A FORMALIZED SHARED DECISION MAKING PROCESS WITH INDIVIDUALIZED DECISION AIDS IMPROVES COMPREHENSION AND DECISIONAL QUALITY AMONG FRAIL, ELDERLY CARDIAC SURGERY PATIENTS

Purpose: Comprehension of risks, benefits, and alternative treatment options is poor among patients referred for cardiac interventions. We have demonstrated that an increasing proportion of frail and elderly patients are undergoing complex cardiac surgical procedures with increased risk of both mortality and prolonged institutional care.  The objective of the current study is to explore the impact of a formalized shared decision making on patient comprehension and decisional quality.

Method(s): A paper-based decision aid for cardiac surgery was developed and evaluated within the context of a pre-post study design.  Surgeons were trained in shared decision making through a web based programme. Research team members acted as decisional coaches, going through the decision aids with the patients and their families, and remaining available for consultation. Patients (65 and over) undergoing isolated valve, Coronary Artery Bypass Graft (CABG) or CABG+Valve surgery were eligible.  Participants in the pre-intervention phase (n=100) were followed through the standard course of care to establish a baseline.  Participants in the interventional group (n=100) were presented with a decision aid following cardiac catheterization populated with individualized risk assessment, personal profile, and co-morbidity status. Surgeon training in shared decision making occurred just prior to instituting the post intervention phase. Decisional coaching only applied to the post intervention phase.  Both groups were assessed pre-operatively on comprehension (Maritime Heart Center Comprehension Scale), decisional conflict (Decisional Conflict Scale), decisional quality (9-item Shared Decision Making Questionnaire), anxiety and depression (Hospital Anxiety and Depression Scale), Primary outcomes were comprehension and decisional quality scores.

Result(s): Patients who received decision aids through a formalized shared decision making approach scored higher in comprehension (median: 15.0; IQR: 12.0-18.0) compared to those who did not (median: 9.0; IQR: 7.0-12.0) (p < 0.001). Decisional quality was greater in the interventional group (median: 80.0; IQR: 73.0-91.0) compared to those in the pre-intervention group (median: 75.0; IQR: 62.0-82.0) (p<0.05). Anxiety and depression scores showed no significant difference between pre-intervention (median: 9.0; IQR: 4.0-12.0) and post-intervention groups (median: 7.0; IQR: 5.0-11.0) (p<0.28).

Conclusion(s): Institution of a formalized shared decision making process including individualized decision aids improve comprehension of risks, benefits and alternatives to cardiac surgery, decisional quality, and did not result in increased levels of anxiety.