” between being promotional and negative may exist. The data, however, raise concerns regarding potential dismissal of clinically meaningful benefits and illustrate challenges identifying appropriate contextualizing language. The impact of various framings warrants further study, as does integration of decision aids with patient-specific out-of-pocket cost information during clinical encounters.

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Professionals’ views on shared decision-making in severe aortic stenosis

Heart ◽

10.1136/heartjnl-2021-320194 ◽

2021 ◽

pp. heartjnl-2021-320194

Author(s):

Judith J A M van Beek-Peeters ◽

Jop B L van der Meer ◽

Miriam C Faes ◽

Annemarie J B M de Vos ◽

Martijn W A van Geldorp ◽

...

Keyword(s):

Decision Making ◽

Aortic Stenosis ◽

Shared Decision Making ◽

Nurse Practitioners ◽

Patient Participation ◽

Severe Aortic Stenosis ◽

Shared Responsibility ◽

Health Improvement ◽

Decision Making Process ◽

Shared Decision

ObjectiveTo provide insight into professionals’ perceptions of and experiences with shared decision-making (SDM) in the treatment of symptomatic patients with severe aortic stenosis (AS).MethodsA semistructured interview study was performed in the heart centres of academic and large teaching hospitals in the Netherlands between June and December 2020. Cardiothoracic surgeons, interventional cardiologists, nurse practitioners and physician assistants (n=21) involved in the decision-making process for treatment of severe AS were interviewed. An inductive thematic analysis was used to identify, analyse and report patterns in the data.ResultsFour primary themes were generated: (1) the concept of SDM, (2) knowledge, (3) communication and interaction, and (4) implementation of SDM. Not all respondents considered patient participation as an element of SDM. They experienced a discrepancy between patients’ wishes and treatment options. Respondents explained that not knowing patient preferences for health improvement hinders SDM and complicating patient characteristics for patient participation were perceived. A shared responsibility for improving SDM was suggested for patients and all professionals involved in the decision-making process for severe AS.ConclusionsProfessionals struggle to make highly complex treatment decisions part of SDM and to embed patients’ expectations of treatment and patients’ preferences. Additionally, organisational constraints complicate the SDM process. To ensure sustainable high-quality care, professionals should increase their awareness of patient participation in SDM, and collaboration in the pathway for decision-making in severe AS is required to support the documentation and availability of information according to the principles of SDM.

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The Impact of a Decision Aid on Depressed Patients’ Involvement in Shared Decision Making: A Pilot Randomized Controlled Double-Blinded Study

Value in Health ◽

10.1016/j.jval.2016.03.409 ◽

2016 ◽

Vol 19 (3) ◽

pp. A19

Author(s):

K Al Jumah

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Decision Aid ◽

Shared Decision ◽

Randomized Controlled ◽

Depressed Patients ◽

Blinded Study ◽

Double Blinded ◽

The Impact

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Shared decision making in older patients with symptomatic severe aortic stenosis: a systematic review

Heart ◽

10.1136/heartjnl-2019-316055 ◽

2020 ◽

Vol 106 (9) ◽

pp. 647-655 ◽

Cited By ~ 3

Author(s):

Judith J A M van Beek-Peeters ◽

Elsemieke H M van Noort ◽

Miriam C Faes ◽

Annemarie J B M de Vos ◽

Martijn W A van Geldorp ◽

...

Keyword(s):

Decision Making ◽

Aortic Stenosis ◽

Shared Decision Making ◽

Older Patients ◽

Severe Aortic Stenosis ◽

Informal Caregivers ◽

Information Support ◽

Shared Decision ◽

Patient Goals ◽

Informal Information

This review provides an overview of the status of shared decision making (SDM) in older patients regarding treatment of symptomatic severe aortic stenosis (SSAS). The databases Embase, Medline Ovid, Cinahl and Cochrane Dare were searched for relevant studies from January 2002 to May 2018 regarding perspectives of professionals, patients and caregivers; aspects of decision making; type of decision making; application of the six domains of SDM; barriers to and facilitators of SDM. The systematic search yielded 1842 articles, 15 studies were included. Experiences of professionals and informal caregivers with SDM were scarcely found. Patient refusal was a frequently reported result of decision making, but often no insight was given into the decision process. Most studies investigated the ‘decision’ and ‘option’ domains of SDM, yet no study took all six domains into account. Problem analysis, personalised treatment aims, use of decision aids and integrating patient goals in decisions lacked in all studies. Barriers to and facilitators of SDM were ‘individualised formal and informal information support’ and ‘patients’ opportunity to use their own knowledge about their health condition and preferences for SDM’. In conclusion, SDM is not yet common practice in the decision making process of older patients with SSAS. Moreover, the six domains of SDM are not often applied in this process. More knowledge is needed about the implementation of SDM in the context of SSAS treatment and how to involve patients, professionals and informal caregivers.

