Stephen Lord describes for SIIC his article published in Patient Education and Counseling 87(1):49-53, April 2012

Newcastle Upon Tyne, Reino Unido (special for SIIC)
Making complex decisions is difficult at the best of times. Patients with cardiac electrophysiological disease are faced with a variety of different treatments each with their own list of risks and benefits. The success rates of different treatment strategies do not even approach 100% and some risks can be significant. Take atrial fibrillation (AF) as an example. Patients contemplating AF ablation must balance a high chance (say 80%) of improvement in symptoms against a small but significant risk of serious complication, including stroke. Neither the patient nor the doctor can predict the future and both are taking a risk. The long term outlook after AF ablation remains unknown

It can be argued that in these situations the doctor can take decisions in a patient’s best interests, acting as an expert. Some patients expect this approach, but it is not suitable for all. There is good evidence that an approach which takes into account the expertise of both parties in a consultation leads to better outcomes, more likely to be owned by the patient, even where the subsequent clinical outcome is not perfect. In this approach, both the patient and the doctor share the decision and both are experts. Evidence of good quality shared decision making is increasingly searched for by healthcare commissioners.

Much work has been done to evaluate the quality of shared decision making in clinical practice. We chose to use a tool developed in general practice, but since validated across a range of clinical areas. The OPTION scale divides the consultation into 12 domains. Important domains include the explanation that there are a number of treatment options each with their own pros and cons, that doing nothing is an option with its own pros and cons. The patient’s understanding of the explanation, their preferred mode of receiving information and the preferred level of involvement in the process should be elicited. Opportunities for clarification should be given, and the option of deferment offered.

We wanted to know the quality (or otherwise) of our consultations, and so we recruited and trained an independent observer in the use of the OPTION scale. Consultations were observed, audiotaped and subsequently analysed according to a standard protocol. We observed 49 consecutive consultations with one of two trained electrophysiologists in a tertiary referral clinic. Patients had been referred by another cardiologist for an invasive procedure –for instance ablation of tachycardia– or for device implantation, usually an ICD or biventricular pacemaker.

In each case there was a genuine choice between an invasive option and continuing with the present treatment. We wondered whether consultation quality affected this decision.

Of the 49 consultations 16 were for consideration of device implantation and 29 for ablation. There was no difference between the two groups and I deal with them together in subsequent discussions. Consultation quality was satisfactory in most areas, but not in all. Areas where there could have been improvement included elicitation of the patient’s preferred mode of receiving information, and exploring the patient’s concerns and fears about treatment. Patients were generally offered a choice of a do nothing or no change option but this did not always happen. Interestingly patient satisfaction was uniformly high and did not correlate with consultation quality, indicating that this alone is not sufficient to guarantee a good shared decision.

We looked at the outcome of consultations and how this related to consultation quality. We specifically looked at whether the expected decision of the patient and of the referring physician changed after the consultation. We found that in 7 of 49 the decision was different to that expected by the patient and in 13 of 49 it differed to that expected by the referring physician. There was no relationship between these two differences.

We found that in 12 patients the expected invasive strategy was replaced by a non invasive option or a decision to defer invasive treatment. In only one patient was an expected non-invasive strategy replaced by an invasive one. When we looked at consultation quality we found that there was a significant improvement for patients whose decision changed the expected management and for patients who subsequently opted for non invasive treatment.

This was of course an open study –consultations were observed directly and analysed without blinding. It is possible that those consultations where the decision changed required more detailed explanation which could have been driven by the doctor rather than being a truly shared decision. Further work is needed to finally answer this point.

Good consultations did not take a long time. The median length was 16 minutes. There was no relationship between time and quality.

We believe that seeing patients in the clinic and coming to a truly shared decision is a vital skill of the electrophysiologist. There is room for improvement in our consultations. Most interestingly we find that patients who get a good quality consultation in tertiary care seem to be more likely to choose non invasive options. Providers of electrophysiological services should be able to demonstrate high quality shared decision making.