Shared decision-making and use of patient decision aids before percutaneous left atrial appendage occlusion are widely reported in US practice. A large national cohort study suggests that their use depends more on the treating institution than on patient characteristics.
Analyzing data from more than 147,000 percutaneous left atrial appendage occlusion procedures recorded in the American College of Cardiology’s National Cardiovascular Data Registry, investigators found that about two-thirds of encounters documented both shared decision-making (SDM) and a decision aid, with rates increasing steadily between late 2022 and mid-2024. However, variation across institutions was significant, with adjusted analyses showing that institutional factors accounted for the majority of observed differences in SDM reporting.
In hierarchical models, the median odds of a patient receiving documented SDM with a decision aid differed more than 100-fold between institutions, even after accounting for patient characteristics, procedural volume, and clinical risk. By contrast, differences related to age, sex, race, ethnicity, or insurance status were modest. Notably, patients with Medicare coverage – despite a Centers for Medicare & Medicaid Services requirement for SDM as a condition of reimbursement – did not have higher odds of documented SDM with a decision aid.
“Surprisingly, whether a patient is reported to have undergone SDM and been presented with a DA [patient decision aids] is much better explained by knowing at which institution the patient is having the procedure than any patient or operator characteristic we identified,” the authors wrote, calling attention to potential gaps between policy requirements and real-world implementation.
An accompanying invited commentary raises questions about how shared decision-making is being applied in procedural cardiology, suggesting it may sometimes function more as risk communication or documentation compliance than as preference-sensitive deliberation. The commentators also note that higher-risk patients were more likely to have documented SDM, a pattern that may reflect use of decision aids to reinforce clinical recommendations rather than to explore alternatives.
The authors emphasize that improving consistency may likely require institutional investment, clearer standards for documenting SDM quality – not just its occurrence – and evaluation of whether available decision aids actually improve patient understanding and alignment with individual values.
Source: JAMA Network Open
