Decisional Quality for Patients with Stable Coronary Artery Disease

稳定性冠状动脉疾病患者的决策质量

• 批准号: 8506046
• 负责人: R. Adams Dudley
• 金额: $ 69.78万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-08-01 至 2017-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8506046
• 关键词: Address; Automobile Driving; Benefits and Risks; Caring; Clinical; Coronary Arteriosclerosis; Decision Aid; Decision Making; Development; Discrimination; Elements; Feedback; Future; Generations; Goals; Healthcare Systems; Individual; Intervention; Knowledge; Life; Longevity; Measurement; Measures; Medical; Modification; Nature; Outcome; Patient Education; Patient Preferences; Patients; Patterns of Care; Physicians; Probability; Process; Property; Psychometrics; Questionnaires; Reporting; Risk; Risk Factors; Role; Savings; Surveys; Symptoms; Testing; Time; Validation; Validity and Reliability; Variant; Work; base; billing data; compliance behavior; cost; effective intervention; improved; instrument; mortality; patient oriented; patient population; percutaneous coronary intervention; preference; routine care; routine practice; shared decision making; time interval; tool; treatment as usual; willingness

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.

描述（由申请人提供）：对于稳定的冠状动脉疾病（CAD）的患者，经皮冠状动脉干预（PCI）可能会改善症状，但只有在罕见的和特定的临床情况下才显示出降低死亡率。拥有PCI既涉及风险和不便，因此代表了经典的“偏好敏感”情况，其中应将治疗决策与患者的价值观和偏好保持一致。 有证据表明，当前的实践并不能辜负这一理想。调查表明，患者经常失去PCI的益处和风险，有时认为这可以治愈他们的CAD并消除控制危险因素的需求。共同的决策试验表明，一旦患者了解PCI的作用，他们就会选择比当前实践少的17％。此外，计费数据显示PCI使用的区域差异很大。其他研究发现，12％的PCI不适当，而38％的PCI不确定。 我们的长期目标是确定是什么原因导致这种护理差异，并确定使决策过程以患者为中心的方式。目前，没有足够短的调查表可以衡量PCI决策的制定方式 - 即，对PCI的知识渊博，他们的参与程度以及他们的偏好是什么。没有这样的问卷，我们无法分辨观察到的差异和不适当性是由患者对PCI的误解所驱动的，这是由于医生在决策过程中教育和参与患者的方法的差异，还是其他方法。一旦确定了问题，该修复程序将非常重要，原因有三个。首先，只有在理解和想要的情况下，患者更有可能获得PCI。其次，由于美国每年在PCI上花费200亿美元，即使使用17％的使用也可以节省数十亿美元而不会增加死亡率。第三，如果患者对PCI益处的短期性质的理解提高了对PCI后遵守风险因素修改的意愿，则结果可能会有所改善。 在这个项目中，我们将开发第一个全面的，患者报告的CAD决策质量的度量，在各种环境中实施是可行的。我们将通过：1）使用患者和专家反馈（AIM 1）来确定捕获决策质量并确定候选问题以解决这些要素的关键要素； 2）在多样化的患者人群中测试初步工具以评估测量特性并选择减少的候选问题以进行进一步测试（AIM 2）； 3）建立了单次检查和重复考试的新综合决策质量度量的可靠性和有效性（AIM 3）。这将为CAD患者提供多维决策质量仪器，并准备在常规护理中实施。