Decisional Quality for Patients with Stable Coronary Artery Disease

描述(申请人提供)：对于稳定性冠状动脉疾病(CAD)患者，经皮冠状动脉介入治疗(PCI)可能会改善症状，但只有在罕见和特定的临床情况下，它才被证明能降低死亡率。接受经皮冠状动脉介入治疗既有风险又有不便，因此它代表了一种典型的“偏好敏感”情况，在这种情况下，治疗决定应该与患者的价值观和偏好保持一致。有证据表明，目前的做法并不符合这一理想。调查显示，患者经常错误地陈述经皮冠状动脉介入治疗的好处和风险，有时认为它可以治愈他们的冠心病，消除控制风险因素的需要。共同的决策试验表明，一旦患者更好地理解了经皮冠状动脉介入治疗的作用，他们选择它的频率比目前的做法低约17%。此外，账单数据显示，PCI的使用存在巨大的地区差异；其他研究发现，12%的PCI是不合适的，38%的PCI不确定是否合适。我们的长期目标是确定是什么导致了护理上的这种差异，并确定了使决策过程更加以患者为中心的方法。目前还没有一份足够短的问卷可以衡量患者是如何做出经皮冠状动脉介入治疗决定的--即，患者对经皮冠状动脉介入治疗的了解程度，他们的参与程度，以及他们的偏好。如果没有这样的问卷，我们无法判断观察到的差异和不恰当是由患者对冠状动脉介入治疗的误解、医生在教育和让患者参与决策过程中的方法的差异，还是其他原因造成的。一旦确定了问题，修复将非常重要，原因有三。首先，患者只有在理解并想要的情况下才更有可能接受冠状动脉介入治疗。其次，由于美国每年在经皮冠状动脉介入治疗上花费200亿美元，即使减少17%的使用也能在不增加死亡率的情况下节省数十亿美元。第三，如果患者对经皮冠状动脉介入治疗的短期益处的理解提高了他们在经皮冠状动脉介入治疗后坚持危险因素调整的意愿，结果可能会有所改善。在这个项目中，我们将为CAD开发第一个全面的、由患者报告的决策质量衡量标准，该衡量标准可以在各种环境下实施。我们将通过以下方式实现这一点：1)确定捕捉决策质量的关键要素，并使用患者和专家反馈确定解决这些要素的候选问题(目标1)；2)在不同的患者群体中试行一种初步工具，以评估测量属性并选择一组减少的候选问题进行进一步测试(目标2)；以及3)为单次和重复检查建立新的综合决策质量衡量标准的可靠性和有效性(目标3)。这将为冠心病患者带来一个多维的决策质量工具，并将准备好实施到常规护理中。

DESCRIPTION (provided by applicant): For patients with stable coronary artery disease (CAD), percutaneous coronary intervention (PCI) may improve symptoms, but only in uncommon and specific clinical scenarios has it been shown to reduce mortality. Having PCI involves both risk and inconvenience, and thus it represents a classic "preference- sensitive" situation, in which treatment decisions should be aligned with the patient's values and preferences. There is evidence that current practice does not live up to this ideal. Surveys show that patients often misstate the benefits and risks of PCI and sometimes believe it cures their CAD and eliminates the need to control risk factors. Shared decision-making trials show that, once patients understand the role of PCI better, they choose it about 17% less often than in current practice. Furthermore, billing data show vast regional variation in PCI use; other studies have found that 12% of PCIs are inappropriate and 38% are of uncertain appropriateness. Our long-term goal is to determine what causes such variation in care and identify ways of making the decision-making process more patient-centered. There is currently is no questionnaire short enough for routine use that can measure how PCI decisions are made - i.e., how knowledgeable patients are about PCI, how involved they are they, and what their preferences are. Without such a questionnaire, we cannot tell whether the observed variation and inappropriateness are driven by patient misunderstanding of PCI, by variation in physicians' approaches to educating and involving patients during decision-making, or something else. Once the problem is identified, the fix will be very important for three reasons. First, patients wll be more likely to get PCI only if they understand and want it. Second, since the US spends $20 billion per year on PCI, even a 17% reduction in its use would save billions without increasing mortality. Third, if patients' understanding of the short-term nature of PCI benefits improves thei willingness to adhere to risk factor modification after PCI, outcomes could improve. In this project we will develop the first comprehensive, patient-reported measure of decisional quality for CAD that is feasible to implement in a variety of settings. We will accomplish this by: 1) Identifying the key elements to capture decisional quality and identifying candidate questions to address these elements, using patient and expert feedback (Aim 1); 2) Pilot testing a preliminary instrument in a diverse patient population to assess measurement properties and select a reduced set of candidate questions for further testing (Aim 2); and 3) Establish the reliability and validity of a new comprehensive decisional quality measure for single and repeated examinations (Aim 3). This will result in a multidimensional decisional quality instrument for patients with CAD that will be ready for implementation into routine care.