Establishing Shared Decision Making Among Vulnerable Patients Referred for Cardiac Surgery, a Maritime-Wide Initiative

Anticipated Findings

This work could change decision making approaches around cardiac surgery throughout Maritime Canada (approximately 1,800 procedures per annum) and result in a likely downturn in uptake of interventions among older adults living with frailty  (anticipated  about  15%).  Furthermore,  these  results  will  have  the  potential  of  informing decision making practices among all older patients facing choices about surgical interventions where there is significant equipoise.

About the Project

Current approaches to decision making fail to inform patients of risks or to prompt patients to express their preferences. Adequately informed of risks to independence,  different  patients  with  different  personal  situations  and  values, may make very different choices about going forward with valve replacement. This is not a possibility with present approaches to informed consent, which would be based on an assumption that surgery will be chosen.

Patients referred for cardiac surgery are increasingly older and live with frailty. We have shown that a degree of frailty is common (40%) among patients over 65 referred for cardiac surgery, and we have also shown that patients living with frailty are at increased risk after cardiac surgery including further or complete loss of independence, reduction in quality of life and increased rates of death. It is very important to communicate risk and include patient preferences (a process known as shared decision making or SDM) when surgeon and patient come together to make a decision about whether to go forward. This is not what usually happens, and many patients opt for surgery without a clear understanding of what is at stake. We have pioneered an approach to SDM for these patients, using decision aids customized for each patient that effectively communicate the risks of surgery and help engage the patient. While we have shown that our approach is effective at improving the understanding of risk, there has been little uptake in the clinical environment where decisions are made. The work in this grant will study both the barriers to and facilitators of SDM routinely going forward.

Click here to read more about the project and its impact.

Project Team

Principal Investigators:

Greg Hirsch, MD – Nova Scotia Health Authority

Ansar Hassan, MD – Dalhousie University

Co-Investigators:

Marcy Braithwaite, PhD – Nova Scotia Health Authority

Jeanine Doucette, BSc – Saint John Regional Hospital

Ryan Gainer, BA – Nova Scotia Health Authority

Debbie Hutching, BSc – Nova Scotia Health Authority

Jean-François Légaré, MD – Saint John Regional Hospital

Paige Moorhouse, MD – Nova Scotia Health Authority

Robin Urquhart, PhD – Dalhousie University

Project Contact: Dr. Greg Hirsch – greg.hirsch@nshealth.ca

Key words: frailty; shared decision making; cardiac surgery; outcomes research; decision aids; knowledge translation; implementation science; consolidated framework for implementation research

Hypothesis

Our hypotheses are:

  1. The current state of decision making around cardiac surgery in Maritime Canada, among older patients, is deficient in comprehension, and does not allow for the effective expression of patient preferences.
  2. A formalized SDM approach, informed by focus groups among HCPs and patients/families, will improve decisional quality and significantly increase decisional quality and the informed expression of patient preferences.
  3. A rigorous implementation science approach informed by CFIR will identify barriers and facilitators that will make the routine practice of SDM in these patients achievable.
Objectives

The goals of this study include:

  1. Identification of the information required by patients to make a truly informed choice about surgery (focus groups with patients, families, health care providers (HCPs).
  2. Demonstration of the efficacy of the current standard of decision making in Maritime Canada around cardiac surgery options. This will provide a clear picture of both decisional quality as well as the degree to which patients and their families actively participate in understanding their choices and put forward their preferences.
  3. Demonstration of the efficacy of a formalized SDM intervention that consists of the following: formal SDM training for HCP’s; creation and distribution of individualized decision aids that contain activation prompts, describe procedures and  alternatives, and communicate relevant  risks  through  dot  plot  displays; provision of a decisional coach to engage the decision aid and the health care team.
  4. Determination of the barriers and facilitators to routine embedding of formal SDM approaches in older cardiac surgery patients. The utilization of a qualitative approach rooted in CFIR will ensure a comprehensive and organized approach to objective 4.
Research Plan

This study will provide a comprehensive implementation science assessment of establishing effective shared decision making (SDM) among older patients referred for consideration of cardiac surgery intervention, rooted in The Consolidated Framework of Implementation Research (CFIR). We will study the barriers and facilitators of implementing shared decision making among older patients living with frailty facing decisions about cardiac surgery. Data from initial focus group work with patients and health care providers will be used to select, design, and/or tailor implementation strategies for the shared decision-making intervention.

In a pre-post study design, participants in Phase I will undergo decision making around surgery as currently practiced to provide baseline measures. In Phase II, patients will be required to engage in a shared decision making process, including interacting with an individualized decision  aid, and a decisional coach. A subset of patients, who will be separately consented, will have their decision making process audio or audio and video recorded.