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Patient Experience With Current Clinical Decision Making In Prosthetic Aortic Valve Selection
Nelleke M. Korteland1, Frans J. Bras2, Fabienne MA van Hout, MD3, Jolanda Kluin, MD PhD2, Robert JM Klautz, MD PhD3, Ad JJC Bogers, MD PhD1, Johanna JM Takkenberg, MD PhD1.
1Erasmus MC, Rotterdam, Netherlands, 2University Medical Center Utrecht, Utrecht, Netherlands, 3Leiden University Medical Center, Leiden, Netherlands.

BACKGROUND: To assess and compare among adult patients accepted for aortic valve replacement: (1) experience with current clinical decision making regarding valve selection, (2) preferences for shared decision making (SDM) and risk presentation, and (3) patient knowledge and numeracy.
METHODS: In a prospective multicenter cohort study patients scheduled for AVR were surveyed preoperatively and 3 months post-surgery.
RESULTS: Preoperatively 132 patients (89 males/43 females; mean age 67 years (range 23-86)) responded. Ninety-nine percent of patients was aware that there are different types of aortic valve prostheses. Sixty-four percent of patients felt they had sufficient time to make a deliberate choice regarding the type of aortic valve prosthesis. Sixty-eight percent of patients wanted to be involved in decision-making, whereas 53% agreed that they actually were. Most patients (68%) preferred scientific evidence presentation in a pie chart. Fifty-five percent of patients thought they had sufficient knowledge about the different types of aortic valve prostheses, and 68% of patients was actually able to answer three basic knowledge questions concerning prosthetic valves correctly. Regarding numeracy of patients: 38% of patients was able to answer three basic numeracy questions correctly. Sixty-four percent of patients experienced decisional conflict, and 28% to such extent that it made them feel unsure about the decision. Three months post-surgery 111 patients responded. Seventy-three percent of patients was satisfied with their aortic valve prosthesis, with no difference between patients with mechanical and bioprostheses. With regard to anxiety, patients with a bioprosthesis were more anxious about a possible re-operation than patients with a mechanical prosthesis (32% versus 11% respectively), while 26% of patients worried about oral anticoagulation treatment.
CONCLUSIONS: In current clinical practice patients who undergo aortic valve replacement experience decisional conflict and suboptimal involvement in decision making, often have difficulties in understanding their choices and exhibit overt statistical illiteracy. Given the broad support for SDM among patients and the obvious need for understandable information, the introduction of a decision aid to support SDM in the setting of prosthetic aortic valve selection is expected to result in better informed and more actively involved patients, and less decisional conflict.

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