NSTEMI Decide: Development of a Decision Aid for Older Adults with Non ST Elevation Myocardial Infarction

Abstract

Background: Many patients hospitalized with non-ST elevation myocardial infarction (NSTEMI) are older adults (age 75 and older), in whom invasive coronary angiography confers potential benefits but also higher risks than the general population. Our goal was to therefore develop a patient decision aid (PtDA) to assist with shared decision making between cardiologists and older adults with this condition. Methods: We followed International Patient Decision Aid Standards to develop the NSTEMI Decide PtDA. The initial prototype was based on structured interviews from 20 patients and 20 clinicians. Risks and benefits of invasive coronary angiography were derived from the available literature in older adults, with an emphasis on findings from randomized trials. The PtDA was then revised through an iterative, user-centered design approach with rapid prototyping using input from both clinician and patients to meet the needs of both stakeholders. Results: The PtDA went through 8 iterations. The final decision aid was 11 pages and included background information (6 pages), explanation of benefits and risks (4 pages), and a summary (1 page). Large font (≥26 point) was used to accommodate visual difficulties. Language was tailored to an 8th grade reading level. Based on the best available literature, we included benefits of invasive coronary angiography (recurrent myocardial infarction, repeat revascularization) and risks (stroke, bleeding, acute kidney injury). The final PtDA was converted to a mobile health application to increase usability on portable digital devices in the clinical setting. Conclusions: We developed the first PtDA tailored to older adults hospitalized with NSTEMI. This PtDA will be prospectively tested to evaluate dimensions including feasibility of use, satisfaction with care, medical knowledge, and decisional conflict.