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: 8708196
• 负责人: R. Adams Dudley
• 金额: $ 92.63万
• 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/8708196
• 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）：对于稳定型冠状动脉疾病（CAD）患者，经皮冠状动脉介入治疗（PCI）可能会改善症状，但仅在不常见和特定的临床情况下显示可降低死亡率。进行PCI涉及风险和不便，因此它代表了典型的“偏好敏感”情况，其中治疗决定应该与患者的价值观和偏好一致。 有证据表明，目前的做法没有达到这一理想。调查显示，患者经常错误地陈述PCI的益处和风险，有时认为它治愈了他们的CAD并消除了控制风险因素的需要。共同决策试验表明，一旦患者更好地理解了PCI的作用，他们选择PCI的频率比目前的做法低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不合适，38%的PCI不确定是否合适。 我们的长期目标是确定是什么原因导致这种护理差异，并确定使决策过程更加以患者为中心的方法。目前没有足够短的问卷用于常规使用，可以测量如何做出PCI决策-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，我们无法判断观察到的变化和不适当性是否是由患者对PCI的误解，医生在决策过程中教育和参与患者的方法的变化或其他原因引起的。一旦发现问题，修复将非常重要，原因有三。首先，只有当患者理解并愿意接受PCI时，他们才更有可能接受PCI。其次，由于美国每年在PCI上花费200亿美元，即使减少17%的使用也会节省数十亿美元，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他们在PCI后坚持风险因素修改的意愿，结果可能会改善。 在这个项目中，我们将开发第一个全面的，病人报告的CAD决策质量的措施，是可行的，在各种设置实施。我们将通过以下方式实现这一目标：1）使用患者和专家反馈，识别捕获决策质量的关键要素，并识别解决这些要素的候选问题（目标1）; 2）在不同患者群体中对初步工具进行试点测试，以评估测量属性，并选择候选问题的简化集合用于进一步测试（目标2）;（3）建立一种新的综合决策质量测量方法的信度和效度。这将为CAD患者提供一个多维度的决策质量工具，可用于常规护理。