Shared Decision Making in the Heart Team: Current Team Attitudes and Review

A 72-year-old retired physician living independently presents with shortness of breath on exertion. She is found to have severe aortic stenosis and two-vessel coronary artery disease. Both are amenable to a surgical and transcatheter approach. Heart valve disease (HVD) patients like the one above, facing an array of potential treatment options, are often encountered by the Heart Team. These types of decisions are ideally driven by an approach termed shared decision-making (SDM): a bidirectional exchange of information between physicians and patients, distinct from the one-way stream of information in patient education or informed consent.1Coylewright M O’Neill E Sherman A et al.The learning curve for shared decision-making in symptomatic aortic stenosis.JAMA Cardiol. 2020; 5 (doi:10.1001/jamacardio.2019.5719.): 442-448Google Scholar However, this approach has not received a wide application, perhaps due to a lack of understanding and/or support by Heart Team members. In this article, we explore Heart Team attitudes to shared decision-making by Heart Team members, review the current status of SDM for HVD, and consider the requirements for the implementation of an SDM approach in clinical practice. As defined by the National Learning Consortium, SDM is a key component of patient-centered health care. It is a process in which clinicians and patients work together to make decisions and select tests, treatments, and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values. SDM should not be confused with informed consent, which is the legal process used to promote patient autonomy. A physician presents information about anticipated management, detailing benefits, risks, and alternatives, and seeking the patient’s yes or no decision as to how to proceed. SDM is a widely promoted ethical approach, in which patients’ goals and preferences are central to the process. Clinicians share information about the alternatives, benefits, and harms for management. The unique patient facing the decision shares in their own words prior experiences, expectations, values, and goals.2Whitney S McGuire A McCullough LA Typology of shared decision making, informed consent, and simple consent.Ann Intern Med. 2004; 140 (doi:10.7326/0003-4819-140-1-200401060-00012.): 54Google Scholar The patient and physician interact to reach the best decision for the patient management. Best practices of SDM recommend the use of a patient decision aid (DA) to guide the conversation.3Dharmarajan K Foster J Coylewright M et al.The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers.PLoS One. 2017; 12 (doi:10.1371/journal.pone.0175926.): e0175926Google Scholar The American College of Cardiology/American Heart Association clinical practice guidelines recommend that treatment decisions for HVD utilize a Heart Team approach, SDM process, and incorporate patient values and preferences.4Nishimura R Otto C Bonow R et al.AHA/ACC guideline for the management of patients with valvular heart disease: executive summary.Circulation. 2014; 129 (doi:10.1161/cir.0000000000000029.): 2440-2492Google Scholar The European Society of Cardiology/European Association for Cardio-Thoracic surgery guidelines reference the importance of informed patient preference for prosthetic valve selection.5Falk V Baumgartner H Bax J et al.ESC/EACTS guidelines for the management of valvular heart disease.Eur J Cardiothorac Surg. 2017; 52 (2017. doi:10.1093/ejcts/ezx324.): 616-664Google Scholar There are both opportunities and challenges in implementing SDM, driven in part by the rapid evolution of the field of HVD and an increasing number of options for a wide range of patients (i.e. transcatheter vs. surgical valve replacement).6Sepucha K Wasfy J Implementing shared decision making in the rapidly evolving field of valvular heart disease.Circulation. 2017; 10 (doi:10.1161/circoutcomes.117.003549.): 2Google Scholar Adoption of SDM into routine HVD practice has been remarkably slow. Although SDM is increasingly recommended4Nishimura R Otto C Bonow R et al.AHA/ACC guideline for the management of patients with valvular heart disease: executive summary.Circulation. 2014; 129 (doi:10.1161/cir.0000000000000029.): 2440-2492Google Scholar,5Falk V Baumgartner H Bax J et al.ESC/EACTS guidelines for the management of valvular heart disease.Eur J Cardiothorac Surg. 2017; 52 (2017. doi:10.1093/ejcts/ezx324.): 616-664Google Scholar and literature supports added value in terms of improved patient outcomes (patient knowledge, decisional conflict, and satisfaction), the implementation of SDM for HVD patients is still in its infancy.7Coylewright M Forrest J McCabe J Nazif T TAVR in low-risk patients.J Am Coll Cardiol. 2020; 75 (doi:10.1016/j.jacc.2019.12.057.): 1208-1211Google Scholar Heart Team physicians continue to make inaccurate assumptions about patient values and preferences, particularly in a medical culture that is focused on a “disease-outcome-based paradigm.”8Reuben D Tinetti M Goal-oriented patient care — an alternative health outcomes paradigm.N Engl J Med. 2012; 366 (doi:10.1056/nejmp1113631.): 777-779Google Scholar Although Heart Team physicians often feel they already perform SDM, SDM is rarely practiced in real-world decision-making between physicians and their patients.9Godolphin W Shared decision-making.Healthcare Q. 2009; 12 (doi:10.12927/hcq.2009.20947.): e186-e190Google Scholar Research also suggests that clinicians often confuse basic patient education with an SDM process.10Coylewright M Dick S Zmolek B et al.PCI choice decision aid for stable coronary artery disease.Circulation. 