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Head to head randomized trial of two decision aids for prostate cancer

10.31219/osf.io/u9vh2 ◽

2019 ◽

Author(s):

Angela Fagerlin ◽

Margaret Holmes-Rovner ◽

Timothy P. Hofer ◽

David Rovner ◽

Stewart C. Alexander ◽

...

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Decision Aid ◽

Physician Visit ◽

Treatment Preference ◽

Decision Making Process ◽

Shared Decision ◽

Patient Centered ◽

Standard Language ◽

The Impact

Purpose: While many studies have tested the impact of a decision aid (DA) compared to not receiving any DA, far fewer have tested how different types of DA affect key outcomes such as treatment choice, patient-provider communication, or decision process/satisfaction. This study tested the impact of a typical medical oriented DA compared to a patient centered decision aid designed to encourage shared decision making and the decision making process in men with clinically localized prostate cancer.Patients and Methods: 1028 men at 4 VA hospitals were recruited after a scheduled prostate biopsy. Participants completed baseline measures and were randomized to receive either a patient centered or standard language DA. Participants were men with clinically localized cancer (N = 285) by biopsy and whom completed pre-clinic surveys. Survey measures: baseline (Time 1); immediately prior to seeing the physician for biopsy results (Time 2); one week following the physician visit (Time 3). Outcome measures included treatment preference and treatment received, knowledge, preference for shared decision making, decision making process, and patients’ use and satisfaction with the DA.Results: Participants who received the patient centered DA had greater interest in shared decision making after reading the DA (p=0.03), found the DA more helpful (p’s<0.01) and were more likely to be considering surveillance (p=0.03) compared to those receiving the standard language DA at Time 2. While these differences were present before patients saw their urologists, there was no difference between groups in the treatment patients received.Conclusions: The patient centered DA led to increased desire for shared decision making and for less aggressive treatment. However, these differences disappeared following the physician visit, which appeared to change patients’ treatment preferences.

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The Learning Curve for Shared Decision-making in Symptomatic Aortic Stenosis

JAMA Cardiology ◽

10.1001/jamacardio.2019.5719 ◽

2020 ◽

Vol 5 (4) ◽

pp. 442 ◽

Cited By ~ 3

Author(s):

Megan Coylewright ◽

Elizabeth O’Neill ◽

Ariel Sherman ◽

Megan Gerling ◽

Kaavya Adam ◽

...

Keyword(s):

Decision Making ◽

Aortic Stenosis ◽

Learning Curve ◽

Shared Decision Making ◽

Shared Decision

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Abstract 397: Shared Decision Making In Cardiology: Measures Of Shared Decision Making In Patients With Severe Aortic Stenosis Considering Valve Replacement

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.397 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

KD Valentine ◽

Felisha Marques ◽

Alexandra Selberg ◽

Laura Flannery ◽

Nathaniel Langer ◽

...

Keyword(s):

