Medical decision making among patients with heart failure - does migration background matter?
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ABSTRACT:
SUBMITTER: von dem Knesebeck O
PROVIDER: S-EPMC7488718 | biostudies-literature | 2020 Sep
REPOSITORIES: biostudies-literature
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Medical decision making among patients with heart failure - does migration background matter?
von dem Knesebeck Olaf O Scherer Martin M Marx Gabriella G Koens Sarah S
BMC family practice 20200913 1
<h4>Background</h4>Some studies, mainly coming from the U.S., indicate disparities in heart failure (HF) treatment according to migration/ethnicity. However, respective results are inconsistent and cannot be transferred to other health care systems. Thus, we will address the following research question: Are there differences in the diagnosis and management of HF between patients with and without a Turkish migration background in Germany?<h4>Methods</h4>A factorial experimental design with video ...[more]
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Project description:Background Race influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies. Methods and Results Members of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think-aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (-0.58; 95% CI, -1.15 to -0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation. Conclusions Black race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.
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Project description:A growing number of elderly patients with end-stage renal disease start dialysis. We examined elderly (?65 years) patients' views about their decision-making experience after starting dialysis in comparison with patients aged 50-64 years, and patients ?49 years.Ninety-nine patients from 15 outpatient dialysis centers in North Carolina, USA completed a semi-structured interview asking them about the context of decision-making and their decision-making experience, and a 10-item investigator-developed Informed Decision-Making (IDM) questionnaire with binary response options (yes/no).While IDM scores were low for all three groups (<5 out of 10), they were significantly lower for the older group compared to the other two younger groups (p = 0.02). A significantly lower percentage of the older group said that the doctor explained underlying conditions that led to kidney failure (p = 0.04), the impact of dialysis on daily life (p = 0.04), and the life-long need for dialysis (p < 0.01), and that the doctor tried to make sure the patient understood the information (p = 0.01). Also a significantly higher percentage of elderly patients felt the decision was made by the doctor rather than on their own or with their family, or collaboratively with the doctor (p = 0.04).Informed decision-making is significantly poorer in patients aged 65 years or older than in younger patients. Clinicians should communicate clearly about the benefits and burdens of dialysis to older adults and provide an opportunity for them to understand the significant trade-offs that dialysis may require.
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Project description:BackgroundAdolescents and young adults undergoing heart transplantation experience risks of morbidity and mortality both pre- and post-transplant. To improve end-of-life care for this population, it is necessary to understand their medical and end-of-life decision-making preferences.Aim(1) To examine adolescent/young adult decision-making involvement specific to heart transplant listing, and (2) to characterize their preferences specific to medical and end-of-life decision making.DesignThis cross-sectional research study utilized survey methods. Data were collected from October 2016 to March 2018.Setting/participantsTwelve adolescent and young adult patients listed for heart transplant (ages = 12-19 years) and one parent for each were enrolled at a single-center, US children's hospital.ResultsConsistent with their preferences, the majority of adolescent/young adult participants (82%) perceived a high level of involvement in the decision to be listed for transplant. Patient involvement in this decision was primarily by way of seeking advice or information from their parents and being asked to express their opinion from parents. Despite a preference among patients to discuss their prognosis and be involved in end-of-life decision making if seriously ill, only 42% of patients had discussed their end-of-life wishes with anyone. Few parents recounted having such discussions. Preferences regarding the timing and nature of end-of-life decision-making discussions varied.ConclusionsAlthough young people are involved in the decision to pursue heart transplantation, little attention is paid to involving them in discussions regarding end-of-life decision making in a manner that is consistent with individual preferences.
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