Decisional Quality for Patients with Stable Coronary Artery Disease

描述（由申请人提供）：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）可以改善症状，但只有在罕见和特定的临床情况下才显示出它可以降低死亡率。接受PCI既有风险又不方便，因此它代表了典型的“偏好敏感”情况，在这种情况下，治疗决策应与患者的价值观和偏好保持一致。有证据表明，目前的做法没有达到这一理想。调查显示，患者经常误解PCI的益处和风险，有时认为它可以治愈他们的CAD并消除控制风险因素的需要。共同决策试验表明，一旦患者更好地了解PCI的作用，他们选择它的几率比目前的实践低17%。此外，账单数据显示PCI使用的地区差异很大；其他研究发现，12%的pci不合适，38%的pci不确定合适。我们的长期目标是确定导致这种护理差异的原因，并确定使决策过程更加以患者为中心的方法。目前还没有足够短的问卷用于常规使用，可以衡量如何做出PCI决定-即，患者对PCI的了解程度，他们的参与程度以及他们的偏好。如果没有这样的调查问卷，我们无法判断所观察到的差异和不适宜性是由患者对PCI的误解、医生在决策过程中教育和让患者参与的方法的差异还是其他原因引起的。一旦确定了问题，修复将非常重要，原因有三。首先，只有当患者理解并想要PCI时，他们才更有可能接受PCI。其次，由于美国每年花费200亿美元用于PCI，即使减少17%的使用也会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PCI短期获益的理解提高了他们在PCI后坚持修改危险因素的意愿，结果可能会改善。在这个项目中，我们将开发第一个全面的、患者报告的CAD决策质量测量方法，该方法在各种环境中都是可行的。我们将通过以下方式实现这一目标：1)利用患者和专家的反馈，确定捕捉决策质量的关键要素，并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对初步仪器进行试点测试，以评估测量特性，并选择一组减少的候选问题进行进一步测试（目标2）；3)为单次和重复检查建立新的综合决策质量测量的信度和效度（目标3）。这将为CAD患者提供一个多维决策质量工具，并将其应用于日常护理。

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.