Decision Making ◽

Cardiac Surgery ◽

Aortic Stenosis ◽

Shared Decision Making ◽

Valve Replacement ◽

Severe Aortic Stenosis ◽

Interventional Cardiology ◽

Decision Making Process ◽

Concomitant Disease ◽

Shared Decision

Objective: To identify the degree to which shared decision making (SDM) is occurring for patients with severe aortic stenosis (AS) considering aortic valve replacement (AVR) as measured by the Shared Decision Making Process (SDMP) measure. Methods: Patient eligibility was ascertained via the electronic medical record. Eligible patients were between 18-85, spoke English, were diagnosed with severe AS, either had no prior AVR or had AVR more than 6 months prior, and were at low to intermediate risk for surgical AVR (SAVR). Patients were ineligible if they had a concomitant disease of the aorta or another heart valve that required intervention. Eligible patients were approached in either the Interventional Cardiology or Cardiac Surgery clinic after the respective visit and asked to complete the Shared Decision Making Process (SDMP) Measure, which includes 6 questions with a total score ranging from 0-4. The questions focus on if options were presented (yes/no), preferences elicited (yes/no), and if the pros and cons of transcatheter AVR (TAVR) and SAVR were discussed (“a lot”, “some”, “a little”, or “not at all”). A higher score indicates greater shared decision making occurred. Results: Of 60 enrolled patients, 59 (98%) returned their survey. Most patients were recruited after the visit with an interventional cardiologist (68%, 40 of 59). The average age was 72 years (SD=7 years), all patients were white, 67.8% (40 of 59) were men, and 82.1% (46 of 56) had more than a high school education. There was a trend toward patients reporting higher SDMP scores if patients were recruited in the cardiac surgery clinic (M=3.0, SD=0.7) when compared to those recruited in the interventional cardiology clinic (M=2.6, SD=1.1; t(57)=1.4, p=.164, d=.39). Nearly all (96.6%, 57 of 59) patients stated they were presented with different options to treat their AS and 88.1% (52 of 59) reported discussing the pros of TAVR while 78.0% (46 of 59) discussed SAVR “some” or “a lot.” Conversely, fewer patients stated they discussed the cons of TAVR (57.6%, 34 of 59) or SAVR (49.2%, 29 of 59) “some” or “a lot.” Most patients stated they were asked what they wanted to do to treat their AS (64.4%, 38 of 59). Conclusions: One third of patients did not recall being asked for their preference—a key component of shared decision making conversations. Given the importance of patients being well informed in this preference sensitive decision context, future work should seek to understand both how this multidisciplinary approach may benefit patients, and how to ensure the downsides of options and patient preferences are discussed during the visit.

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The Impact of a Novel Computer-Based Decision Aid on Shared Decision Making for Colorectal Cancer Screening

Medical Decision Making ◽

10.1177/0272989x10369007 ◽

2010 ◽

Vol 31 (1) ◽

pp. 93-107 ◽

Cited By ~ 63

Author(s):

Paul C. Schroy ◽

Karen Emmons ◽

Ellen Peters ◽

Julie T. Glick ◽

Patricia A. Robinson ◽

...

Keyword(s):

Colorectal Cancer ◽

Decision Making ◽

Cancer Screening ◽

Shared Decision Making ◽

Colorectal Cancer Screening ◽

Decision Aid ◽

Shared Decision ◽

Computer Based ◽

The Impact

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Head to head randomized trial of two decision aids for prostate cancer

BMC Medical Informatics and Decision Making ◽

10.1186/s12911-021-01505-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Angela Fagerlin ◽

Margaret Holmes-Rovner ◽

Timothy P. Hofer ◽

David Rovner ◽

Stewart C. Alexander ◽

...

Keyword(s):

Prostate Cancer ◽

Decision Making ◽

Shared Decision Making ◽

Decision Aid ◽

Physician Visit ◽

Treatment Preference ◽

Baseline Survey ◽

Treatment Preferences ◽

Shared Decision ◽

The Impact

Abstract Background While many studies have tested the impact of a decision aid (DA) compared to not receiving any DA, far fewer have tested how different types of DAs affect key outcomes such as treatment choice, patient–provider communication, or decision process/satisfaction. This study tested the impact of a complex medical oriented DA compared to a more simplistic decision aid designed to encourage shared decision making in men with clinically localized prostate cancer. Methods 1028 men at 4 VA hospitals were recruited after a scheduled prostate biopsy. Participants completed baseline measures and were randomized to receive either a simple or complex DA. Participants were men with clinically localized cancer (N = 285) by biopsy and who completed a baseline survey. Survey measures: baseline (biopsy); immediately prior to seeing the physician for biopsy results (pre- encounter); one week following the physician visit (post-encounter). Outcome measures included treatment preference and treatment received, knowledge, preference for shared decision making, decision making process, and patients’ use and satisfaction with the DA. Results Participants who received the simple DA had greater interest in shared decision making after reading the DA (p = 0.03), found the DA more helpful (p’s < 0.01) and were more likely to be considering watchful waiting (p = 0.03) compared to those receiving the complex DA at Time 2. While these differences were present before patients saw their urologists, there was no difference between groups in the treatment patients received. Conclusions The simple DA led to increased desire for shared decision making and for less aggressive treatment. However, these differences disappeared following the physician visit, which appeared to change patients’ treatment preferences. Trial registration This trial was pre-registered prior to recruitment of participants.

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