Caution Regarding Government-Mandated Shared Decision Making for Patients With Atrial Fibrillation
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Although cardiovascular clinicians are increasingly encouraged to incorporate a shared decision-making (SDM) approach with their patients with atrial fibrillation (AF) at risk for stroke, limited guidance is available on how to navigate this complex interaction. Referring physicians, who know their patients best, struggle to present risks and benefits of newer therapies, whereas subspecialists are challenged to rapidly learn new patients’ values and preferences. Decision aids are consistently shown to improve patient outcomes, such as knowledge, engagement, and satisfaction,1 yet poor implementation of an SDM approach by clinicians across routine practice speaks to the ongoing need for a greater understanding of where in the care process SDM is best used and with what tools.2
In this context, the Centers for Medicare and Medicaid Services (CMS) mandated SDM for patients with AF seeking to reduce their stroke risk. In March 2015, the US Food and Drug Administration approved Watchman (Boston Scientific), a cardiac device that occludes the left atrial appendage where most clots are formed in AF. The device was approved for patients with an appropriate rationale to select a percutaneously implanted device over anticoagulation, “taking into account the safety and effectiveness of the device.”3 CMS then released a National Coverage Determination, which prescriptively outlined the healthcare delivery processes required to take place before left atrial appendage closure (LAAC). Referring physicians (nonimplanters) must document evidence of an SDM interaction regarding anticoagulation …