Shared Decision Making in the Heart Team: Current Team Attitudes and Review

A 72-year-old retired physician living independently presents with shortness of breath on exertion. She is found to have severe aortic stenosis and two-vessel coronary artery disease. Both are amenable a surgical transcatheter approach. Heart valve disease (HVD) patients like the one above, facing an array potential treatment options, often encountered by Team. These types decisions ideally driven approach termed shared decision-making (SDM): bidirectional exchange information between physicians patients, distinct from one-way stream in patient education or informed consent.1Coylewright M O’Neill E Sherman et al.The learning curve for symptomatic stenosis.JAMA Cardiol. 2020; 5 (doi:10.1001/jamacardio.2019.5719.): 442-448Google Scholar However, this has not received wide application, perhaps due lack understanding and/or support Team members. In article, we explore attitudes members, review current status SDM HVD, consider requirements implementation clinical practice. As defined National Learning Consortium, key component patient-centered health care. It process which clinicians work together make select tests, treatments, care plans based evidence that balances risks expected outcomes preferences values. should be confused consent, legal used promote autonomy. about anticipated management, detailing benefits, risks, alternatives, seeking patient’s yes no decision as how proceed. widely promoted ethical approach, patients’ goals central process. Clinicians share harms management. The unique shares their own words prior experiences, expectations, values, goals.2Whitney S McGuire McCullough LA Typology making, simple consent.Ann Intern Med. 2004; 140 (doi:10.7326/0003-4819-140-1-200401060-00012.): 54Google interact reach best Best practices recommend use aid (DA) guide conversation.3Dharmarajan K Foster J Coylewright medically managed TAVR era: characteristics, reasons medical quality making at heart centers.PLoS One. 2017; 12 (doi:10.1371/journal.pone.0175926.): e0175926Google American College Cardiology/American Association practice guidelines HVD utilize process, incorporate values preferences.4Nishimura R Otto C Bonow al.AHA/ACC guideline management valvular disease: executive summary.Circulation. 2014; 129 (doi:10.1161/cir.0000000000000029.): 2440-2492Google European Society Cardiology/European Cardio-Thoracic surgery reference importance preference prosthetic selection.5Falk V Baumgartner H Bax al.ESC/EACTS disease.Eur Cardiothorac Surg. 52 (2017. doi:10.1093/ejcts/ezx324.): 616-664Google There both opportunities challenges implementing SDM, part rapid evolution field increasing number options range (i.e. vs. replacement).6Sepucha Wasfy Implementing rapidly evolving disease.Circulation. 10 (doi:10.1161/circoutcomes.117.003549.): 2Google Adoption into routine been remarkably slow. Although increasingly recommended4Nishimura Scholar,5Falk literature supports added value terms improved (patient knowledge, decisional conflict, satisfaction), still its infancy.7Coylewright Forrest McCabe Nazif T low-risk patients.J Am Coll 75 (doi:10.1016/j.jacc.2019.12.057.): 1208-1211Google continue inaccurate assumptions preferences, particularly culture focused “disease-outcome-based paradigm.”8Reuben D Tinetti Goal-oriented — alternative paradigm.N Engl 2012; 366 (doi:10.1056/nejmp1113631.): 777-779Google feel they already perform rarely practiced real-world patients.9Godolphin W Shared decision-making.Healthcare Q. 2009; (doi:10.12927/hcq.2009.20947.): e186-e190Google Research also suggests confuse basic process.10Coylewright Dick Zmolek B al.PCI choice stable 2016; 9 (doi:10.1161/circoutcomes.116.002641.): 767-776Google DAs tools designed help choices health-care preferences.11Stacey D, Légaré F, Lewis K, al. Decision aids people screening decisions. Cochrane Database Syst Rev. 2017. doi:10.1002/14651858.cd001431.pub5.Google Currently, publicly available exist, created through cardiovascular professional societies grant-funded efforts.12Shared making. Tools. Available at: https://sharedcardiology.org/tools/ Accessed April 8, 2020.Google clarification exercises however infrequently employed.10Coylewright Scholar,13Joseph-Williams N, Lloyd A, Edwards NHS: lessons MAGIC programme. BMJ. 2017;j1744. doi:10.1136/bmj.j1744.Google important, skill sets favorable physicians’ even more critical successful SDM.14Gravel F Graham I Barriers facilitators practice: systematic professionals’ perceptions.Implementat Sci. 2006; 1 (doi:10.1186/1748-5908-1-16.): 1Google little inclination skillsets lead families fact, published data suggest individual difficulty real-word practice, supporting additional training, embedded workflow. Moreover, it was suggested policies encourage supportive context leading among would benefit.15Joseph-Williams N Elwyn G Knowledge power patients: thematic synthesis patient-reported barriers making.Patient Educ Couns. 