Patient preferences for radial versus femoral vascular access options by coronary angiography and intervention (PREVAS)

Fens, A.L. (2015) Patient preferences for radial versus femoral vascular access options by coronary angiography and intervention (PREVAS).

Abstract:Background: Coronary artery disease (CAD) can lead to a symptomatic vascular blockage. Angiography (CAG) is used to diagnose the vascular blockage that may then be treated by a percutaneous coronary intervention (PCI). Both CAG and PCI require arterial access in order to reach the coronary arteries. While trans-femoral access (TFA) had been the universal default since the late 1970s, there is an increasing interest in trans-radial access (TRA) as it is associated with a reduction in haemorrhagic entry site complications and permits earlier patient ambulation. Both access-sites have advantages and disadvantages. When the study was designed neither approach was generally proven to be superior in clinical outcome, which complicates the task for vascular choice. Literature suggests that the systematic incorporation of patient preferences into the decision could be regarded of supplementary importance, as a mutual involvement of the physician and the patient in the decision may provide directions for selecting procedural options and planning health care services. However, little is known about patient preferences within CAG and/or PCI procedures. Objectives: The aim of this study was to determine patient preferences over procedural characteristics and benefits and risks of vascular access sites in CAG and/or PCI. A secondary aim is to determine patients’ perspective on shared decision-making for the scheduled catheterization procedure. Methods: In a collaboration between Thoraxcentrum Twente (TCT) of the Medisch Spectrum Twente (MST) and the University of Twente (UT), a single-centre cross-sectional prospective study was carried out. A patient preference questionnaire (PPQ) was constructed and applied among a consecutive series of patients (n=148) who were, in the period from July 2014 to august 2014, electively admitted for CAG and/or PCI procedures in the MST hospital. The PPQ consisted of four parts and focused on background characteristics of patients, patient preferences for vascular access, and patients’ informational and decisional agreement regarding procedure. The choice-based method Case 2 Best-Worst Scaling (BWS) was used to elicit patients’ preferences on six attributes of care: length of hospital stay, peri-procedural changing of access-site, suitability of the vessel for next procedure, post-procedural patient comfort, peri-/post-procedural bleeding, and post-procedural mobilisation. The attributes had two or three levels. Eight choice sets were presented to patients, with patients indicating the ‘best’ and ‘worst’ attribute-level in each choice set. Best-minus-worst- scores (B-W method) and conditional logistic regression (Clogit) scores were calculated to assess which attributes and attribute-levels matter most to patients and to assess the overall utility of the radial or femoral procedural option. In addition, overall preference was measured within a direct question format. Informational and decisional agreement were assessed by using an ‘agree-disagree’ statement-format and independent multiple choice questions. Results: Patients generally preferred the femoral approach (59%) over the radial approach (41%) (p<0.05). The BWS method showed that patients considered the peri-/post-procedural bleeding as most important procedural characteristic, followed by the length of hospital stay and post-procedural mobilisation. More specifically, patients valued most that the procedure takes place in day-care (0.585), that there are no bleedings after procedure (0.364) and that the procedure through the vessel succeeds (0.390). Least preferred were that there will be a major bleeding which requires blood-transfusion (-0.705), the incidence of hematoma (-0.398) or that patients need to lie flat for up to 6 hours (-0.344) (p<0.05). Most patients indicated to understand the information about the benefits (IQR=1) and risks (IQR=0) of procedure and knew which benefits and risks were most important to them (Mdn=2). When considering decisional agreement, patients were satisfied with the course of procedure (Mdn=1; IQR=1) and had post-procedural preferences for the current access route (84.2%). A significant amount of patients in this study desired to have more, or less decisional power in the procedure than they actually had, but only a few individuals would like the physician or themselves to be the only decision owner (p<0.05). Discussion and conclusion: Patients were slightly in favour of the femoral approach, except from those who experienced both vascular routes, who were in favour of the radial approach. Besides, patients were able to express their preferences on the most important procedural characteristics and potential benefits and risks of procedure through the BWS method. Most important to patients were peri-/post-procedural bleeding, the length of hospital stay and post-procedural mobilisation – characteristics that are positively associated with the radial access route. No evident preferred procedural access option could be elicited from patients in this study; this contributes to the fact that the decision for vascular access is a preference-sensitive decision in which the characteristics of procedure can be of different importance to individual patients or subgroups. Therefore, the study may provide insight and clinical awareness on existing patient preferences. Although different opinions were noted on the extent to which the decision should be shared, the perceived decisional agreement in this study indicates that patients appreciate to participate in (or share) the decision on vascular access in CAG and/or PCI. The findings in this study may provoke discussion on the capability and desirability of shared decision-making (SDM) in cardiology by both health care professionals and patients and may lead to better defensible choices and a more patient-centered care.
Item Type:Essay
Thorax Centrum Twente, Enschede, the Netherlands
Faculty:BMS: Behavioural, Management and Social Sciences
Subject:70 social sciences in general
Programme:Health Sciences MSc (60022)
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