Implementing Shared Decision Making in the Rapidly Evolving Field of Valvular Heart Disease.

Abstract

In shared decision making (SDM), healthcare providers engage patients in selecting the best treatment for their clinical and personal circumstances. SDM is an interactive process that combines the latest evidence with clinicians’ and patients’ relevant expertise (eg, how the disease is impacting their life, their goals, and preferences).1,2 Patient decision aids (PtDAs) are evidence-based tools designed to support SDM. More than 100 randomized controlled trials of PtDAs have demonstrated their efficacy in increasing patients’ knowledge, confidence in decision-making, and clarifying goals of treatment.3 See Article by Korteland et al The study by Korteland et al4 in this issue of Circulation: Cardiovascular Quality and Outcomes is the first published randomized controlled trial of a PtDA for valvular heart disease. The PtDA addresses the choice of prosthetic valve (mechanical versus bioprosthetic) for patients who have decided to have elective surgical aortic or mitral valve replacement. The major benefit of mechanical prosthetic valves is increased durability and reduced need for reoperation, whereas the major benefit of bioprosthetic valves is the avoidance of the need for permanent anticoagulation. Earlier work by this group had uncovered gaps in patients’ understanding of these issues and evidence that patients were not involved in decision-making as much as they would like to be.5 Korteland et al6 also found that Dutch cardiothoracic surgeons were more willing to involve patients in selection of valve type compared with Dutch cardiologists. Further, Dutch surgeons tended to prefer bioprosthetic valves, whereas cardiologists preferred mechanical.6 In short, patients may not be well informed or engaged in decisions about the selection of the type of valve, and PtDAs may be needed to help clinicians involve patients in an unbiased manner. Although Korteland’s multicenter randomized controlled trial did not find any difference between groups in the primary outcome …