Professional Abstract

Objective

To test the effectiveness of a shared decision making aid, with and without decision coaching, for patients undergoing percutaneous coronary intervention (PCI) who have the choice of receiving drug-eluting or bare-metal stents

Study Design

Design Elements	Description
Design	Pre versus post-intervention comparison
Population	331 patients undergoing PCI
Interventions/ Comparators	Shared decision making aid with decision coaching Shared decision making aid alone Personalized consent form without shared decision making aid (usual care)
Outcomes	Primary: participation in stent choice discussion Secondary: stent knowledge, patient preference for stent type, participation in decision making, concordance of patient stent preference with type of stent received
Timeframe	Immediate post-procedure follow-up for primary outcome

In shared decision making, patients are active partners in deciding their treatment with their clinicians. In this study, researchers developed a shared decision making aid for patients undergoing PCI using feedback from patient focus groups and clinician interviews. The aid used clinical information to create a personalized comparison of the benefits of avoiding a repeat procedure PCI procedure and drawbacks of drug-eluting stents and bare-metal stents.

Researchers compared outcomes in patients who received the decision aid with and without coaching with outcomes in patients who received usual care. The first group reviewed the shared decision making aid with coaching from a trained nurse, who talked about the displayed risks and benefits of the two types of stents and encouraged patients to discuss their preferences with their doctor before the procedure. The second group reviewed the decision aid without any coaching before choosing a stent type. The third group received usual care, which was a personalized consent form without the shared decision making aid. Researchers interviewed all patients on the study outcomes before and after the procedure.

The study included 331 patients scheduled to receive PCI at two hospitals in Kansas City, Missouri. Of these patients, 80% were white and 20% were African American. The average patient age was 67, and 64% of patients were male. The three groups did not differ significantly in demographics.

Patients, clinicians, and a payer were part of the study’s steering committee and provided feedback throughout all phases of the research.

Results

Compared with patients who received usual care, those who reviewed the shared decision making aid with coaching from a nurse

• Were more likely to discuss stent options with nurses (p<0.001) or doctors (p<0.001)
• Had higher stent knowledge scores (p<0.001)
• Were more likely to state a stent preference (p<0.001)
• Were more likely to participate in shared decision making (p<0.001)

The study found no differences between patients who reviewed the shared decision making aid without coaching and those who received usual care.

In this study, patients who preferred to receive drug-eluting stents received them 98% of the time, while patients who preferred bare-metal stents received these stents 53% of the time. Use of the shared decision making aid with or without coaching did not affect this finding.

Limitations

Because patients reviewed the shared decision making aid right before their stent procedure, they may not have had enough time to reflect on the information and fully engage in shared decision making. Hospital nursing staff were often unavailable to provide decision coaching, and nurses from the research team had to fill in, suggesting that decision coaching may not be sustainable without hospitals investing in decision coaches.

Conclusions and Relevance

Findings suggest that the shared decision making aid was only effective at encouraging discussions and increasing patient knowledge of stent options when paired with decision coaching. The inconsistency of concordance between patients’ stent preference and the type of stent they received suggests that clinicians may not always place a high priority on patients’ preferences in stents.

Future Research Needs

Future research could explore strategies to deliver the shared decision making aid to patients earlier and investigate why patients who preferred bare-metal stents did not always receive these stents.