Informed Decision Making for Percutaneous Coronary Intervention for Stable Coronary Disease

Prior studies suggest patients are often misinformed about the anticipated benefits of PCI for stable coronary disease.  However, there is little data on patient-provider discussions that may explain discrepancies in patient understanding about the limited benefits of PCI in this setting.   Rothberg and colleagues performed a cross-sectional analysis of 59 conversations between providers and patients about PCI.  The conversations included 23 cardiologists (all male, 6 interventionalists, median 19 years experience) representing all regions of the United States from 2008 to 2012.  Conversations were analyzed for discussion of 7 elements central to shared-decision making: (1) the patient’s role in decision making, (2) the clinical issue or nature of the decision, (3) alternatives to PCI, (4) pros and cons of the alternatives, (5) the uncertainties associated with the decision, (6) assessment of the patient’s understanding, and

(7) exploration of patient preference.  Only 2 conversations (3%) included all 7 elements of shared-decision making.  Patients were less likely to choose PCI if the conversation included discussion of uncertainty (odds ratio [OR], 20.5; 95% confidence interval [CI], 2.3-204.9), exploration of alternatives (OR, 9.5; 95% CI, 2.5-36.5) and discussion of patient preferences (OR, 4.8; 95% CI, 1.2-19.4).  Interventional cardiologists more often discussed the pros and cons of PCI, alternatives, and the patient’s role in decision-making. More informed patients (as assessed by the number of shared-decision making elements discussed) were less likely to choose angiography and possible PCI (OR per additional element, 3.2; 95% CI, 1.4-7.1; P = .005)

 

Conclusions: The process of informed decision-making is often incomplete in conversations with patients about PCI for stable ischemic heart disease.  This study provides insight as to the potential reasons for patient misperception about the limited benefits of PCI for stable coronary disease.  Better-informed patients were seen to pursue angiography and PCI less often.

 

Summarized by Amneet Sandhu and Steven M. Bradley

 

Rothberg MB, Sivalingam SK, Kleppel R, Schweiger M, Hu B and Sepucha KR.  Informed decision making for percutaneous coronary intervention for stable coronary disease.  JAMA Intern Med.  2015; 175(7): 1199-1206.