Shared Decision-Making for Implantable Cardioverter-Defibrillators: Past, Present, and Future Öffentlichkeit

Abstract

Background: In 2018, the Centers for Medicare and Medicaid Services (CMS) mandated that patients and physicians undergo a shared decision-making (SDM) encounter prior to receiving an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death.

Methods: To understand how this mandate has impacted care, we surveyed patients who received ICD within Emory Healthcare between 2017-2019 (pre and post SDM mandate) about their experience. Pre and post mandate responses were compared using either student’s t-test or chi-squared tests. Using purposeful sampling, a subset of patients was chosen to participate in a follow-up key-informant interview study. Qualitative descriptive analysis of the interviews was performed utilizing a multilevel templated coding strategy.

Results: Of 101 patients who completed the survey, 45 were in the pre-mandate period and 56 were post. There were no major differences between knowledge (55.0+19.1 vs 57.4 +19.5, p=0.245), decisional conflict (11.89+16.25 vs 6.96+11.19, p=0.0877), values choice concordance (4.35+3.11 vs 4.82+3.82), or patient engagement (48+47.52 vs 23+51.11, p=0.701). Twenty patients completed key-informant interviews. Patients’ paths to an ICD decision often involved multiple visits with multiple clinicians. However, decision aids were, almost exclusively, provided during electrophysiology clinic visits. Patients’ use of numerical risk-benefit data to make their ICD decision varied.

Conclusions: Policy effects to promote SDM that solely focus on a decision-aid delivered primarily during electrophysiology clinic visits may not substantively impact patient-centered care. Aligning the implementation of SDM strategies with trajectories of care may improve SDM.

Table of Contents

Table of Contents

 

Introduction---------------------------------------------------------------------------------------------------1

Methods-------------------------------------------------------------------------------------------------------2

Results---------------------------------------------------------------------------------------------------------5

Discussion----------------------------------------------------------------------------------------------------12

Table 1--------------------------------------------------------------------------------------------------------17

Figure 1-------------------------------------------------------------------------------------------------------18

Table 2--------------------------------------------------------------------------------------------------------19

Table 3--------------------------------------------------------------------------------------------------------22

Table 4--------------------------------------------------------------------------------------------------------24

Table 5--------------------------------------------------------------------------------------------------------26

Table 6--------------------------------------------------------------------------------------------------------27

Table 7--------------------------------------------------------------------------------------------------------28

References----------------------------------------------------------------------------------------------------29

About this Master's Thesis

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School	Laney Graduate School
Department	Health Services and Research Health Policy
Degree	M.S.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Medicine and Surgery
Stichwort	shared decision-making electrophysiology implantable cardioverter-defibrillators
Committee Chair / Thesis Advisor	Neal Dickert, Emory University
Committee Members	Faisal Merchant, Emory University Amita Manatunga, Emory University

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