Patient perspectives on engagement in decision-making in early management of non-ST elevation acute coronary syndrome: a qualitative study.

BACKGROUND: Surveys of patients suggest many want to be actively involved in treatment decisions for acute coronary syndromes. However, patient experiences of their engagement and participation in early phase decision-making have not been well described. METHODS: We performed a patient led qualitative study to explore patient experiences with decision-making processes when admitted to hospital with non-ST elevation acute coronary syndrome. Trained patient-researchers conducted the study via a three-phase approach using focus groups and semi-structured interviews and employing grounded theory methodology. RESULTS: Twenty patients discharged within one year of a non-ST elevation acute coronary syndrome participated in the study. Several common themes emerged. First, patients characterized the admission and early treatment of ACS as a rapidly unfolding process where they had little control. Participants felt they played a passive role in early phase decision-making. Furthermore, participants described feeling reduced capacity for decision-making owing to fear and mental stress from acute illness, and therefore most but not all participants were relieved that expert clinicians made decisions for them. Finally, once past the emergent phase of care, participants wanted to retake a more active role in their treatment and follow-up plans. CONCLUSIONS: Patients admitted with ACS often do not take an active role in initial clinical decisions, and are satisfied to allow the medical team to direct early phase care. These results provide important insight relevant to designing patient-centered interventions in ACS and other urgent care situations.

Preferences of Patients With Chronic Kidney Disease for Invasive Versus Conservative Treatment of Acute Coronary Syndrome: A Discrete Choice Experiment.

Background Patients with chronic kidney disease (CKD) can experience acute coronary syndromes (ACS) with high morbidity and mortality. Early invasive management of ACS is recommended for most high-risk patients; however, choosing between an early invasive versus conservative management approach may be influenced by the unique risk of kidney failure for patients with CKD. Methods and Results This discrete choice experiment measured the preferences of patients with CKD for future cardiovascular events versus acute kidney injury and kidney failure following invasive heart procedures for ACS. The discrete choice experiment, consisting of 8 choice tasks, was administered to adult patients attending 2 CKD clinics in Calgary, Alberta. The part-worth utilities of each attribute were determined using multinomial logit models, and preference heterogeneity was explored using latent class analysis. A total of 140 patients completed the discrete choice experiment. The mean age of patients was 64 years, 52% were male, and mean estimated glomerular filtration rate was 37 mL/min per 1.73 m2. Across the range of levels, risk of mortality was the most important attribute, followed by risk of end-stage kidney disease and risk of recurrent myocardial infarction. Latent class analysis identified 2 distinct preference groups. The largest group included 115 (83%) patients, who placed the greatest value on treatment benefits and expressed the strongest preference for reducing mortality. A second group of 25 (17%) patients was identified who were procedure averse and had a strong preference toward conservative management of ACS and avoiding acute kidney injury requiring dialysis. Conclusions The preferences of most patients with CKD for management of ACS were most influenced by lowering mortality. However, a distinct subgroup of patients was strongly averse to invasive management. This highlights the importance of clarifying patient preferences to ensure treatment decisions are aligned with patient values.

Patient Experience After Risk Stratification and Follow-up for Acute Kidney Injury After Cardiac Catheterization: Patient Survey.

BACKGROUND: Acute kidney injury (AKI) after cardiac catheterization procedures is associated with poor health outcomes. We sought to characterize the experiences of patients after receiving standardized information on their risk of AKI accompanied by instructions for follow-up care after cardiac catheterization. METHODS: We implemented an initiative across 3 cardiac catheterization units in Alberta, Canada to provide standardized assessment, followed by guidance for patients at risk of AKI. This was accompanied by communication to primary care providers to improve continuity of care when patients transition from the hospital to the community. A structured survey from a sample of 100 participants at increased risk of AKI determined their perceptions of information provided and experiences with follow-up steps after the initiative was implemented in each cardiac catheterization unit in Alberta. RESULTS: The mean age of participants was 72.4 (SD 10.4) years, 37% were female, and the mean risk of AKI was 8.8%. Most (63%) participants were able to recall the information provided to them about their risk of kidney injury, 68% recalled the education provided on strategies to reduce risk, and 65% believed their primary care practitioner had received enough information to conduct appropriate follow-up care. Eighty-six percent of patients were satisfied with their transition to the community, and 53% were reassured by the information and follow-up care they received. CONCLUSIONS: These findings suggest that communicating risk information to patients, in combination with education and collaboration for follow-up with primary care providers, is associated with positive patient experiences and satisfaction with care.

