Journal Scan Summary
Patient Preference in the Decision to Place Implantable Cardioverter-Defibrillators
June 14, 2012
Caverly TJ, Al-Khatib SM, Kutner JS, Masoudi FA, Matlock DD.
Arch Intern Med 2012;Jun:[Epub ahead of print].
How do physicians weigh patient preferences and mortality benefits in guiding their recommendations for implantable cardioverter-defibrillator (ICD) therapy?
This was a web-based anonymous cross-sectional study of US cardiologists who were members of the American College of Cardiology. Cardiologists were asked to rank: “To what extent does each of the following factors influence your decision to recommend ICD therapy for primary prevention?” The Likert scale was used for ranking responses, ranging from “not at all” (scored 0) to “a great deal” (scored 5).
Of the 9,969 physicians sent surveys, 1,210 (12%) responded. Of these, 1,124 (11%) were included in the analysis. Responders were more likely to be board-certified electrophysiologists (12% vs. 4%, p < 0.001) and to practice in an academic setting (32% vs. 21%, p < 0.001) than survey nonresponders. When it came to guiding recommendations provided to patients for ICD therapy, no physician reported that data on mortality benefits “mattered very little or not at all” and 86% believed that mortality data “mattered a great deal.” In contrast, only 38% felt patient preferences “mattered a great deal” when providing ICD recommendations, and 12% thought that patient preferences “mattered very little or not at all.” Practitioners who rated mortality benefit data higher than patient preference had more positive attitudes toward ICD therapy (e.g., were less concerned about financial implications of ICDs).
Physicians weigh patient preferences lower than mortality data when considering recommendations for ICD therapy to their patients.
This survey suggests that patient-centered care and the shared decision making process has room for improvement when it comes to the ICD discussions that we have with our patients. While data and guidelines are integral to improving patient outcomes, mortality is not the only factor that warrants consideration when offering ICD therapy to an often elderly and moribund cohort of patients. This survey does not include 88% of ACC members and a large cohort of physicians who are non-ACC members. It does not explore the impact of physician attitude toward patient preferences on overall ICD utilization. We also do not know if the percentage of patients consenting to ICD implant differs based on physician attitudes toward patient preference. Regardless, a shared decision making process is hard to ‘share’ unless both parties are heard.
Jennifer Ann Cowger, M.D., M.S. (Disclosure)
Arrhythmias, Cardiac Rhythm Management, General Cardiology, Heart Failure/Transplant