Shared Decision Making in Cardiovascular Disease in the Outpatient Setting

Abstract

The authors developed a patient decision aid (PDA) to educate patients regarding CAD. Patients were randomized to standard of care or a PDA. PDA group had increased medical knowledge of CAD and decreased decisional conflict. Patients presenting in an outpatient setting with symptoms may benefit from the use of a PDA. (Level of Difficulty: Beginner.).

Keywords: CAD, coronary artery disease; PDA, patient-centered decision aid tool; coronary artery disease; decision aid; management; pilot program.

Graphical abstract

Figure 1

Flowchart of Participant Selection Between 2014 and 2019, patients presenting to the MedStar Georgetown University Hospital outpatient cardiology clinic for evaluation of chest pain or other symptoms concerning for underlying coronary artery disease (CAD) were evaluated for enrollment in the study. Patients were approached for enrollment, and those who agreed and signed informed consent forms were then randomized to either the patient-centered decision aid (PDA) group or the standard of care group. The final results were analyzed at the completion of the study.

Figure 2

Overview of PDA Enrolled patients randomized to use of the PDA were provided an iPad with the website before their office visit. The PDA provided basic introductory information on American Heart Association recommendations for CAD testing, including commonly used screening and diagnostic tests. Patients were also provided information on the definition, symptoms, natural history, prevalence, and mortality related to CAD. Abbreviations as in Figure 1.

Figure 3

Patient-Specific Risk Stratification Section III of the PDA goes over the various types of cardiovascular testing that may be used for diagnosis of CAD, including a description (with pictures) of what is involved, results to expect, potential risks (with graphical representation), and benefits, as well as limitations, for each test, including a comparison table of the various tests. Patients are then able to input their own information to calculate their personal risk estimates for having significant CAD and/or having a cardiac event. Furthermore, patients can recalculate individual estimated risk dependent on positive or negative results for different cardiac tests. Abbreviations as in Figure 1.

Figure 4

Parametric and Nonparametric Outcome Measures Comparing the PDA Group to the Standard of Care Group Bell curve scatter plot of parametric outcome measures and box and whisker plots of nonparametric outcome measures comparing the PDA group to the standard of care group are shown. When compared with the standard of care group (mean 6.94 ± 1.44), participants in the PDA group (mean 8.05 ± 1.29) had statistically significant increased medical knowledge of CAD (p < 0.001) (A). They also had statistically significant decreased decisional conflict (p < 0.001) (B). Both groups reported high patient satisfaction (p = 0.42) (C) and trust in the provider (p = 0.26) (D) with no statistically significant difference between the groups. Abbreviations as in Figure 1.

Figure 5

Cardiac Tests Performed After Initial Consult A total of 64 of the 99 patients (64.6%) underwent further cardiac testing after their initial consult, whereas 36 (36.4%) did not undergo further testing. Some patients also underwent >1 cardiac test. Of the 119 additional cardiac tests performed after the initial office visit, 42 (35.3%) were transthoracic echocardiogram (TTE), 25 (21.0%) were stress echocardiogram (ECHO), 6 (9.0%) were cMRI/cMRA (cardiac magnetic resonance imaging/cardiac magnetic resonance angiogram), 6 (9.0%) were computed tomography (CT) scans of the heart/chest, and 5 (7.5%) were CT angiography (CTA) of the chest.