Improving coordination of care for stable coronary artery disease (CAD): Primary care shared decision-making

Research Objective: The National Priorities Partnership has identified coordination of care as an “area to avoid waste, conflicting plans of care, and over-, under-, or misuse of prescribed medications, tests, and therapies.” Regional variation research has identified clinical problems where contemporary diagnostic and treatment approaches may not extend life, and have varying effects on quality of life. There is increasing evidence that engaging patients in shared decision-making using patient decision aids may improve appropriateness, and reduce excessive utilization. Stable coronary artery disease (CAD) and elective angiography and percutaneous coronary intervention (PCI) is one of several utilization problems that serve as models. Improved communication and coordination among patients, primary care providers, and specialists may ensure agreement about goals and utilization to achieve the best outcomes. The purpose of the CAD shared decision-making project is to provide primary care practices with tools for shared decision-making about CAD early in the diagnostic and therapeutic process and improved referral and coordination of care among specialists and primary care providers who share the care of patients with stable CAD.

Methods: Feasibility pilot to test implementation of coronary artery disease shared decision-making in 2 primary care practices in Michigan with 29 primary care providers (PCPs), and 193 patients with ICD-9 codes 411., 414., 413.9, 429.2 (CAD).

Results: 21/29 PCPs (72 %) attended 90-minute education workshops, which included didactic material, role play demonstrations, and performing role plays with feedback. 21/193 (10 %) of patients attended 90-minute group visits, which included didactic material and open discussion. PCPs were enthusiastic, but concerned about breaching cardiology boundaries. Patients in the group visits appreciated the education about lack of contribution of PCI to longevity or heart attack rates and the opportunity to discuss treatment experience with other patients. For PCPs, the key motivation was consistency with the patient centered medical home, and the opportunity to focus on one clinical problem for the patient visit. EMR integration and extension to joint primary care/cardiology implementation is in process. Unintended findings are that our patient recruitment “hit rate” is emerging as a considerable challenge. To address this, future participants will be recruited at pre-stress test when active decisions are underway.

Conclusions: The physician workshops and use of patient decision aid are feasible within the primary care patient workflow and current billing practices. Improving the communication between PCPs and cardiologists will be essential for addressing the concerns about cardiology interface.