Patient Decision Aid Improves Shared Decision-making in Aortic Stenosis

A novel point-of-care decision aid for patients with severe aortic stenosis not only can improve their knowledge and empower them in making choices about their care, but also seems to clarify the treating physician’s own understanding of each patient’s goals and values, according to new data.

“Elevating the patient voice has become more important than ever before,” lead author Megan Coylewright, MD, MPH (University of Tennessee Health Science Center, Chattanooga), told TCTMD.

As TAVI is now indicated for patients with severe aortic stenosis across surgical-risk categories, heart team discussions have become more complex, often having to consider the lifetime management of these valves for patients with longevity. This has become a hot topic among surgeons and cardiologists alike, with several studies showing an increasing trend toward TAVI in patients under the age of 65 that’s contrary to guideline recommendations.

The idea for creating a new decision aid that can “really demonstrate trustworthiness” between the patient and physician, said Coylewright, came from “when patients shared with us: ‘When I sit down with the heart team and they ask me immediately what is it that I want, I have no idea how to answer that question on the spot.’”

Elevating the patient voice has become more important than ever before. Megan Coylewright

With her team, Coylewright and colleagues developed and tested the interactive, online Aortic Valve Improved Treatment Approaches (AVITA) tool based on past patient experiences. Designed to be given to patients after being referred to the heart team by their primary care physician and/or cardiologist, AVITA presents a variety of options to patients with the goal of homing in on their values and generates a summary that is shared with clinicians.

“This decision aid is not designed to guide the patient towards one decision or another,” Coylewright stressed, adding that it’s only meant for use by patients who are eligible for both TAVI and SAVR. “It's designed to lead to informed preferences that match with their goals and values, and lead to a shared decision-making discussion with their heart team so that they can come to consensus together.”

Positive Feedback, High Decision Quality

For the study, published online this week in PLoS ONE, Coylewright et al included 30 patients (30% women; mean age 70.4 years) and 14 clinicians (28.6% women; 50% cardiothoracic surgeons) comprising 28 clinical encounters.

All clinicians included said they practiced shared decision-making with their patients, but none of the 22 patient-evaluated encounters met all criteria for shared decision-making, with discussion of the cons of TAVI and SAVR missing from 50% and 59.1%, respectively. More than one-third of encounters did not include asking if the patient wanted SAVR or TAVI, and clinicians didn’t share that there was more than one treatment option in 27.3% of encounters.

In total, 85.7% of patients and 84.6% of clinicians endorsed AVITA’s use. Most patients said the tool was easy to use (89.3%) and assisted them with choosing a treatment option (95.5%). Notably, most clinicians said the summary helped them understand their patients’ values (80.8%) and make recommendations aligned with them (61.5%).

Patient knowledge significantly improved from baseline after using the intervention and after the clinical encounter (P = 0.004).

An initial preference is often uninformed, and it has low quality. Diana Otero

Importantly, 60% of patients changed their treatment preference at least once from baseline to after their clinical encounter, and 20% changed their preference twice. Baseline treatment preferences were associated with low knowledge, high decisional conflict, and poor decision quality, but their final preferences were opposite, with high knowledge, low conflict, and high quality. All but two patients’ final treatment choice was in line with what their physician’s recommendation.

Co-author Diana Otero, MD (Columbia University Medical Center, New York, NY), said the frequency with which patients changed their preferences after using AVITA suggests that not only is the typical TAVI versus SAVR decision-making process ripe for improvement, but that “an initial preference is often uninformed, and it has low quality.”

This experience can burden patients with added stress, she continued. “Shared decision-making is a multidimensional process, and it should involve discussion of all treatment options, the pros and cons of all treatment options, and ask what is it that would you prefer to have.”

What’s more, Otero said, the fact that all clinicians said they initially went through the shared decision-making process and the realities of those encounters highlights a disconnect. “So obviously there is a different perception of what shared decision-making is for clinicians and for patients,” she said. “And I think this tool will create a more homogeneous process.”

Trustworthiness Ahead

Building trust is a goal for physicians and patients alike, but that takes work.

“We're talking to patients about having them take a leap of faith, to join us on this journey of procedures,” Coylewright said. Rather than conceding that a patient doesn’t have trust, she added, physicians should feel empowered to “be trustworthy” based on their actions.

Co-author Aaron Horne Jr, MD (Summit Health, Berkeley Heights, NJ), said part of this is related to implicit bias. “We oftentimes have these preconceived ideas about our patients before they come in for that particular appointment,” he told TCTMD. The value of this study was that it challenged clinicians to reconsider their practice patterns and rethink if the way they do things might be altered to better meet patients’ needs, he said.

“The reason why there is a trust deficit, particularly among certain communities, is because of that preconceived conception that patients can feel,” said Horne. “This tool helps engender trust when we’re saying that we don't know exactly what your thought process is, but we want to engage you and learn from that. And then have a true conversation together to help try to share goals.”

This tool helps engender trust. Aaron Horne Jr

Of the physicians who did not report that AVITA was helpful, one of the most common reasons cited was that it did not lead the patient to agree with the physician’s initial recommendation. Horne highlighted, however, that this was never the intention of the tools use. “We obviously are advocating for high-quality, value-based care,” he said. “But the whole point of this tool is to understand what's important to that patient, what are their values and belief systems.”

Coylewright added that they don’t yet have a formal qualitative analysis of what patients and physicians alike might not have liked about AVITA, but she did note that perception and acceptability changed with use. Previous research has shown that it takes about five uses before clinicians feel comfortable integrating a new decision aid into their workflow, she said. “It was very reassuring that with multiple uses, the clinicians felt favorably and would report that they would use it again in the future. But the first couple times it can be quite a change.”

The study was “too small,” however, to be able to note a difference in perception of the tool by type of physician, such as a surgeon compared with interventional cardiologist, according to Coylewright. However, she did note that AVITA “was effective with cardiologists, interventional cardiologists, cardiac surgeons, [and] advanced practice providers [in leading] to high-quality decisions.”

Real-world Use to Come

Going forward, Otero said would like to see how the tool affects real-world practice. “In general there is so much information online, and unfortunately so much misinformation, that I think is our responsibility to educate our patients,” she said, noting that the AVITA tool “offers very concise but comprehensive information about aortic stenosis and treatment options.”

Horne agreed that validation of the data is key, but he also wants to “see trends, and hopefully those trends spark more questions and encourage potentially changes in behavior, most importantly, trust in the patient and really paying attention to what their core values and beliefs are, making sure that the treatment plan is consistent with [that].”

Coylewright said they are working with the American College of Cardiology to include AVITA in its CardioSmart umbrella of tools and hopes to have it available for broad use soon.