Eliciting Patient Risk Willingness in Clinical Consultations as a Means of Improving Decision-Making of Aortic Valve Replacement

Abstract

Background: Treatment decisions for aortic valve replacement (AVR) should be sensitive to patient preferences. However, we lack knowledge of patient preferences and how to obtain them.

Methods and results: We assessed the mortality risk patients were willing to accept when undergoing AVR by using the Standard Gamble method and aimed to show how this risk willingness was affected by level of disease burden. We report findings from 439 patients, aged >18 years with severe aortic stenosis who were referred for evaluation of AVR to our institution. The vast majority of patients accepted a mortality risk regarded as high or prohibitive according to current guidelines. Of the 439 patients, 51% patients were willing to forego surgery with high mortality risk (8-50%) and 19% were willing accept a prohibitive mortality risk (>50%) as defined in current guidelines. However, the risk willingness varied considerably. Acceptance of prohibitive risk willingness (>50%) was associated with reporting of 3 to 5 different restricting symptoms, with an odds ratio of 4.07 (95% CI 1.56-10.59) opposed by increasing score on EuroQol-Visual Analog Scale, with an odds ratio of 0.99 (95% CI 0.97-1.00). The poor ability to predict risk willingness based on available clinical variables and health status suggests that other factors may be important advocating the need for tools for soliciting patient's preferences individually.

Conclusion: When undergoing AVR, patients were willing to accept considerably higher perioperative risk than what is considered acceptable in current guidelines and practice. Patient preferences varied considerably, and they should be directly assessed and taken into account in decision-making and guidelines.

Clinical trial registration: URL: https://ichgcp.net/clinical-trials-registry/NCT01794832" title="See in ClinicalTrials.gov">NCT01794832.

Keywords: aortic stenosis; cardiovascular diseases; patients; shared decision‐making; surgery; valves.

© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1

Distribution of risk willingness (N=439). The overall median risk willingness was 25% (range 25–50%). The distribution had 1 peak at 0 reported by 104 patients, the next peak median value of 25% was reported by 44 patients, and the third peak at 50% risk willingness was reported by 92 patients.

Figure 2

Association between risk willingness, New York Heart Association Functional classification, reported number of weekly symptoms, and health transition (median and IQR). Symbols represent the median risk willingness (whiskers=IQR) that patients in each category were willing to take. All median values were significantly different (P<0.001), based on the Mann–Whitney U test with Bonferroni adjustments for multiple testing. Weekly symptoms reported were angina or chest pain, dizziness, dyspnea, fatigue, and syncope. The health transition (item 2 on the Short Form 36‐Item) reflects the patient's perceptions of health change compared with 1 year earlier.