CONTEXTE: L'insuffisance rénale aiguë (IRA) après un cathétérisme cardiaque est associée à de mauvais résultats en matière de santé. Nous avons voulu décrire l'expérience des patients après qu'on leur ait transmis de l'information standardisée concernant le risque d'IRA et des directives pour les soins de suivi après un cathétérisme cardiaque. MÉTHODOLOGIE: Nous avons mis en place une initiative dans trois unités de cathétérisme cardiaque en Alberta, au Canada, afin de permettre une évaluation standardisée, puis d'offrir des directives concernant les patients à risque d'IRA. Notre initiative comprenait également des communications aux fournisseurs de soins primaires en vue d'améliorer la continuité des soins prodigués aux patients quittant l'hôpital pour retourner en milieu communautaire. Un sondage structuré mené auprès de 100 participants présentant un risque accru d'IRA a permis de connaître leurs perceptions quant à l'information reçue et à leur expérience à l'égard du suivi après la mise en place de l'initiative dans chacune des unités de cathétérisme cardiaque en Alberta. RÉSULTATS: L'âge moyen des participants était de 72,4 ans (écart type : 10,4), 37 % étaient des femmes, et le risque moyen d'IRA était de 8,8 %. La plupart des participants (63 %) étaient en mesure de se souvenir de l'information qui leur avait été transmise au sujet de leur risque d'insuffisance rénale, 68 % se rappelaient la formation reçue concernant les stratégies pour réduire leur risque, et 65 % estimaient que leur médecin de soins primaires avait recueilli suffisamment d'information pour effectuer un suivi adéquat. Quatre-vingt-six pour cent (86 %) des patients étaient satisfaits de leur transition en milieu communautaire, et 53 % étaient rassurés par l'information reçue et le suivi dont ils faisaient l'objet. CONCLUSIONS: Ces résultats suggèrent que le fait de transmettre aux patients de l'information au sujet des risques, en plus de les éduquer et de leur permettre de collaborer avec leur fournisseur de soins primaires pour le suivi est associé à une expérience positive pour le patient et à la satisfaction à l'égard des soins reçus.

Patient and physician perspectives on shared decision-making for coronary procedures in people with chronic kidney disease: a patient-oriented qualitative study.

BACKGROUND: Patients with chronic kidney disease (CKD) and heart disease face challenging treatment decisions. We sought to explore the perceptions of patients and physicians about shared decision-making for coronary procedures for people with CKD, as well as opinions about strategies and tools to improve these decisions. METHODS: We partnered with 4 patients with CKD and 1 caregiver to design and conduct a qualitative descriptive study using semi-structured interviews and content analysis. Patient participants with CKD and either acute coronary syndrome or cardiac catheterization in the preceding year were recruited from a provincial cardiac registry, cardiology wards and clinics in Calgary between March and September 2018. Cardiologists from the region also participated in the study. Data analysis emphasized identifying, organizing and describing themes found within the data. RESULTS: Twenty patients with CKD and 10 cardiologists identified several complexities related to bidirectional information exchange needed for shared decision-making. Themes identified by both patients and physicians included challenges synthesizing best evidence, variable patient knowledge seeking, timeliness in the acute care setting and influence of roles on decision-making. Themes identified by physicians related to processes and tools to help support shared decision-making in this setting included personalization to reflect the variability of risks and heterogeneity of patient preferences as well as allowing for physicians to share their clinical judgment. INTERPRETATION: There are complexities related to bidirectional information exchange between patients with CKD and their physicians for shared decision-making about coronary procedures. Processes and tools to facilitate shared decision-making in this setting require personalization and need to be time sensitive.