Decision support tool does not improve Black patients' assent to receive cardiac device

Key takeaways:

• A video decision support tool did not increase the number of Black patients who agreed to receive an implantable cardioverter defibrillator.
• Cultural values and miscommunication are possible causes of hesitancy.

A video-based decision support tool increased Black patients’ knowledge of implantable cardioverter defibrillators, but it did not address their reluctance to receive the device, according to researchers.

Kevin L. Thomas, MD, an associate professor of medicine at Duke University School of Medicine, and colleagues wrote that Black patients are less likely than white patients to receive implantable cardioverter defibrillators (ICDs), despite having higher risk profiles.

“Shared, well-informed decision making is critical for patients contemplating ICD implantation and their families,” they wrote in Annals of Internal Medicine. “Effectively communicating the benefits of ICD therapy and its short- and long-term risks is difficult, and the decision to undergo ICD implantation is complex.”

A prior single-center pilot study showed that a video-based decision support tool may help increase acceptance of ICDs among Black patients at risk for sudden cardiac arrest. Thomas and colleagues assessed the tool’s impact in a larger, multicenter randomized clinical trial.

The study cohort consisted of 330 Black patients (mean age, 59 years) with heart failure, 36.8% of whom were women. The patients were randomly assigned to:

• watch a video decision support tool with a Black clinician and Black patients (n = 108);
• watch a video decision support tool with a white clinician and white patients (n = 111); or
• usual treatment (n = 111).

The primary analysis included data on 311 patients. The researchers found that 58.6% of patients in the video groups assented to ICD implantation compared with 59.4% in the usual care group, for a difference of -0.8 percentage points (95% CI, -13.2 to 11.1).

When additionally compared with usual care patients, those in the video groups had a higher mean knowledge score, for a mean difference of -0.7 percentage points (95% CI, 0.2-1.1), and similar decisional conflict score, for a mean difference of -2.6 percentage points (95% CI, -5.7 to 0.4).

Video group patients had a mean visit time of 22 minutes with their clinician, less than the mean 27 minutes spent by those receiving usual care (95% CI, -9.4 to -0.3).

The outcomes were similar among patients in both video groups.

Thomas and colleagues wrote that there are likely multiple factors contributing to Black patients’ hesitancy to undergo ICD implantation, including:

• adverse social determinants of health (SDOH) and cultural values;
• patient and clinician communication;
• health system-related factors;
• insurance coverage; and
• patient comorbidities.

For clinicians, “one question to ask is how a patient feels about their quality of life rather than longevity,” Thomas said in a press release. “Furthermore, I've had patients say, ‘I don't want something inside my body, I just don't.’ And so, the question becomes, do those personal values that influence preferences differ by race and culture.”

Time constraints may be another barrier to shared decision-making, according to Thomas and colleagues. Although they did not compare times experienced by white patients, “data support the notion that when time pressures exist, clinicians' biases and stereotypes about certain populations are more likely to emerge and negatively affect provider-patient communication, which in turn negatively affects the [shared decision-making] process for Black patients.”

The researchers acknowledged several limitations to the study, such as a lack of data on insurance coverage and the findings not being generalizable to patients who do not have access to highly specialized care.

Ultimately, “the aversion to risk related to cardiac procedures in Black communities is prevalent and complex in its underpinnings, and it represents additional opportunities for research that examines the effect of measures of SDOH on ICD decision making and qualitative research methods that offer more granular insights,” the researchers wrote.

References:

• Study examines reluctance of Black patients to get defibrillators. https://corporate.dukehealth.org/news/study-examines-reluctance-black-patients-get-defibrillators. Published April 3, 2023. Accessed April 4, 2023.
• Thomas K, et al. Ann Intern Med. 2023;doi:10.7326/M22-2934.