A shared decision-making program between caregivers and patients with end-stage heart failure regarding the implantation of a destination therapy left ventricular assist device (DT LVAD) was associated with noticeable improvement in patient knowledge and a lower rate of LVAD implantation compared with patients who did not participate in a shared decision-making intervention, according to findings from a randomized trial published in JAMA Internal Medicine.
Investigators enrolled patient and caregiver dyads from 6 mechanical circulatory support programs in the United States in the Decision Support Intervention for Patient and Caregivers Offered DT LVAD trial (DECIDE-LVAD; ClinicalTrials.gov Identifier: NCT02344576). A total of 248 patients who were eligible and being considered for a DT LVAD were included in the analysis. The investigators randomly assigned patients to undergo a shared decision-making intervention (n=113) or a control intervention (n=135).
For the intervention, investigators provided clinician education as well as a DT LVAD education pamphlet and video decision aids for patients. Decision quality, or the extent to which medical decision making is representative of a well-informed patient preference, comprised the primary outcome. The investigators used a 10-item knowledge test to assess patients’ treatment knowledge at 1- and 6-month follow-up.
At 1 month following intervention, a greater proportion of patients in the intervention arm demonstrated improved patient knowledge from baseline during the decision-making period vs those in the control group (59.1% to 70.0% vs 59.5% to 64.9%, respectively; adjusted difference of difference, 5.5%; P =.03). More patients in the intervention group were likely to favor a less aggressive treatment option for improving survival than those in the control group, as assessed by values on the 10-tier Likert scale (scale 1 = do everything I can to live longer to 10 =live with whatever time I have left; mean 2.37 vs 3.33, respectively; P =.03). Comparatively, patients in the control arm were more likely to favor LVAD implantation than those receiving patient education (95 [92.2%] vs 47 [61.0%]; P <.001).
By 6-month follow-up, patients in the control group had a higher adjusted rate of LVAD implantation than those undergoing intervention (79.9% vs 53.9%, respectively; P =.008).
Missing data, particularly because of mortality or study withdrawal, was somewhat common in individuals who did not receive DT LVAD, which may have limited the findings. In addition, the study population consisted of predominantly white men, which prevented the generalizability of the findings to women and patients of other races.
Overall, the findings from this study “suggest that institutional culture and processes can influence medical decisions in life-threatening illness.”
Allen LA, McIlvennan CK, Thompson JS, et al. Effectiveness of an intervention supporting shared decision making for destination therapy left ventricular assist device: the DECIDE-LVAD randomized clinical trial [published online February 26, 2018]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.8713