94 (doi:10.1016/j.pec.2013.10.031.): 291-309Google recent study perceive poor despite reports knowledge encounters.1Coylewright Taken together, appears toward remain limited, render unlikely.1Coylewright mainly identified perspectives.15Joseph-Williams Scholar,16Dua Dang P Shaker al.Barriers class indications replacement.J Valve Dis. 2011; 20: 396-400Google most frequently barrier insufficient (“too little” “unimportant”).2Whitney An appropriate level important principal enabler Comorbidities mentioned influences symptom interpretation expectations.17Lytvyn L Guyatt Manja al.Patient replacement therapy stenosis: review.BMJ Open. 6 (doi:10.1136/bmjopen-2016-014327.): e014327Google Scholar,18Montori Kunneman Brito improving care.JAMA. 318 (doi:10.1001/jama.2017.10168.): 617Google On other hand, comorbidities seen facilitator “experienced,” rely history, comparison past significant ongoing management.17Lytvyn Scholar,19Olsson Näslund U Nilsson Hörnsten Å Patients’ experiences implantation trajectory: grounded theory study.Nurs 2018; (doi:10.1002/nop2.124.): 149-157Google summary, recommendations guidelines, yet common patients. While role likely implementation, literature, attitudes, perceived underexplored. essential understand effective strategies (e.g. awareness, familiarity, agreement factors associated environment).13Joseph-Williams To match dramatic advancements treatment, further research needed implement SDM. variable alternatives present prime example condition could play critically role. define needs caring invited registrants 2018 Annual Scientific Meeting opinions physicians, including cardiologists cardiothoracic surgeons, were approached e-mail asked complete anonymous online survey (Appendix 1) before attending meeting (N = 800) using cross-sectional (Poll Everywhere). We performed in-depth interviews. Given included project, institutional board approval sought. All interviewed participants provided consent interviews anonymized. Using scenario 78-year-old equipoise, varying patterns reported (Figure 1). Almost all (91%) indicated take steps achieve engagement if leave entirely physicians. Less than half evidence-based (43%), while 48% typically actions engage verbal communication. No correlations attitude gender, age, specialty found. Physicians who expressed positive had view regarding balance costs. Physicians’ answers consistent promotion shown Figure 2, 3. need training upper-level emphasized.Figure 2Heart responses rank effectively answer figure ranked top (dark green) least bottom (gray). 6th option “No changes all.” arranged position.View Large Image ViewerDownload Hi-res image Download (PPT)Figure 3Heart 7th (PPT) Nine four five participated (see appendix 2) gain perceptions Five claimed familiar concept but three unable differentiate small experience DAs, perception too time-intensive. Despite considered impossible consultation time. Most agreed DAs; however, only ever DA. interest straightforward easy DA tool clinics must evidence-based. might necessary train them members engaging decision-making. overwhelm some raised, none asking desire actively sharing When considering future better-informed may save time potentially improve conversation. results exploratory forecast long, winding road adopt agree involving decisions, leaned final addition, limited poses another Finally, hampering wider primary limitation initial assessment introduction bias nature, convenience sample, sample size, low response rate. introduces physician. Further, those academic focus thus representative settings. strength provision new Changing challenge any change program. structural changes, pathways delivery, attitudinal required become routine. Thus, clinician integrated organizations, scientific sessions, educational initiatives teams. mixed effect costs reflect existing literature.18Montori Scholar,20Walsh Barr Thompson Ozanne Undetermined impact interventions healthcare savings: review.BMJ. 348 (doi:10.1136/bmj.g188.): g188Google there strong compared usual generally seems unavoidable.21Wyatt Branda Anderson al.Peering black box: meta-analysis during encounters.Implementat (doi:10.1186/1748-5908-9-26.): Scholar, 22Elwyn May al.Collaborative deliberation: model care.Patient 97 (doi:10.1016/j.pec.2014.07.027.): 158-164Google 23Pieterse Stiggelbout Montori time.JAMA. 2019; 322 (doi:10.1001/jama.2019.3785.): 25Google step increase what entails differs consent. reveal requirement. This line require activities targeting diverse group clinicians.15Joseph-Williams this, sessions whole create collective commitment. For example, interactive skills opportunities, building coherence, skills, promoting attitudes.24Elwyn Tsulukidze Newcombe ‘talk’ propose observation-based measure: observer OPTION5 item.Patient 2013; 93 (doi:10.1016/j.pec.2013.08.005.): 265-271Google play-based emphasizes practical worked better heavy presentations.13Joseph-Williams adoption, within leadership prominent nursing curriculums interprofessional way, shift “We do already” can better.” professionals question effectively. Prior studies emphasized demonstrated multiple benefits,24Elwyn Scholar,25Coylewright Grande Choice PCI Cardiovascular clinicians’ disease.Patient 100 (doi:10.1016/j.pec.2017.01.010.): 1136-1143Google cause underuse DAs.1Coylewright Recent in-consultation facilitating discussions outside consultation. HVD.12Shared will risk remains brief enhance transfer talk rather patients.13Joseph-Williams area widespread adoption. conclusion, means delivery HVD. exist Teams, arise shifts realize our merely explorative several limitations, Teams paved changing DAs.