Assessing Patient Preferences for Shared Decision-Making in Peripheral Artery Disease
2019; Lippincott Williams & Wilkins; Volume: 12; Issue: 8 Linguagem: Inglês
10.1161/circoutcomes.119.005730
ISSN1941-7705
AutoresJeremy Provance, John A. Spertus, Carole Decker, Philip G. Jones, Kim G. Smolderen,
Tópico(s)Health Systems, Economic Evaluations, Quality of Life
ResumoHomeCirculation: Cardiovascular Quality and OutcomesVol. 12, No. 8Assessing Patient Preferences for Shared Decision-Making in Peripheral Artery Disease Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBAssessing Patient Preferences for Shared Decision-Making in Peripheral Artery DiseaseInsights From the PORTRAIT Registry Jeremy B. Provance, MS, John A. Spertus, MD, MPH, Carole Decker, PhD, Philip G. Jones, MS and Kim G. Smolderen, PhD Jeremy B. ProvanceJeremy B. Provance Department of Biomedical & Health Informatics, University of Missouri-Kansas City School of Medicine (J.B.P., J.A.S., K.G.S.). , John A. SpertusJohn A. Spertus Department of Biomedical & Health Informatics, University of Missouri-Kansas City School of Medicine (J.B.P., J.A.S., K.G.S.). Cardiovascular Outcomes Research Group, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S., C.D., P.J., K.G.S.). , Carole DeckerCarole Decker Cardiovascular Outcomes Research Group, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S., C.D., P.J., K.G.S.). University of Missouri-Kansas City School of Nursing (C.D.). , Philip G. JonesPhilip G. Jones Cardiovascular Outcomes Research Group, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S., C.D., P.J., K.G.S.). and Kim G. SmolderenKim G. Smolderen Kim G. Smolderen, PhD, UMKC School of Medicine—Biomedical & Health Informatics, 1000 E 24th St, 5th Floor, Kansas City, MO 64108. Email E-mail Address: [email protected] Department of Biomedical & Health Informatics, University of Missouri-Kansas City School of Medicine (J.B.P., J.A.S., K.G.S.). Cardiovascular Outcomes Research Group, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S., C.D., P.J., K.G.S.). Originally published15 Aug 2019https://doi.org/10.1161/CIRCOUTCOMES.119.005730Circulation: Cardiovascular Quality and Outcomes. 2019;12:e005730Peripheral artery disease (PAD) increases cardiovascular risk, can cause pain and diminishes patients' quality of life. To obtain claudication symptom relief, patients may have multiple effective treatment options available to address their symptoms, including medications, supervised exercise therapy, and revascularization procedures, each having different risks and benefits. It is unclear what patients' preferences are as to whether they want to be involved in making PAD treatment decisions for PAD symptom relief. Accordingly, in patients with new or worsening symptoms of PAD, we aimed to (1) document their preferences for shared decision-making and (2) determine whether patients' decision-making preferences were honored by their provider.Methods and ResultsThe Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) Study is a multi-center, prospective, observational registry that enrolled patients with stable PAD (Rutherford 1–3) from 16 PAD specialty clinics in the United States, the Netherlands, and Australia.1 Because of the unique health care system and documented cultural differences that may exist for medical decision preferences among countries,2 we only focused on the US patient cohort in this analysis. Patients were consented and interviewed at baseline by local data collectors after PAD diagnosis, but before PAD treatment. Interviews collected information about their sociodemographic and psychosocial characteristics and decision-making preferences. Medical chart abstraction was conducted at baseline to collect information about medical history, diagnostic tests, medications, and treatments. Centralized phone follow-up interviews were conducted at 3 months by the data coordinating center at Saint Luke's Mid America Heart Institute in Kansas City, Missouri to collect information about patients' health status and quality of medical decision-making. Institutional review board approval was received from each site participating in PORTRAIT, and all patients provided informed consent. Data can be made available on request by contacting the authors.Preferences for shared decision-making were measured at enrollment (before PAD care and treatment) with the Problem-Solving Decision-Making Scale (PSDM) Questionnaire.3 The PSDM Questionnaire asks patients questions about who should determine their medical treatments (Figure I in the Data Supplement). The PSDM was scored, and preferred decision-making roles were derived, using a previously described method.4 Based on the responses, 2 groups were created: patients whose responses were reflective of a shared or autonomous role were grouped into a single active group5 versus patients who expressed to prefer a passive role. It should be noted that autonomous patients typically differ from shared patients in that they not only want an active role in decision-making, but they also wish to be active in problem-solving (ie, decide which treatment options are applicable to them). At the 3-month follow-up and after patients received their PAD treatments, we used a purposely designed question to ask patients who actually had made their treatment decision and mirrored the response options after the PSDM scale. We compared responses with the preferred decision-making role and defined discrepancies in responses as decision discordance. For example, if the patient preferred to have a shared role, but the doctor alone made the decision, decision discordance would be present.Patient characteristics were described for the overall cohort and compared by PSDM categories using Student t test for continuous variables, Mann-Whitney U for ordinal variables, and χ2 for categorical variables. Decision discordance between patients' desired and actual roles in decision-making was quantified by comparing PSDM roles with the actual decision-making process. Missing data were present in <5% of patients (the highest missing rate for any covariate was 1.8%). Missing values were imputed using sequential regression imputation. Data were analyzed with R software version 3.5.0 (R Foundation for Statistical Computing). All tests were 2-tailed, and P values <0.05 were considered statistically significant.A total of 797 US patients were enrolled for the US cohort of PORTRAIT and 744 completed the PSDM Questionnaire at the baseline interview (Figure II in the Data Supplement). The majority of patients preferred shared or autonomous roles (N=523, 70.3%), with less than a third preferring a passive role (N=221, 29.7%; Figure). Of the 523 patients preferring shared or autonomous roles, only 11 patients preferred autonomous roles. Compared with those who preferred shared or autonomous roles, patients who adopted passive roles typically had a lower education level, a history of coronary artery bypass grafting, and expressed more treatment satisfaction on the disease-specific Peripheral Artery Questionnaire (Table I in the Data Supplement).6Download figureDownload PowerPointFigure. Patient preferences for shared decision-making in peripheral artery disease treatment decisions by the presence of decision discordance.Decision discordance (ie, PSDM preferred role did not match with what actually happened) occurred in 97 patients (15.3%, Table II in the Data Supplement) and was more prevalent in patients who preferred shared or autonomous roles (18.7% in shared role versus 7.4% in passive role, P=0.00047, Figure). Decision discordance was more prevalent among those without a history of a peripheral vascular intervention, lower PAD-specific treatment satisfaction scores before treatment, and among those with low social support7 scores. The presence of decision discordance did not statistically vary by site (median odds ratio=1.32; 95% CI, 1.00–2.07; P=0.07) or provider (unadjusted median odds ratio=1.56; 95% CI, 1.00–2.44; P=0.06; Figure III in the Data Supplement).CommentUnderstanding patient values and preferences and how they intersect with medical treatment choices and outcomes has increasingly become important. In PAD, we have not studied these processes yet, even though treatment choices for PAD symptom relief are preference-sensitive.8 In our prospective, multi-center cohort of patients with newly diagnosed or a recent exacerbation of their PAD, we found that a large majority of patients prefer a shared or autonomous role in their PAD treatment decision-making. Patients who preferred passive roles tended to be less educated, had a history of heart surgery, and typically less satisfied with PAD treatment at baseline. While the majority of patients indicated that their preferences were honored during the actual decision-making process, in 15% of the