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144 Cardiologists’ recommendations and perceptions of shared decision making for implantable cardioverter defibrillator placement
  1. Carmen L Lewis1,
  2. Bryan C Wallace2,
  3. Christopher E Knoepke3,
  4. Daniel D Matlock4
  1. 1Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
  2. 2Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO
  3. 3Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
  4. 4Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO; Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO

Abstract

Background The decision about Implantable cardioverter defibrillator (ICD) placement requires significant trade-offs for individual patients. To ensure patients are appropriately informed, the Centers for Medicare and Medicaid Services in the U.S. mandated that physicians conduct and document a shared decision- making process with a decision aid. The purpose of this study is to examine cardiologists’ recommendations and their perceptions of the shared decision-making process.

Methods Survey of cardiologists caring for 564 patients participating in an implementation trial of a patient decision aid. Risk ratios for probability of a positive recommendation by age, CHF etiology, gender, and number of comorbidities were obtained via a series of Poisson models.

Results Most of the cardiologists perceived that the majority of the decision was made by the patient (56%) and that the discussion was easy (76%). Based on the clinical situation, 85% of physicians reported that the benefits of the device outweigh the downsides. When asked about the benefits and downsides based on the patients’ values and opinions, 87% thought that the benefits outweighed the risks. Eighty three percent recommended the procedure. In adjusted models, physicians were significantly less likely to recommend the procedure in patients ages 75 to 84 (RR (95%CI:0.87 (0.78, 0.96)) and 85 and older (0.64 0.43, 0.94) than in younger patients, controlling for site, sex, CHF etiology, and number of comorbidities.

Discussion ICD implantation is a high stakes decision with potentially significant downsides for patients. From a physician perspective, strong evidence demonstrating a mortality benefit favors ICD placement.

Conclusions Cardiologists in this study had perceptions that the vast majority of the patients would benefit from the device, perceived that the patients’ values and opinion aligned with this notion, and recommended placement. Importantly, physicians demonstrated less enthusiasm in recommending the device to older patients in whom the evidence is less robust.

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