IMPLEMENTATION OF DECISION AIDS FOR IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS: LESSONS LEARNED AND PATIENT PERSPECTIVES

Purpose:

   Evaluate the implementation process and explore patient perspectives regarding the acceptability and usability of four decision aids (DAs) to support decision making for Implantable Cardioverter Defibrillators (ICDs).

 Method:

   Heart failure patients eligible for an ICD for primary prevention at three sites in the Denver metropolitan area were randomly assigned to intervention or control in a 2:1 ratio.  Intervention patients received four decision aids: a one-page option grid; a four-page in-depth decision aid; a 17-minute video; and an interactive website. Controls received usual decision makingas provided by the clinic.  We conducted semi-structured qualitative telephone interviews with patients one month after the electrophysiology (EP) visit and three months after enrollment.  Interviews addressed acceptability and usability of the decision aids and data were analyzed for themes related to decision influence.

 Result:

   Across the three sites, six patients were randomized to the control arm and 15 to the intervention arm. Most patients preferred the infographic and video decision aids over the option grid and website.  At least half of the intervention patients reviewed the tools prior to meeting with their EP; many reviewed with a family member. “I've used that to explain what's going on and why I made that decision, to my family.” A minority brought the tools with them to the EP appointment yet patients found tools stimulated additional questions to pose to the EP, “[It] guided me in the right direction…I had enough information to ask intelligent questions.” Suggested improvements included providing just one or two tools to avoid repetition among information and to promote patients’ independent use of the DAs.  The timing of delivery of the DAs was acceptable.  Patients identified the volume of accompanying research-related paperwork  as overwhelming and therefore sometimes ignored. Access to a nurse during the decision window encouraged patient questions and improved patient perceived confidence.

 Conclusion:

  Patients determined for themselves how they used the decision aids to augment the decision context (e.g., to prompt more questions for the EP, to explain their decision to family, to confirm or re-confirm the decision already made, or to revisit post-decision.) Further exploration of this larger context of DA use as well as strategies to promote independent use related to EP visit are needed.