Exploring Patient Involvement in Decision Making for Vascular Procedures

Abstract

Initiatives to develop patient-centered approaches to health care are a priority that may have profound effects on health care, particularly within value-based purchasing and risk-sharing models. Patient-centered care requires more direct engagement of patients in their own care, including treatment decisions. Patient participation in treatment selection for vascular procedures has not been characterized, and the potential effects of greater patient involvement are unknown. We conducted a prospective study among patients undergoing vascular procedures to identify important sources of information and characterize experienced vs desired decision-making roles. Patients undergoing elective vascular procedures were identified from an outpatient clinic and vascular laboratory. An instrument consisting of multiple choice and open-ended response items related to patients' roles in decision making, sources of information, and perceived treatment success was administered. Diagnostic, demographic, and educational data were collected. Descriptive statistics are presented as count (%) for categoric variables or mean ± standard deviation for continuous variables. Categoric responses are presented as median (interquartile range) based on a 1-5 ordinal scale. The participants were 74 patients undergoing intervention for abdominal aortic aneurysm (n = 20), hemodialysis access (n = 14), carotid stenosis (n = 20), and peripheral arterial disease (n = 20). Mean age was 68.8 ± 12.4 years, 43% were women, and 26% were African American. Highest educational level was college or graduate school for 35% of participants, 61% had computer access, and 41% regularly used e-mail. Participants identified providers as the most important information sources (1 [1, 1] for doctors and 2 [1, 3] for nurse practitioners, where 1 = “very important” and 5 = “not important”), whereas family and friends, written materials, and other patients were less important (3 [1, 5], 3 [2, 4], and 3 [2, 5], respectively), and television/video and internet resources were least important (4.5 [3, 5] and 5 [3, 5], respectively). Although participants had high levels of confidence in provider recommendations (1 [1, 1] for all procedure categories, where 1= “very satisfied” and 5 = “not satisfied”), they had a strong preference to discuss all potential treatment options (1 [1, 1], where 1 = “strongly agree” and 5 = “strongly disagree”) and to choose their treatment together with their doctor (1 [1, 2]) as opposed to only discussing the recommended treatment (2 [1, 3]) or delegating selection to the doctor alone (2 [1, 3]). Patients undergoing hemodialysis access and abdominal aortic aneurysm procedures most often reported discussion of more than one option (1.5 [1, 3] and 1.5 [1, 5], respectively), whereas discussion of multiple options was less common for peripheral arterial disease (2 [1, 3.5]) and carotid stenosis (3 [1, 5]). Thirty-seven participants (50%) considered their first treatment successful, 27 (36.5%) considered another subsequent treatment successful, and 10 (13.5%) considered none successful. Patients experience varying participation levels in decision making for vascular procedures and often believe that their treatments are unsuccessful. Although patients consider providers an important source of information and have confidence in their recommendations, they prefer to discuss all treatment options being considered. Patients also prefer shared decision making over complete delegation to the provider. Increasing patient involvement in treatment decisions has potential to improve patient satisfaction but may require tools to facilitate more active participation. Potential impacts on other outcomes remains to be determined.