2016; 9 (doi:10.1161/circoutcomes.116.002641.): 767-776Google Scholar DAs are information tools designed to help patients make informed choices about health-care options based on their values and preferences.11Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017. doi:10.1002/14651858.cd001431.pub5.Google Scholar Currently, publicly available DAs for patients with aortic stenosis exist, created through cardiovascular professional societies and grant-funded efforts.12Shared decision making. Tools. Available at: https://sharedcardiology.org/tools/ Accessed April 8, 2020.Google Scholar DAs and values clarification exercises however are infrequently employed.10Coylewright M Dick S Zmolek B et al.PCI choice decision aid for stable coronary artery disease.Circulation. 2016; 9 (doi:10.1161/circoutcomes.116.002641.): 767-776Google Scholar,13Joseph-Williams N, Lloyd A, Edwards A, et al. Implementing shared decision making in the NHS: lessons from the MAGIC programme. BMJ. 2017;j1744. doi:10.1136/bmj.j1744.Google Scholar Although DAs are important, professional skill sets in SDM and favorable physicians’ attitudes are even more critical for the successful implementation of SDM.14Gravel K Légaré F Graham I Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals’ perceptions.Implementat Sci. 2006; 1 (doi:10.1186/1748-5908-1-16.): 1Google Scholar There is little evidence that Heart Team physicians have the inclination or skillsets to lead patients and their families in an SDM process. In fact, published data suggest that individual physicians continue to have difficulty implementing SDM in real-word practice, supporting the importance of additional training, tools embedded in the clinical workflow. Moreover, it was suggested that policies that encourage favorable attitudes and a supportive context leading to SDM among physicians would be of benefit.15Joseph-Williams N Elwyn G Edwards A Knowledge is not power for patients: a systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making.Patient Educ Couns. 2014; 94 (doi:10.1016/j.pec.2013.10.031.): 291-309Google Scholar A recent study of SDM in patients with severe aortic stenosis found that Heart Team physicians perceive that patients have poor understanding of DAs despite patients’ reports that SDM with DAs improved their knowledge and the quality of clinical encounters.1Coylewright M O’Neill E Sherman A et al.The learning curve for shared decision-making in symptomatic aortic stenosis.JAMA Cardiol. 2020; 5 (doi:10.1001/jamacardio.2019.5719.): 442-448Google Scholar Taken together, it appears that physicians’ attitudes toward SDM and DAs remain limited, which would render implementation unlikely.1Coylewright M O’Neill E Sherman A et al.The learning curve for shared decision-making in symptomatic aortic stenosis.JAMA Cardiol. 2020; 5 (doi:10.1001/jamacardio.2019.5719.): 442-448Google Scholar Barriers and facilitators to SDM have been mainly identified from patients’ perspectives.15Joseph-Williams N Elwyn G Edwards A Knowledge is not power for patients: a systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making.Patient Educ Couns. 2014; 94 (doi:10.1016/j.pec.2013.10.031.): 291-309Google Scholar,16Dua A Dang P Shaker R et al.Barriers to surgery in severe aortic stenosis patients with class I indications for aortic valve replacement.J Heart Valve Dis. 2011; 20: 396-400Google Scholar The most frequently identified barrier for patients is insufficient information support (“too little” or “unimportant”).2Whitney S McGuire A McCullough LA Typology of shared decision making, informed consent, and simple consent.Ann Intern Med. 2004; 140 (doi:10.7326/0003-4819-140-1-200401060-00012.): 54Google Scholar,16Dua A Dang P Shaker R et al.Barriers to surgery in severe aortic stenosis patients with class I indications for aortic valve replacement.J Heart Valve Dis. 2011; 20: 396-400Google Scholar An appropriate level of knowledge is important as this is the principal enabler of SDM.14Gravel K Légaré F Graham I Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals’ perceptions.Implementat Sci. 2006; 1 (doi:10.1186/1748-5908-1-16.): 1Google Scholar Comorbidities are also frequently mentioned as a barrier to SDM, and one which influences symptom interpretation and expectations.17Lytvyn L Guyatt G Manja V et al.Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic stenosis: a systematic review.BMJ Open. 2016; 6 (doi:10.1136/bmjopen-2016-014327.): e014327Google Scholar,18Montori V Kunneman M Brito J Shared decision making and improving health care.JAMA. 2017; 318 (doi:10.1001/jama.2017.10168.): 617Google Scholar On the other hand, comorbidities are also seen as a facilitator by making patients more “experienced,” as they rely on their medical history, comparison with past significant medical experiences, and ongoing medical management.17Lytvyn L Guyatt G Manja V et al.Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic stenosis: a systematic review.BMJ Open. 2016; 6 (doi:10.1136/bmjopen-2016-014327.): e014327Google Scholar,19Olsson K Näslund U Nilsson J Hörnsten Å Patients’ experiences of the transcatheter aortic valve implantation trajectory: a grounded theory study.Nurs Open. 2018; 5 (doi:10.1002/nop2.124.): 149-157Google Scholar In summary, despite recommendations in professional guidelines, SDM is not yet common practice in the Heart Team decision-making process in the treatment of HVD patients. While the role of the Heart Team physician is likely central in the lack of SDM implementation, in the current literature, attitudes, and perceived barriers and facilitators among Heart Team physicians remain underexplored. These data are essential to understand effective strategies for the implementation of SDM (e.g. awareness, familiarity, agreement with SDM, factors associated with patients and environment).13Joseph-Williams N, Lloyd A, Edwards A, et al. Implementing shared decision making in the NHS: lessons from the MAGIC programme. BMJ. 2017;j1744. doi:10.1136/bmj.j1744.Google Scholar To match the dramatic evolution of the advancements in treatment, further research is needed to implement HVD SDM. The variable alternatives for the management of HVD present a prime example of a clinical condition in which SDM could play a critically important role. To explore and further define the knowledge, attitudes, and needs of Heart Team clinicians caring for HVD patients, we invited registrants for the 2018 Annual Scientific Meeting of the Heart Valve Society to share opinions about SDM and their perceived requirements for implementation in clinical practice. Heart Team physicians, including cardiologists and cardiothoracic surgeons, were approached by e-mail and asked to complete an anonymous online survey (Appendix 1) before attending the meeting (N = 800) using a cross-sectional online survey (Poll Everywhere). We also performed in-depth interviews. Given that patients were not included in this project, institutional review board approval was not sought. All interviewed participants provided informed consent and interviews were anonymized. Using the clinical scenario of the 78-year-old retired physician with treatment equipoise, varying physicians’ practice patterns were reported (Figure 1). Almost all physicians (91%) indicated that they would take additional steps to achieve patient engagement in the decision-making process if the patient indicated a preference to leave the decision entirely to the physicians. Less than half of the physicians reported using evidence-based DAs (43%), while 48% indicated they typically take further actions to engage patients through verbal communication. No correlations between attitude toward SDM and gender, age, or specialty were found. Physicians who expressed a more positive attitude toward SDM also had a more positive view regarding the balance between SDM and health-care costs. Physicians’ answers to the requirements for consistent SDM implementation and the most important facilitators to SDM promotion are shown in Figure 2, Figure 3. The need for physician training and upper-level support were emphasized.Figure 2Heart Team physicians’ responses to rank importance of requirements to effectively implement SDM in heart valve disease practice. The 5 answer options in the figure were ranked from most important at the top (dark green) to least important at the bottom (gray). The 6th answer option is “No changes are needed at all.” The figure is arranged at number 1 position.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Heart Team physicians’ responses to rank importance of facilitators to effectively implement SDM in heart valve disease practice. The 6 answer options in the figure were ranked from most important at the top (dark green) to least important at the bottom (gray). The 7th answer option is “No changes are needed at all.” The figure is arranged at number 1 position.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Nine Heart Team physicians, including four cardiologists and five cardiothoracic surgeons, participated in interviews (see appendix 2) to gain an in-depth understanding of their perceptions toward the implementation of SDM in HVD practice. Five physicians claimed to be familiar with the concept of SDM but three were unable to differentiate patient education from SDM. Given the small experience with SDM and the use of DAs, the perception was that SDM is too time-intensive. Despite supporting the concept of SDM, it was considered impossible due to lack of consultation time. Most physicians agreed on the added value of DAs; however, only one had ever used a DA. Most physicians expressed their interest for a straightforward and easy to use DA tool in their clinics and that information tools must be evidence-based. To effectively implement SDM, Heart Team physicians claimed it might be necessary to train them and other Team members in engaging patients in decision-making. The potential to overwhelm some patients with the SDM process was raised, but none had experience with asking patients about their desire to actively engage in the decision-making process by sharing values. When considering future benefits, the physicians agreed that a better-informed patient may save consultation time and could potentially improve the conversation. The results of this exploratory study forecast a long, winding road for HVD Heart Team physicians to adopt SDM into clinical practice. Although physicians agree on the importance of involving patients in treatment decisions, half leaned toward the Heart Team making final decisions. In addition, limited understanding of the concept of SDM poses another barrier for physicians in involving patients in their own clinical