Patient Preference Less Important than Mortality Benefit in ICD Decision-making

Tuesday, June 12, 2012

Physicians rate patient preferences lower than mortality benefit in the decision to place implantable cardioverter-defibrillators (ICDs), show results of a web-based survey of physicians.

“Despite the increasing focus on shared decision making and patient-centered care, over half of the respondents in this survey rated patient preferences lower than expected mortality benefits,” say the study authors.

Furthermore, “a considerable minority indicated that patient preference mattered ‘very little’ or ‘not at all’ in decision making around primary prevention ICD therapy.”

Writing in the Archives of Internal Medicine, the researchers explain that ICDs have been shown to reduce mortality in certain patients with symptomatic heart failure and no history of sudden cardiac death (SCD). This has led to guidelines recommending placement of an ICD for primary SCD prevention in patients with heart failure meeting specific criteria.

However, ICDs have also been associated with several important risks, such as short-term procedural complications and increased hospitalization. Therefore, patient preferences around ICD therapy tend to vary.

The team, led by Daniel Matlock from the University of Colorado in Aurora, US, investigated how physicians weigh patient preferences and the evidence of mortality benefit in their decision to recommend an ICD for primary prevention to potentially eligible patients.

A web-based survey was sent to a random sample of nearly 10,000 physicians, of which 1,210 (12 %) responded. The survey asked to what extent mortality benefits, patient preferences, and 12 other factors affect a physician’s recommendations regarding an ICD for primary prevention of sudden cardiac death.

Responses were scored on a 5-point scale from ‘not at all’ (scored 0) to ‘a great deal’ (scored 4).

Overall, mortality benefit data mattered ‘a great deal’ for 962 (85.9 %) respondents. By contrast, fewer than half of the respondents (n=423 [37.7 %]) thought that patient preferences mattered ‘a great deal’.

None of the respondents reported that mortality mattered ‘very little’ or ‘not at all’, whereas 138 (12.3 %) said patient preferences mattered to this extent.

Furthermore, mortality benefit data were given a higher importance rating than patient preferences by 628 (56 %) of the respondents.

“Although this cross-sectional survey cannot determine cause and effect, it may be that the more convinced a physician is of the benefits of an intervention, the less important patient preferences become in decision making,” concludes the team.

By Nikki Withers