Prevalence and Continuity of Medical Decisions Made in Encounters with Heart Failure Patients

Abstract

Background: Patients with heart failure (HF) are faced with a lot of tough decisions. Treatment of HF has made great advancements, largely due to scientific studies proving significant effects of drugs aimed at HF improvement, and increased life expectancy. Still, treatment is rigidly guideline directed, which may come at the expense of patient autonomy. Our study aims to investigate the prevalence and continuity of medical decisions in consecutive encounters with HF patients. <p>

<p>Method: We’ve analyzed 32 transcribed encounters between physicians and eleven HF patients, in both hospital and general practice. In these transcripts we’ve identified and categorized medical decisions with the Decision Identification and Classification Taxonomy for Use in Medicine (DICTUM) and evaluated shared decision-making (SDM) for drug related decisions using OPTION5 on a 0-100 scale. <p>

<p>Results: Our data consisted of 4862 transcribed lines yielding 453 codes containing clinically relevant decisions, averaging 14.2 decisions per encounter. Drug related decisions (DRDs) were most frequent (21.4%), with 58.8% being made at discharge. The majority (48.5%) were about drug therapy initiation. We found 13 (12.0 %) attempts of SDM concerning DRDs in ten (31.2%) different transcriptions; six of which were from encounters with the general practitioner (GP). The mean OPTION5-score was 15. We found eight (1.8%) instances of prognosis related decisions. <p> <p>Conclusion: Our study demonstrates that most decisions made in encounters with heart failure patients revolve around drug therapy, and that patient involvement in these decisionmaking processes are minimal. The limited involvement may be due to rigid guidelines, and insufficient focus on shared decision-making. The level of continuity regarding drug related decisions does not provide comprehensive overview, as the follow-up provided by the general practitioner is not exclusively limited to drug therapy. Furthermore, an important finding is that physicians talk too little about the prognosis with their patients. Early conversation about prognosis can promote patient understanding and may facilitate their participation in shared decision-making.