Decision Making in Advanced Heart Failure Larry A. Allen, MD, MHS - - PowerPoint PPT Presentation

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Decision Making in Advanced Heart Failure Larry A. Allen, MD, MHS - - PowerPoint PPT Presentation

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Decision Making in Advanced Heart Failure Larry A. Allen, MD, MHS Ginny Meadows, MSHI, RN-BC Professor, University of Colorado School of Medicine Caregiver #PCORI2018 Larry Allen, MD, MHS Disclosures Rela latio ionship ip Company ny(ies

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#PCORI2018

Decision Making in Advanced Heart Failure

Larry A. Allen, MD, MHS Ginny Meadows, MSHI, RN-BC

Professor, University of Colorado School of Medicine Caregiver

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2 • November 15, 2018

Larry Allen, MD, MHS

Disclosures

Rela latio ionship ip Company ny(ies es) Speakers Bureau Advisory Committee Consultancy ACI Clinical, Amgen/Cytokinetics, Boston Scientific, Janssen Review Panel Board Membership Honorarium Ownership Interests blank blank blank blank blank blank

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3 • November 15, 2018

A Caregiver’s Experience with End-Stage Heart Failure

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4 • November 15, 2018

Presentation Outline

  • 1. The LVAD Environment
  • 1. What is an LVAD?
  • 2. Tradeoffs
  • 3. Decision Making in Serious Illness
  • 2. Developing an LVAD Decision Aid
  • 3. Testing Decision Aid’s Effectiveness
  • 4. Dissemination of Decision Aid
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5 • November 15, 2018

What is an LVAD?

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6 • November 15, 2018

Tradeoffs

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7 • November 15, 2018

Tradeoffs

McIlvennan, Magid, Ambardekar, Thompson, Matlock, Allen. Circ Heart Fail. 2014

Benefits Risks/Burdens

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8 • November 15, 2018

Preference-Sensitive Decision

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9 • November 15, 2018

Marketing = Suboptimal “Education”

Content analysis of 77 LVAD educational materials

  • 97% describe benefits
  • 53% mention any risk
  • 1% offer an alternative (palliative care)

Iacovetto et al. Circ Qual Care Outcomes. 2014.

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10 • November 15, 2018

Decision Making in Serious Illness

Hi High-stake kes Emotion Unc Uncer ertainty Cognit itiv ive Biases es Careg egiver ers

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11 • November 15, 2018

Dichotomy in Decision Approach

McIlvennan et al. Circ Qual Care Outcomes. 2014.

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12 • November 15, 2018

Developing an LVAD Decision Aid

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13 • November 15, 2018

Developing an LVAD Decision Aid

Thompson et al. JACC-HF. 2016.

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14 • November 15, 2018

Testing Decision Aid’s Effectiveness: DECIDE-LVAD Trial

McIvennan et al. J Cardiovasc Nurs. 2016.

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15 • November 15, 2018

Study Design

  • Test effectiveness of decision aids
  • 6-site, stepped wedge trial
  • Phased rollout of intervention

McIvennan et al. J Cardiovasc Nurs. 2016.

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16 • November 15, 2018

Patients

  • 248 patients enrolled (from n=385 eligible); 190 caregivers

blank Control (n=135) Intervention (n=113) Age, mean years (SD) 63.5 (9.7) 63.2 (10.2) Male 82.2% 86.7% White, non-Hispanic 79.1% 82.7% Some college or more 56.4% 69.2% On Disability 27.6% 32.0% Married 72.5% 65.4% Diagnosed < 2 years 11.9% 12.4% Enrolled in ICU 21.5% 26.5% INTERMACS 4-7 (p<0.01) 18.3% 44.6%

Allen et al. JAMA-IM. 2018.

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17 • November 15, 2018

Primary Outcome: Decision Quality

Allen et al. JAMA-IM. 2018.

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18 • November 15, 2018

Primary Outcome: Decision Quality – 1

Allen et al. JAMA-IM. 2018.

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19 • November 15, 2018

Secondary Outcome: 6-Month Implant

26% decrease in patient going

  • n to LVAD

Yin Yang

Patients avoid aggressive therapy inconsistent with their goals at end-of-life Limit use of a $300,000 treatment Scare people out of life-saving therapy Undermine lucrative services offered by well-meaning programs

Allen et al. JAMA-IM. 2018.

80% 54%

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20 • November 15, 2018

Dissemination and Implementation: I-DECIDE-LVAD

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21 • November 15, 2018

Dissemination of Decision Aid

  • Starts today!
  • Encourage adoption, implementation, maintenance of evidence-

based patient-caregiver decision aids at all 173 LVAD programs across the U.S.

  • Evaluate successful and unsuccessful dissemination of decision aids
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22 • November 15, 2018

Learn More

  • www.pcori.org
  • info@pcori.org
  • #PCORI2018

Larry.Allen@ucdenver.edu

www.patientdecisionaid.org