Documentation of shared decision making around primary prevention defibrillator implantations

Abstract

Introduction:Patients eligible for primary prevention implantable cardioverter-defibrillator (ICD) therapy are faced with a complex decision that needs a clear understanding of the risks and benefits of such an intervention. In this study, our goal was to explore the documentation of primary prevention ICD discussions in the electronic medical records (EMRs) of eligible patients. Methods:In 1523 patients who met criteria for primary prevention ICD therapy between 2013 and 2015, we reviewed patient charts for ICD-related documentation: "mention" by physicians or "discussion" with patient/family. The attitude of the physician and the patient/family toward ICD therapy during discussions was categorized into negative, neutral, or positive preference. Patients were followed to the end-point of ICD implantation. Results:Over a median follow-up of 442 days, 486 patients (32%) received an ICD. ICD was mentioned in the charts of 1105 (73%) patients, and a discussion with the patient/family about the risks and benefits of ICD was documented in 706 (46%) charts. On multivariable analyses, positive cardiologist (hazard ratio [HR]: 7.9, 95% confidence of intervals [CI]: 1.0-59.7, P < .05), electrophysiologist (HR: 7.7, 95% CI: 1.9-31.7, P < .001), and patient/family (HR: 9.9, 95% CI: 6.2-15.7, P < .001) preferences toward ICD therapy during the first documented ICD discussion were independently associated with ICD implantation. Conclusions:In a large cohort of patients eligible for primary prevention ICD therapy, a discussion with the patient/family about the risks and benefits of ICD implantation was documented in less than 50% of the charts. More consistent documentation of the shared decision making around ICD therapy is needed.

Patient Information Needs and Decision-Making Before a Cardiac Implantable Electronic Device: A Qualitative Study Utilizing Social Media Data

“…These findings primarily reflect the perspectives of younger individuals anticipating or considering pacemaker implantation. While these results share similarities with previous research that has employed retrospective surveys and interviews to examine decision-making (Barakat et al, 2020;Carroll et al, 2013;Chan et al, 2016;Green et al, 2016;Lewis et al, 2014;Matlock et al, 2011;Ottenberg et al, 2014;Varghese et al, 2020), the use of social media data has provided new insights.…”

“…These frequencies were used to bolster the credibility of the analysis. It was believed that the sample of posts was sufficient to contribute to current literature (Malterud et al, 2016) as previous studies have predominantly considered retrospective accounts of decision-making (Barakat et al, 2020;Carroll et al, 2013;Chan et al, 2016;Green et al, 2016;Lewis et al, 2014;Matlock et al, 2011;Ottenberg et al, 2014;Varghese et al, 2020). The first author, a male PhD student, conducted the analysis using the NVivo 12 Plus software.…”

“…Limited research has considered the decision-making experiences associated with CIED implantation (Malecki-Ketchell et al, 2017;Ottenberg et al, 2014). The majority of research has focused on decisions regarding implantable cardioverter-defibrillators (Barakat et al, 2020;Carroll et al, 2013Carroll et al, , 2018Chan et al, 2016;Green et al, 2016;Lewis et al, 2014;Matlock et al, 2011), with other device types receiving less attention (Ottenberg et al, 2014;Thomas, 2012). Additionally, current research has largely relied on patients' retrospective accounts of implantation decision-making (Barakat et al, 2020;Carroll et al, 2013;Chan et al, 2016;Green et al, 2016;Lewis et al, 2014;Matlock et al, 2011;Ottenberg et al, 2014;Varghese et al, 2020), with few studies including prospective participants or those who have deferred their decision (Carroll et al, 2018;Thomas, 2012).…”

Major gaps in the information provided to patients before implantation of cardioverter defibrillators: a prospective patient European evaluation

“…However, in our study, only half of ICD recipients were actively involved in the decision-making process, which is not dissimilar to what a previous study has shown. 14 This emphasizes a clear need for better communication between physicians and patients, with the former dedicating more time to explain the procedure, risks, and implications of the ICD, as well as the possibility of device deactivation in particular cases. A transition from a paternalistic healthcare system to patient-empowerment whenever possible is necessary.…”

Experiences Implementing a Suite of Decision Aids for Implantable Cardioverter Defibrillators: Qualitative Insights From the DECIDE-ICD Trial

“…5,6 With these barriers to patient-centered care as context, Centers for Medicare & Medicaid Services (CMS) has begun requiring documented use of DAs as a condition for reimbursement, including the decision of whether to accept implantable cardioverter defibrillator (ICD) placement for primary prevention of sudden cardiac death. 5,7,8 However, despite the political acceptability of SDM and explicit policy support from the CMS for using DAs with these patients, documented use of DAs (or other educational efforts) with those considering ICDs is poor 9 resulting in an unclear relationship between these mandates and actualized improvements in the patient-centered qualities of care. 10 Additionally, recent investigations into implementation of SDM in cardiology have either not explicitly focused on the use of DAs, 11 were conducted largely in the inpatient or critical care setting, 12 did not include CMS documentation requirements, 7,8 or some combination of all the three.…”