patients this was not the case. Decision discordance was associated with those patients who had not previously undergone a peripheral vascular intervention, those having lower PAD treatment satisfaction scores before treatment, and with those who had low social support.Our work significantly extends the literature about shared decision-making in the care of patients with PAD. Patients enrolled in PORTRAIT experienced claudication for which the recommended treatment is optimal medical treatment (statins, antiplatelet therapy, and supervised exercise therapy) before considering invasive options. Invasive options can still be considered with life-limiting symptoms and are thus preference-sensitive, given its risks and benefits against treating PAD symptoms noninvasively. Patients in our study express a desire to be actively involved in conversations as to which treatment would work best for them given their preferences and the evidence-base that is out there.Decision-support tools can be developed and used to meet the needs of patients who want to have a say and can also be used to educate and invite patients to transition from a more passive role to a more engaged role.9 In addition, it could help to address to resolve some of the discordance that takes place between patients' preferred role and the way their treating physician interacts with the patient in the decision-making process.Few patient characteristics were substantively associated with patient preference for treatment decision-making, thus, the best way to determine which treatment a patient prefers is probably to ask them directly. Currently, there are no formal decision-making tools available in routine clinical practice for patients facing a PAD treatment decision. Initial efforts have been directed towards developing tools specific to PAD invasive treatment decisions,10 but it is unclear whether they are actually used and how these tools affect treatment decision-making. Patient knowledge, value sets associated with individual treatment modalities, and provider skills in shared decision-making will need to be further documented and developed to enable the successful design of standardized shared decision-making platforms in PAD. Future work should seek to develop and test frameworks for PAD treatment decision-making so that treatment decision quality, treatment outcomes, and the shared decision-making process can be studied in patients who are seeking PAD symptom relief.Our study should be interpreted in the context of the following potential limitations. The PORTRAIT registry is an observational study, and it is possible that we did not collect information on all factors that could have accounted for patients' preferences. Second, our assessment of actual decision-making was assessed at the 3-month follow-up interview. This was done intentionally because it often takes few weeks to implement a treatment plan after an initial outpatient visit, but also introduced the possibility for the treatment type and outcome to influence patients' perceptions and responses. Finally, the enrolling sites were led by PAD specialists who elected to voluntarily participate in the PORTRAIT registry and their processes of interacting with their patients may differ from other practitioners.Patients in the US receiving care for their PAD symptoms most often prefer to be involved in their PAD treatment decisions. One in 7 patients experienced decision discordance. Exploring shared-decision–making frameworks and decision-support tools that would meet patients' expectations to become involved in their care, and to study its impact on improving the quality and care of PAD outcomes is an important priority in our quest to make PAD care more patient-centric.AcknowledgmentsWe thank Raisa Deber, PhD, Professor in the Institute of Health Policy at the University of Toronto, for her review and comments on the completed article.Sources of FundingResearch reported in this report was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (CE-1304–6677). The views, statements, and opinions in this report are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute its Board of Governors or Methodology Committee.DisclosuresDr Spertus reports consulting (all minor): AstraZeneca, Novartis; copyright: Peripheral Artery Questionnaire. Dr Spertus is cofounder of Dynamo Health LLC. Dr Smolderen reports support through unrestricted research grants from Abbott Vascular, Boston Scientific, and Terumo. Dr Smolderen is cofounder of Dynamo Health LLC. The other authors report no conflicts.