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，但只有在不常见和特定的临床情况下才被证明可以降低死亡率。 PCI 既涉及风险又带来不便，因此它代表了一种典型的“偏好敏感”情况，其中治疗决策应与患者的价值观和偏好保持一致。 有证据表明，目前的做法并没有达到这一理想。调查显示，患者经常错误地描述 PCI 的益处和风险，有时认为它可以治愈 CAD，并且无需控制风险因素。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 PCI 的频率就会比当前实践减少约 17%。此外，计费数据显示 PCI 使用情况存在巨大的地区差异；其他研究发现，12% 的 PCI 是不适当的，38% 的 PCI 适当性不确定。 我们的长期目标是确定导致护理差异的原因，并找出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调查问卷可供常规使用，可以衡量 PCI 决策的制定方式，即患者对 PCI 的了解程度、参与程度以及偏好是什么。如果没有这样的调查问卷，我们就无法判断所观察到的差异和不适当行为是否是由于患者对 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或其他原因造成的。一旦发现问题，解决问题就非常重要，原因有以下三个。首先，只有患者理解并愿意接受 PCI，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 益处的短期性质的了解提高了他们在 PCI 后坚持改变危险因素的意愿，则结果可能会改善。 在这个项目中，我们将开发第一个全面的、患者报告的 CAD 决策质量衡量标准，该衡量标准可在各种环境中实施。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，确定捕获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 患者提供多维决策质量工具，并准备好实施到常规护理中。