practice. Finally, limited knowledge of and experience with the use of evidence-based DAs is hampering the wider implementation of SDM in clinical practice. The primary limitation of this initial assessment is the introduction of bias due to its exploratory nature, convenience sample, small sample size, and low response rate. The patient scenario used in the survey also introduces bias as this patient was a retired physician. Further, physicians attending the Heart Valve Society meeting are frequently those with an academic focus thus this sample may not be representative of other practice settings. A key strength of this initial assessment is the provision of new data to understand Heart Team physician perceptions of barriers and facilitators for HVD SDM. Changing attitudes is a key challenge for any change program. Both structural changes, in terms of health-care pathways and delivery, and culture and attitudinal change among physicians are required for SDM to become routine. Thus, a positive clinician attitude toward SDM should be integrated into cardiovascular professional organizations, scientific sessions, and educational initiatives for heart teams. The mixed opinions among Heart Team members regarding the effect that SDM has on health-care costs reflect the existing literature.18Montori V Kunneman M Brito J Shared decision making and improving health care.JAMA. 2017; 318 (doi:10.1001/jama.2017.10168.): 617Google Scholar,20Walsh T Barr P Thompson R Ozanne E O’Neill C Elwyn G Undetermined impact of patient decision support interventions on healthcare costs and savings: systematic review.BMJ. 2014; 348 (doi:10.1136/bmj.g188.): g188Google Scholar Although there is no strong evidence that more time is required for SDM compared to usual healthcare delivery, this generally perceived barrier seems unavoidable.21Wyatt K Branda M Anderson R et al.Peering into the black box: a meta-analysis of how clinicians use decision aids during clinical encounters.Implementat Sci. 2014; 9 (doi:10.1186/1748-5908-9-26.): 1Google Scholar, 22Elwyn G Lloyd A May C et al.Collaborative deliberation: A model for patient care.Patient Educ Couns. 2014; 97 (doi:10.1016/j.pec.2014.07.027.): 158-164Google Scholar, 23Pieterse A Stiggelbout A Montori V Shared decision making and the importance of time.JAMA. 2019; 322 (doi:10.1001/jama.2019.3785.): 25Google Scholar An essential step in implementing SDM is to increase understanding of what this ethical approach entails and how it differs from the legal process of informed consent. Both the survey and interviews reveal that physicians value training in SDM skillsets as an important requirement. This is in line with prior literature, which suggests that strategies to implement SDM in clinical practice require training activities targeting a diverse group of health clinicians.15Joseph-Williams N Elwyn G Edwards A Knowledge is not power for patients: a systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making.Patient Educ Couns. 2014; 94 (doi:10.1016/j.pec.2013.10.031.): 291-309Google Scholar To achieve this, training sessions including the whole Heart Team are necessary to create collective commitment. For example, interactive skills training opportunities, based on building coherence, improving skills, and promoting positive attitudes.24Elwyn G M Edwards A Légaré F R Using a model of shared decision making to an Educ Couns. Scholar In addition, role training, which skills, than theory N, Lloyd A, Edwards A, et al. Implementing shared decision making in the NHS: lessons from the MAGIC programme. BMJ. 2017;j1744. doi:10.1136/bmj.j1744.Google Scholar For successful training would need to be embedded the and culture of professional organizations, and medical and and training program. This attitudes may from it to this Heart Team value tools designed to promote SDM, like DAs, the is how to this in cardiovascular care have the importance of DAs to promote SDM and G M Edwards A Légaré F R Using a model of shared decision making to an Educ Couns. M O’Neill E Dick S S perceptions of shared decision making in stable coronary artery Educ Couns. 2017; Scholar but implementation barriers at the clinician level are an important of the of M O’Neill E Sherman A et al.The learning curve for shared decision-making in symptomatic aortic stenosis.JAMA Cardiol. 2020; 5 (doi:10.1001/jamacardio.2019.5719.): 442-448Google Scholar support that tools are often in between patient and clinician than those used the Currently, there are three publicly available DAs for patients with decision making. Tools. Available at: https://sharedcardiology.org/tools/ Accessed April 8, 2020.Google Scholar These help physicians to support and engage with SDM. However, the that physicians use DAs to information and at patients, than improving how they work with N, Lloyd A, Edwards A, et al. Implementing shared decision making in the NHS: lessons from the MAGIC programme. BMJ. 2017;j1744. doi:10.1136/bmj.j1744.Google Scholar Given the rapid changes in the of HVD, further evolution of DAs is likely needed before In SDM is a to improve care for patients with Barriers for successful implementation by Heart yet opportunities as the culture to physicians supporting patient engagement in decision-making. Although we that study was and has it seems that the road toward effective implementation of SDM in Heart is by effectively physician attitudes toward SDM, improving SDM skills and implementing The have no to for this