Introduction
In patients with advanced heart failure, left ventricular assist devices (LVADs) can improve quantity and quality of life but carry potential risks and burdens, creating a complex medical decision.1 The I-DECIDE-LVAD Project aims to implement an effective patient and caregiver shared decision making aid at all LVAD programs in the United States.2 As part of I-DECIDE-LVAD, health care workers of LVAD programs completed a survey designed to characterize LVAD medical decision making in contemporary clinical practice. The survey included a hypothetical question, “Personally, would you get a destination therapy (DT) LVAD If you had end-stage heart failure and were not eligible for transplant?” Health care workers who care for LVAD patients have exposure to a range of outcomes, and thus may provide perspective into the nature of the therapy and the decisional challenges posed by DT- LVAD.
Methods
Four lists maintained by the following professional groups were used to recruit participants: American College of Cardiology – Heart Failure Section, American Association of Heart Failure Nurses, Society for Transplant Social Workers, and a listserv for Mechanical Circulatory Support coordinators. Each entity sent two email invitations to their members to complete the public online survey over two weeks in April 2019. The total members of all lists was 4,645, and we received a response rate of 10%. The survey contained 47 items, including the hypothetical question “Personally, would you get a DT-LVAD if you had end-stage heart failure and were not eligible for transplant?”, with the answer options of “Definitely”, “Probably”, “Probably Not”, and “Definitely Not”. Questions on personal and institutional attitudes toward shared decision making, as well as personal and institutional characteristic and demographic data were collected.
The primary outcome of this analysis was participants’ response to how likely they would be to personally get a DT-LVAD if they had end-stage heart failure and were not eligible for transplant. Counts, percentages, and Chi square p-values of those responding to the hypothetical question were analyzed by gender, age, clinical role, years working with LVAD patients, university affiliation, heart transplant center, number of LVAD patients seen each year, and region of the country. Logistic regression analysis was used to compute crude and adjusted odds ratios where willingness to personally getting a DT-LVAD was categorized into a dichotomous variable (definitely/probably vs. probably not/definitely not).
The original survey and the data that support the findings are available from the corresponding author upon request. The study was approved by the Colorado Multiple Institutional Review Board and each participant provided informed consent.
Results
The 470 health care workers who completed the survey included 191 RNs, 109 advanced practice providers, 71 physicians, 59 social workers, and 40 unspecified. Eighty percent of respondents were female (n=376) and 72% worked at heart transplant centers (n=338). The reported willingness to personally get a DT-LVAD if they had end stage heart failure and were not eligible for a transplant were 55 (11.7%) definitely, 231 (49.2%) probably, 149 (31.7%) probably not, and 35 (7.5%) definitely not. Males were more likely than females to respond affirmative toward getting an LVAD with definitely (18.5%) and probably (55.0%) vs. definitely (10.1%) and probably (47.6%) (p = 0.0171). All other comparisons between responders’ age, role in program, years working with LVAD patients, university affiliation, center number of LVAD patients per year, heart transplant capability, and region were not statistically different.
Crude and adjusted odds ratios (OR) are reported for willingness to personally get an LVAD (definitely/probably vs. probably not/definitely not) (Table). When adjusting for all other variables, gender remained significant where the odds for males willing to get an LVAD were more than twice as likely as the odds for females (adjusted OR 2.53, 95% confidence interval (CI) 1.24, 5.20). Significant adjusted odds ratios were also observed from heart transplant programs, where the odds of responses from programs not performing transplants were 80% higher than the odd of responses from transplant programs (adjusted OR 1.81, 95% CI 1.08, 5.20).
Table.
Odds of willingness to personally get an LVAD (Definitely/Probably vs. Probably not/Definitely not) based on characteristics.
| Characteristic | Crude Odds Ratio (95% CI) | Adjusted Odds Ratio* (95% CI) |
|---|---|---|
| Gender: Male vs. Female (ref) | 2.05 (1.23, 3.40) | 2.53 (1.24, 5.20) |
| Age: <45 vs. 45+ years (ref) | 1.12 (0.77, 1.63) | 1.04 (0.65, 1.68) |
| Role in program | ||
| Registered Nurse | ref | ref |
| Physician Assistant/Nurse Practitioner | 1.56 (0.95, 2.55) | 1.28 (0.73, 2.20) |
| Physician | 1.51 (0.85, 2.66) | 0.76 (0.33, 1.75) |
| Social Worker | 1.05 (0.58, 1.89) | 1.03 (0.54, 1.96) |
| Other | 1.15 (0.58, 2.31) | 0.92 (0.44, 1.95) |
| Yrs. w LVAD | ||
| <6 years | ref | ref |
| 6– 15 years | 1.09 (0.73, 1.63) | 1.31 (0.84, 2.04) |
| 16+ years. | 0.73 (0.41, 1.30) | 0.82 (0.39, 1.71) |
| Institution Type: University vs. all others (ref) | 1.02 (0.70, 1.49) | 1.19 (0.76, 1.88) |
| Transplant center: Yes vs. No (ref) | 1.53 (1.00, 2.38) | 1.81 (1.08, 3.13) |
| Region | ||
| West | ref | ref |
| Northeast | 0.69 (0.35, 1.36) | 0.58 (0.28, 1.20) |
| South | 0.73 (0.37, 1.44) | 0.79 (0.39, 1.62) |
| Midwest | 0.72 (0.36, 1.44) | 0.73 (0.35, 1.52) |
| International | 2.19 (0.43, 11.25) | 1.80 (0.33, 9.90) |
CI = confidence interval; ref = reference group
Adjusted for all other variables listed in table.
Discussion
Many health care workers who routinely care for patients considering and living with LVADs express some ambivalence towards the therapy when considering it for themselves. This finding was similarly shown in end-of-life preferences for tracheostomy and gastrostomy by clinicians for themselves versus what they recommended to patients.3 Men were more likely to pursue an LVAD than women, similar to other literature in which males preferred more aggressive care than females.4 In addition, the availability heuristic may explain the finding that health care workers at non-transplant centers had higher odds of choosing an LVAD.5 Although hypothetical, we believe the sentiment of experts with direct LVAD experience emphasizes the deep importance of personal preference and context dependence for this complex medical decision. These findings support ongoing efforts to engage patients in shared decision making for advanced heart failure treatment options that promotes patient-centered medical care.
Funding
This work was funded through a Patient-Centered Outcomes Research Institute (PCORI) Dissemination and Implementation Award (SDM-2017C2-864). The statements in this work are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.
Footnotes
Financial Conflict of Interest / Disclosures
Dr. Allen reports grant funding from AHA, NIH, and PCORI; and consulting fees from Abbott, ACI Clinical, Amgen, Boston Scientific, Cytokinetics, and Novartis. Dr. Matlock has received funding from the NIH, American College of Cardiology Foundation, and PCORI. Remaining authors report no significant conflicts.
References
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