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCOUTCOMES.119.005730.Kim G. Smolderen, PhD, UMKC School of Medicine—Biomedical & Health Informatics, 1000 E 24th St, 5th Floor, Kansas City, MO 64108. Email [email protected]eduReferences1. Smolderen KG, Gosch K, Patel M, Jones WS, Hirsch AT, Beltrame J, Fitridge R, Shishehbor MH, Denollet J, Vriens P, Heyligers J, Stone MEd N, Aronow H, Abbott JD, Labrosciano C, Tutein-Nolthenius R, A Spertus J. PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories): overview of design and rationale of an international prospective peripheral arterial disease Study.Circ Cardiovasc Qual Outcomes. 2018; 11:e003860. doi: 10.1161/CIRCOUTCOMES.117.003860LinkGoogle Scholar2. Fredriksson M, Eriksson M, Tritter J. Who wants to be involved in health care decisions? Comparing preferences for individual and collective involvement in England and Sweden.BMC Public Health. 2017; 18:18. doi: 10.1186/s12889-017-4534-yCrossrefMedlineGoogle Scholar3. Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making?Arch Intern Med. 1996; 156:1414–1420.CrossrefMedlineGoogle Scholar4. Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations.Health Expect. 2007; 10:248–258. doi: 10.1111/j.1369-7625.2007.00441.xCrossrefMedlineGoogle Scholar5. Krumholz HM, Barreto-Filho JA, Jones PG, Li Y, Spertus JA. Decision-making preferences among patients with an acute myocardial infarction.JAMA Intern Med. 2013; 173:1252–1257. doi: 10.1001/jamainternmed.2013.6057CrossrefMedlineGoogle Scholar6. Spertus J, Jones P, Poler S, Rocha-Singh K. The peripheral artery questionnaire: a new disease-specific health status measure for patients with peripheral arterial disease.Am Heart J. 2004; 147:301–308. doi: 10.1016/j.ahj.2003.08.001CrossrefMedlineGoogle Scholar7. Mitchell PH, Powell L, Blumenthal J, Norten J, Ironson G, Pitula CR, Froelicher ES, Czajkowski S, Youngblood M, Huber M, Berkman LF. A short social support measure for patients recovering from myocardial infarction: the ENRICHD social support inventory.J Cardiopulm Rehabil. 2003; 23:398–403.CrossrefMedlineGoogle Scholar8. Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FG, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RA, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2017; 135:e726–e779. doi: 10.1161/CIR.0000000000000471LinkGoogle Scholar9. Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R, Trevena L. Decision aids for people facing health treatment or screening decisions.Cochrane Database Syst Rev. 2017; 4:CD001431. doi: 10.1002/14651858.CD001431.pub5MedlineGoogle Scholar10. Healthwise Staff. Peripheral Arterial Disease: Should I Have Surgery?https://mowerywomensclinic.com/womens-health/hw-view.php?DOCHWID=ue4756#av2309. Accessed August 15, 2018.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited BySmolderen K, Alabi O, Collins T, Dennis B, Goodney P, Mena-Hurtado C, Spertus J and Decker C (2022) Advancing Peripheral Artery Disease Quality of Care and Outcomes Through Patient-Reported Health Status Assessment: A Scientific Statement From the American Heart Association, Circulation, 146:20, (e286-e297), Online publication date: 15-Nov-2022.Angraal S, Hejjaji V, Tang Y, Gosch K, Patel M, Heyligers J, White C, Tutein Nolthenius R, Mena-Hurtado C, Aronow H, Moneta G, Fitridge R, Soukas P, Abbott J, Secemsky E, Spertus J and Smolderen K (2022) One-Year Health Status Outcomes Following Early Invasive and Noninvasive Treatment in Symptomatic Peripheral Artery Disease, Circulation: Cardiovascular Interventions, 15:6, (e011506), Online publication date: 1-Jun-2022. Lawton J, Tamis-Holland J, Bangalore S, Bates E, Beckie T, Bischoff J, Bittl J, Cohen M, DiMaio J, Don C, Fremes S, Gaudino M, Goldberger Z, Grant M, Jaswal J, Kurlansky P, Mehran R, Metkus T, Nnacheta L, Rao S, Sellke F, Sharma G, Yong C and Zwischenberger B (2022) 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.09.006, 79:2, (e21-e129), Online publication date: 1-Jan-2022. August 2019Vol 12, Issue 8 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.119.005730PMID: 31412733 Originally publishedAugust 15, 2019 Keywordsshared decision-makingpatient-centered careperipheral artery diseasePDF download Advertisement SubjectsPeripheral Vascular DiseaseQuality and Outcomes
Referência(s)