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A majority of patients with acute myocardial infarction said they preferred to actively participate in decision making about their care, a study reported.
Of 6,636 patients in the study, more than two-thirds indicated they would welcome shared decision making, but one-quarter of them want to make the decision alone, according to Harlan M. Krumholz, MD, SM, from Yale University School of Medicine, and colleagues.
In addition, a majority of patients (60%) indicated that the physician and patient should have equal participation, while 15% suggested the patient should dominate the decision, Krumholz and colleagues wrote in a research letter published in the May 27 issue of JAMA Internal Medicine.
"Despite numerous calls for greater participation by patients in the medical decision-making process, shared decision making is not yet integrated into routine medical care, perhaps because of a perception that patients wish to defer to their physicians," they wrote.
However, there still is a substantial number of patients who do not want to share the decision.
"Our challenge now is to develop systems that fully respect these preferences and ensure that patients who prefer an active role are given that opportunity," they concluded.
Combining data from the TRIUMPH and PREMIER registries, Krumholz and colleagues asked patients: "Given the information about risks and benefits of the possible treatments, who should decide which treatment option should be selected?"
A total of 97% of 4,340 patients responded from TRIUMPH and 97% of 2,498 responded from PREMIER.
Seven variables showed a significant and independent association on multivariate analysis with preference for active decision making:
- Female gender
- White race
- Higher education
- Heart failure
- Lower Global Registry of Acute Coronary Events risk score
- Absence of percutaneous coronary intervention during hospital stay
In univariate analysis, younger age was significantly associated with wanting an active participation in decisions. And even within the four age subgroups, there was a significant majority in each one for active participation.
The momentum for shared decision making has been building and some say that a tipping point has been reached. However, research methods about shared decision making "vary enormously," wrote Mack Lipkin, MD, of New York University School of Medicine in New York City, in an accompanying commentary that also addressed other shared decision-themed studies in the current issue of JAMA Internal Medicine.
The variety of study methods, coupled with the inherent limitations of patient recall, leaves open the question: what is being accurately assessed?
- Is recall a halo of liking or disliking the physician?
- Is it dependent on care outcomes?
- Is it a matter of how and when the patient is asked?
- Is it some other set of states or traits related to the person and not the survey or questions themselves?
"None of these plausible options are presently adequately understood," Lipkin said.
He called for a series of prospective studies, "starting with taped interviews, to validate current notions of what embodies shared decision making, to establish how framing and contextual features alter recollections, and to relate accurately and validly measured strong and weak shared decision making to the evolution of recalled views about the decisional process."
A limitation of this study was the potential failure to capture the full scope of patient preferences.
From the American Heart Association:
- Cardiovascular Health: The Importance of Measuring Patient-Reported Health Status
- Decision Making in Advanced Heart Failure
The study was funded in part by CV Outcomes.
Krumholz reported receiving a research grant, through Yale University, from Medtronic. Co-authors reported relationships with Lilly, Genentech, EvaHeart, Amgen, St Jude Medical, Health Outcomes Sciences, and copyright ownership to the Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, and Peripheral Artery Questionnaire.
Lipkin reported no conflicts of interest.
- Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
JAMA Internal MedicineSource Reference: Krumholz H, et al "Decision-making preferences among patients with an acute myocardial infarction" JAMA Int Med 2013.
JAMA Internal MedicineSource Reference: Lipkin M, et al "Shared decision making" JAMA Int Med 2013; DOI: 10.1001 /jamainternmed.2013.6248.