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January 29, 2020

Incorporating the Patient Voice Into Shared Decision-Making for the Treatment of Aortic Stenosis

Author Affiliations
  • 1Structural Heart and Valve Center, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
  • 2Empath Health Services, Seattle, Washington
  • 3Seattle Pacific University, Seattle, Washington
JAMA Cardiol. 2020;5(4):380-381. doi:10.1001/jamacardio.2019.5860

Increased attention has focused on shared decision-making (SDM) and use of decision aids for treatment decisions in cardiology. In this issue of JAMA Cardiology, Coylewright et al1 report the results of a rigorously performed pilot study on the use of a decision aid to facilitate SDM for patients with symptomatic severe aortic stenosis (AS) at high or prohibitive risk for surgery considered for transcatheter aortic valve replacement vs medical therapy. Comparisons were made between encounters before clinicians were trained to use a decision aid and the first and fifth encounters after a decision aid was used. The patient-clinician interactions were audio recorded and later coded by independent reviewers using a validated measure to assess SDM. This mixed-methods study found that SDM significantly improved in a stepwise manner from the initial usual care encounter (before use of a decision aid) to the first and then fifth encounters after implementation of the decision aid. Along with this improvement in SDM, patients (n = 35) demonstrated increased knowledge about their treatment choices and reported increased satisfaction in their care with no increase in decisional conflict. In contrast, clinicians (n = 6) reported that they believed they already engaged in SDM prior to use of the decision aid and, after multiple uses of the decision aid, believed patients did not understand or benefit from this tool. The disconnect between clinician and patient perspectives was sobering and has implications for the adoption of decision aids or other tools to facilitate SDM in the clinical setting. Notable limitations of the study, which are acknowledged by the authors, include (1) small sample size (of clinicians and patients); (2) the decision aid is most useful for the relatively smaller number of patients at high or prohibitive risk for surgery for whom transcatheter aortic valve replacement and medical therapy may both be reasonable options; and (3) the lack of diversity in the clinicians (all male), which reflects the current demographics of interventional cardiology and cardiac surgery.

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