Informed Decision Making for Percutaneous Coronary Intervention for Stable Coronary Disease

Abstract

IMPORTANCE Patients with stable coronary disease undergoing percutaneous coronary intervention (PCI) are frequently misinformed about the benefits of PCI. Little is known about the quality of decision making before angiography and possible PCI. OBJECTIVE To assess the quality of informed decision making and its association with patient decisions. DESIGN, SETTING, AND PARTICIPANTS We performed a cross-sectional analysis of recorded conversations between August 1, 2008, and August 31, 2012, among adults with known or suspected stable coronary disease at outpatient cardiology practices.MAIN OUTCOMES AND MEASURES Presence of 7 elements of informed decision making and the decision to undergo angiography and possible PCI. RESULTSOf 59 conversations conducted by 23 cardiologists, 2 (3%) included all 7 elements of informed decision making; 8 (14%) met a more limited definition of procedure, alternatives, and risks. Specific elements significantly associated with not choosing angiography and possible PCI included discussion of uncertainty (odds ratio [OR], 20.5; 95% CI, 2.3-204.9), patient's role (OR, 5.3; 95% CI, 1.3-21.3), exploration of alternatives (OR, 9.5; 95% CI, 2.5-36.5), and exploration of patient preference (OR, 4.8; 95% CI, 1.2-19.4). Neither the presence of angina nor severity of symptoms was associated with choosing angiography and possible PCI. In a multivariable analysis using the total number of elements as a predictor, better informed patients were less likely to choose angiography and possible PCI (OR per additional element, 3.2; 95% CI, 1.4-7.1; P = .005). CONCLUSIONS AND RELEVANCEIn conversations between cardiologists and patients with stable angina, informed decision making is often incomplete. More complete discussions are associated with patients choosing not to undergo angiography and possible PCI.

Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial

“…4,10 Placebo effects are known to be larger for invasive than non-invasive treatments.11 Interventional cardiologists and patients with stable angina often think that PCI offers symptomatic relief. 12 Additionally, cardiologists present a decisive approach to diagnosis and treatment, which can lead to an enhanced placebo effect. 13 In the absence of blinding, the effect size of PCI on symptomatic endpoints can be overestimated because of the addition of the placebo effect to the true physiological effect of intervention.14 In all previous trials, both investigators and patients were aware of the treatment allocation.…”

PCI Choice Decision Aid for Stable Coronary Artery Disease

“…Many clinicians feel they already perform SDM regularly; yet, data suggest that attitudes are often not aligned, 35,36 and there is little evidence of proficiency in SDM skills. 37 Importantly, the high scores on 2 items from the OPTION scale that focused on patient education suggested that the decision aid was often used as an educational pamphlet rather than a tool to facilitate a shared conversation. This trial suggests that although specialists may report that they already perform SDM, this may be because of a gap in knowledge of how this process is distinct from patient education.…”

Comparative Effectiveness of Ranolazine Versus Traditional Therapies in Chronic Stable Angina Pectoris and Concomitant Diabetes Mellitus and Impact on Health Care Resource Utilization and Cardiac Interventions

“…4 Finally, recent evidence suggests that stable ischemic heart disease patients appropriately informed on the risk/benefit of various treatment options and their alternatives may lead to preferential choice of medical management over angiography and PCI. 19 Our study should be interpreted in the context of the following limitations. First, as this was a claims-based analysis, we were not able to determine or adjust for the angina severity (i.e., Canadian Cardiovascular Society angina class angina class) or burden of coronary atherosclerosis.…”