BACKGROUND

Patients undergoing percutaneous coronary intervention (PCI) may receive drug-eluting stents (DES) or bare-metal stents (BMS). DES reduce the risk of a repeat procedure but necessitate prolonged use of dual antiplatelet therapy (DAPT), which can increase the risk of bleeding, delay elective surgeries, and increase medication costs. Because these trade-offs directly impact patients' experience and outcomes, patients should be engaged in the decision-making process. However, less than a third of patients discuss stent choices with their doctors.

OBJECTIVES

To create and implement a shared decision-making (SDM) tool for stent choice that incorporates individualized estimates of each patient's likely reduction in repeat procedures from DES and describes the drawbacks of prolonged DAPT, and to study the impact of the SDM tool on patient education, stent preference, participation in SDM, and, secondarily, physicians' use of DES or BMS.

METHODS

To create the SDM tool, we interviewed patients and providers to identify the information perceived to be most important in stent selection. We implemented the tool in a nonrandomized, sequential fashion at 2 US hospitals. In the preimplementation phase, we did not use the SDM tool; we interviewed patients to determine their knowledge of stent types, benefits and drawbacks of DES and BMS, and their stent preference. In the 2 sequential postimplementation phases, all patients received the paper SDM tool before their procedures, with or without decision coaching from a trained nurse.

RESULTS

We assessed experiences with stent selection in 336 patients receiving “usual care” without the SDM tool, 113 receiving the SDM tool with coaching and 137 receiving the tool without coaching. In fully adjusted analyses, the SDM tool with coaching group, as compared with usual care, resulted in 1.8 (95% CI, 1.5-2.1) out of 6 more correct responses to questions about BMS and DES. For patients receiving the SDM tool with coaching, the rate ratio (RR) for discussing stent options with nurses was 3.7 (95% CI, 2.8-4.7) and for discussing with doctors was 1.5 (95% CI, 1.26-1.79). Patients receiving the tool with coaching were more likely to state a stent preference (relative risk [RR], 1.9; 95% CI, 1.6-2.3), to report being involved in the decision (RR, 2.87; 95% CI, 1.8-4.5), and to correctly recall the stent that they received (RR, 1.5; 95% CI, 1.1-1.8). No clinically significant differences were observed between use of the SDM tool without coaching and usual care. No differences in physicians' use of DES and BMS were observed after implementation of the SDM tool, and less than 50% of patients who preferred BMS actually received one.

CONCLUSIONS

Implementation of an SDM tool for stent selection, accompanied by decision coaching, was associated with improvements in patient education, participation in SDM, and patient satisfaction, but it resulted in no change in the type of stent used. Use of the SDM tool without decision coaching had no impact on patient education, participation in SDM, or stent selection.

LIMITATIONS AND SUBPOPULATION CONSIDERATIONS

The intervention was designed to be sustainable in routine clinical care. However, the lack of hospital nursing staff to perform decision coaching, despite available funding, was the most significant limitation. To achieve the benefits of SDM with decision coaching, novel incentives will need to be created to enable hospitals to invest resources necessary to support decision coaching.