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Decision-Making Preferences After AMI

Decision-Making Preferences After AMI
Author Information (click to view)

Harlan M. Krumholz, MD, SM

Harold H. Hines, Jr. Professor of Medicine and Epidemiology and Public Health
Yale University School of Medicine
Director, Yale-New Haven Hospital Center for Outcomes Research and Evaluation
Director, Robert Wood Johnson Clinical Scholars Program

Harlan M. Krumholz, MD, SM, has indicated to Physician’s Weekly that he chairs a cardiac scientific advisory board for UnitedHealth and is the recipient of a research grant, through Yale University, from Medtronic to share research data.

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Harlan M. Krumholz, MD, SM (click to view)

Harlan M. Krumholz, MD, SM

Harold H. Hines, Jr. Professor of Medicine and Epidemiology and Public Health
Yale University School of Medicine
Director, Yale-New Haven Hospital Center for Outcomes Research and Evaluation
Director, Robert Wood Johnson Clinical Scholars Program

Harlan M. Krumholz, MD, SM, has indicated to Physician’s Weekly that he chairs a cardiac scientific advisory board for UnitedHealth and is the recipient of a research grant, through Yale University, from Medtronic to share research data.

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In recent years, experts have called for greater partici­pation by patients in medical decision-making processes, but research suggests that shared decision making is not yet routinely incorporated into medical care. “In some cases, there may be a perception among patients that they need to defer decision making to their physicians,” says Harlan M. Krumholz, MD, SM. “This is certainly the sense by many cardiologists about patients hospitalized with an acute myocardial infarction (AMI).”

Surveying the Scene

To further investigate decision-making preferences among patients, Dr. Krumholz and colleagues conducted a study using combined data from two similar AMI registries. Published in JAMA Internal Medicine, the study group asked patients to indicate who they felt should make decisions on treatment options in AMI after they are given information about the risks and benefits of the possible treatments.

Decision-AMI-Callout

 

More than two-thirds of patients reported that they preferred to actively participate in decision making about their care, but about one-quarter stated that they wanted to make the decision alone. Most patients indicated that physicians and patients should have equal participation. About 15% suggested that patients should dominate the decision. “The key take-home message is that decision-making preferences vary among patients after an AMI, but many prefer an active style,” says Dr. Krumholz.

Difficult to Predict

Seven variables were associated with a greater likelihood of patients preferring active decision making, including female sex, Caucasian race, higher education, smoking, heart failure, lower Global Registry of Acute Coronary Events risk score, and not undergoing PCI during the hospitalization. Those who preferred an active role tended to be younger, but the majority of all age groups assessed in the study still preferred active engagement. When compared with patients who did not complete high school, those who had a college or graduate degree had a much greater likelihood of preferring an active approach. However, 57.5% of those with less than a high school education preferred an active style.

Dr. Krumholz says it is important to note that, overall, demographic and clinical characteristics were not good predictors of which patients would prefer an active role in decision making. “Our research shows that clinicians shouldn’t make assumptions as to which patients will be active or passive in decision-making processes,” he says. He adds that more prospective studies on how best to incorporate patient preferences into decision making are warranted.

Challenges Ahead

According to Dr. Krumholz, physicians who aspire to provide patient-centered care should have open and direct dialogue with patients to assess their decision-making preferences. “To know a patient’s preference requires a specific conversation,” he says. “The challenge for physicians is to develop systems and protocols that fully respect patient preferences and ensure that those who prefer an active role are given that opportunity.”

Readings & Resources (click to view)

Krumholz HM, Barreto-Filho JA, Jones PG, Li Y, Spertus JA. Decision-making preferences among patients with an acute myocardial infarction. JAMA Intern Med. 2013;173:1252-1257. Available at http://archinte.jamanetwork.com/article.aspx?articleid=1710073&resultClick=3.

Lipkin M. Shared decision making: comment on “association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients.” JAMA Intern Med. 2013 May 27 [Epub ahead of print]. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1691772.

Allen LA, Stevenson LW, Grady KL, et al; American Heart Association; Council on Quality of Care and Outcomes Research; Council on Cardiovascular Nursing; Council on Clinical Cardiology; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Surgery and Anesthesia. Decision-making in advanced heart failure: a scientific statement from the American Heart Association. Circulation. 2012;125:1928-1952.

Walsh MN, Bove AA, Cross RR, et al; American College of Cardiology Foundation. ACCF 2012 health policy statement on patient-centered care in cardiovascular medicine: a report of the American College of Cardiology Foundation Clinical Quality Committee. J Am Coll Cardiol. 2012;59:2125-2143.

Arnold SV, Chan PS, Jones PG, et al; Cardiovascular Outcomes Research Consortium. Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status (TRIUMPH): design and rationale of a prospective multicenter registry. Circ Cardiovasc Qual Outcomes. 2011;4:467-476.

Spertus JA, Peterson E, Rumsfeld JS, Jones PG, Decker C, Krumholz H; Cardiovascular Outcomes Research Consortium. The Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER): evaluating the impact of myocardial infarction on patient outcomes. Am Heart J. 2006;151:589-597.

Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making? Arch Intern Med. 1996;156:1414-1420.

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