Several weeks ago I had the pleasure of presenting our findings from a qualitative research study we conducted at the AGS 2018 annual meeting, investigating cardiologists’ perspectives and familiarity with shared decision-making (SDM) in older adults after hospitalization for acute myocardial infarction (AMI). SDM has emerged in the literature as a way to move towards patient-centered care and has significant potential to enhance patient adherence, reduce undesired treatments, and improve overall satisfaction with care. In our study, we sought to discover the degree to which practicing cardiologists understood SDM, and whether it was applicable to their practice with older adult patients – particularly in the setting of cardiac catheterization and percutaneous coronary intervention. Five major themes emerged from these interviews:
- Age alone is not a major contraindication to intervention.
Our respondents consistently stated that age would not deter them from sending a patient to cardiac catheterization. Instead, they generally brought up “what kind of 80,” distinguishing chronological and biological age. Further, cardiologists generally reported treating older adults similarly to how they would treat their younger counterparts.
- SDM is important in the setting of NSTEMI, and not practical in STEMI:
Respondents felt that SDM was useful among patients hospitalized for NSTEMI (who represent the largest proportion of older adults with AMI). Conversely, due to the acuity of STEMI (with system-wide pressures on prompt reperfusion therapy), there was near-universal agreement that SDM was not practical in this setting.
- Dementia and functional status emerged as the major contraindications to intervention:
While age was not itself a major contraindication to intervention, age-related impairments such as dementia and functional status were consistently noted as reasons cardiologists would adopt a more conservative approach to care.
- There was some variation in cardiologists’ interpretation of SDM:
While most cardiologists saw SDM as a move away from paternalism towards patient-centered care, there was some variation in what the meaning of “shared” was among our respondents. While some respondents felt it was shared between the cardiologist and her patient, others thought it was between the patient and family members, and still others thought it was between the provider and her colleagues.
- A personalized (and geriatric-informed) risk calculator may help to facilitate SDM in this population for cardiologists:
Cardiologists continually highlighted the paucity of data to guide their care in the older adult population, and emphasized that a risk calculator tailored to these patients would allow them to give more specific and personalized information in order to promote SDM with accurate calculations of risk and benefit.
Our findings have several implications. The take-home message was that cardiologists generally accepted SDM as an optimal model of care, particularly in settings where the risk/benefit ratio was uncertain, but experienced some challenges with accurate prognostication. Future efforts at personalized risk calculators, tailored to older patients’ phenotypes, may help to promote SDM in practice.
By: Eleonore Grant, BA
Eleonore Grant was an Associate Research Coordinator at NYU Langone Health and coordinated studies on shared decision-making. She will be matriculating at medical school this Fall.