Information provision and decision-making in the treatment of abdominal aortic aneurysm: A qualitative study of patient experience.

INTRODUCTION: Shared decision making (SDM) refers to patients and health care professionals working together to reach a decision about treatment/care. In abdominal aortic aneurysm (AAA) treatment options are influenced by patients' clinical characteristics, their preferences, and potential trade-offs between alternative interventions. This is a prime example of where SDM is essential to ensure the right decision is made for the right patient, yet we have little understanding of what happens in practice. This study explored patient experiences to understand SDM practice in AAA surgery. METHODS: We used a qualitative approach to describe, and identify improvements to, current treatment decision making in abdominal aortic aneurysm (AAA) surgery. Two groups of patients were interviewed: those at the point of discussing treatment options (with corresponding digitally recorded consultation data) and following surgical intervention from one hospital. Framework analysis was used. RESULTS: Fifteen patients were interviewed, seven at the point of discussing treatment options and eight following surgical intervention. Timing, format and sources of information, verbal framing of interventions and level of patient engagement were key themes. Four areas for improvement were identified: earlier provision and more detailed written information along with signposting to quality on-line information; both intervention options, risks, benefits, and consequences, were not always discussed; some clinicians were somewhat directive in the decision-making process; and patients' treatment values/preferences were not explored-the only example was in one of the eight recorded consultations. Patients could feel overwhelmed by the information and decision and fearful of the impending surgery. CONCLUSIONS: More emphasis should be placed on the provision of full information and the exploration of patient values and preferences for treatment. Clinician training and support for patients, including decision aids, could facilitate the decision-making process. Providing written information earlier and guidance on reliable on-line resources would benefits patients and their families.

Accuracy of Peripheral Arterial Disease Registers in UK General Practice: Case-Control Study.

BACKGROUND: Approximately 20% of the UK population aged 55 to 75 years have evidence of peripheral arterial disease (PAD). PAD affects quality of life and life expectancy if not appropriately diagnosed and managed. At risk patients require accurate diagnosis to ensure optimal treatment to slow disease progression and minimize adverse outcomes. AIM: To assess the accuracy of general practice (GP) registration of the diagnosis of peripheral arterial disease (PAD). DESIGN AND SETTING: An observational analytic case-control study. As part of a National Institute for Health Research-funded (ISRCTN13301188) project assessing novel diagnostic methods set in GP practice. METHODS: A total of 125 patients registered as having PAD and 125 age- and sex-matched controls were recruited from 15 general practices across North East England. The register was then assessed for accuracy of diagnosis. Duplex vascular ultrasound scanning (DUS) undertaken by vascular scientists was used as the gold standard reference for PAD. RESULTS: The PAD register had a sensitivity of 86% (95% CI 77%-92%) and specificity of 74% (95% CI 67%-81%) when compared with DUS. The positive predictive value, however, was 69.6% (95% CI 63%-75%) and negative predictive value 88.8% (95% CI 82%-92%). The overall diagnostic effectiveness of the PAD register was 79.2% (95% CI 73%-84%). CONCLUSION: This analysis indicates that while PAD is detected with reasonable sensitivity in primary care, many patients registered with a diagnosis of PAD lacked DUS-proven disease. Improved approaches to the objective diagnosis of PAD may improve diagnosis and management of PAD in primary care.

Towards safer carotid artery stenting: a scoring system for anatomic suitability.

BACKGROUNDS AND PURPOSE: To develop a scoring system to facilitate case selection for carotid artery stenting based on anatomic features. METHODS: Twelve experts comprising a multinational and multispecialty panel were convened. Delphi consensus methodology was applied over 4 "rounds" involving emailed questionnaires, private decision-making, structured interaction and explicit aggregation. In round 1 panelists proposed individual anatomic features that were considered relevant during carotid artery stenting. In round 2 each criterion was scored from 1 (straightforward) to 9 (difficult). Round 3 involved removing some factors based on individual scores to reduce the number of subsequent combination anatomies. The final round involved scoring 96 combination anatomies (representing a "full factorial" design) plus a dichotomous response, ie, whether carotid artery stenting should or should not be advised for a "novice." RESULTS: There were 1164 responses, providing a score for 12 individual anatomic features and for 96 combinations anatomies with good level of agreement between panelists. After derivation of mean (and standard deviation) of the cutting scores for 1152 yes/no responses a scoring system for combination anatomy was produced, comprising broad agreement bands presented as traffic light colors: red for particularly difficult anatomy, amber for moderate difficulty and green for lesser difficulty. CONCLUSIONS: A scoring system has been developed, based on objective expert consensus, which can be used to categorise expected difficulty of carotid artery stenting and aid case selection.

Bypass versus angioplasty to treat severe limb ischemia: factors that affect treatment preferences of UK surgeons and interventional radiologists.

OBJECTIVE: There is continuing controversy as to whether surgical bypass or angioplasty should be first-line treatment of severe limb ischemia. We undertook this study to examine angiographic and clinical factors that influence the treatment of severe limb ischemia by vascular surgeons and interventional radiologists. METHODS: Twenty consultant vascular surgeons and 17 consultant vascular interventional radiologists evaluated 596 hypothetical clinical or angiographic scenarios, and recorded whether, in their opinion, the most appropriate first-line treatment was surgical bypass, angioplasty, or primary amputation. Stepwise multiple linear regression was used to identify the factors that significantly affected responses from the entire group and from surgeons and radiologists separately. RESULTS: There were significant differences between surgeons and radiologists with regard to how clinical and angiographic variables determined treatment preferences. Increasing disease severity, absence of runoff into the foot, presence of a suitable vein, and tissue loss as opposed to rest pain only (the latter only significant to surgeons) all increased the response score toward surgery. However, surgeons and radiologists weighted each of these factors quite differently. Even in the most complex statistical model, 19% of surgical and 13% of radiologic response variations remained unexplained. CONCLUSIONS: Individual surgeons and radiologists vary considerably in their views of the relative merits of surgery and angioplasty in patients with severe limb ischemia. This broad gray area mandates the need for randomized controlled trial data to inform joint decision-making and to optimize patient outcome.