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Treatment Decision Making in Multivessel Coronary Artery Disease

机译：多支冠状动脉疾病的治疗决策

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摘要

Multivessel coronary artery disease patients may be treated with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimal medical therapy. Randomized trials and observational analyses have demonstrated risk and benefit tradeoffs between treatment strategies. This thesis examines the decision making processes that occur when determining treatments for multivessel coronary artery disease patients. Study 1 investigates clinical outcomes of multivessel coronary artery disease patients receiving ad-hoc compared to delayed PCI in a procedural registry. There was no significant difference in mortality or repeat revascularization between ad-hoc PCI and delayed PCI in the full cohort. Among three vessel disease patients, ad-hoc PCI resulted in higher rates of repeat revascularization compared to delayed PCI. The second study assessed healthcare provider's attitudes about multivessel treatment options using a survey with three clinical vignettes. Treatment choice was significantly associated with patient vignette and participant type, demonstrating patient characteristics and provider type play a role in treatment choice. Cardiologists were most likely to choose multiple treatments (CABG and PCI) as appropriate options. Surgeons were most likely to choose only CABG as an appropriate treatment option. Study 3 used qualitative semi-structured interviews to document clinicians' experience with decision making and patient engagement with current multivessel disease practice patterns. Direct content analysis resulted in three themes describing clinicians' frustrations with multivessel treatment decision making: 1) Multivessel coronary artery disease treatment decisions are multifaceted due to the number of factors and clinicians involved; 2) Clinician-to--clinician communication is inadequate because clinicians lack formalized pathways and roles; and 3) Patient communication time is not in the clinical workflow and suffers from patients' little prior knowledge of coronary artery disease. By studying the decision points in the multivessel pathway this thesis has elucidated trade-offs among treatment strategies, identified a lack of congruence among clinicians about appropriate treatment options, and documented workflow and communication barriers that prevent clinicians and patients from optimal decision making.
机译：多支冠状动脉疾病患者可以接受冠状动脉旁路移植术（CABG），经皮冠状动脉介入治疗（PCI）或最佳药物治疗。随机试验和观察性分析证明了治疗策略之间的风险和收益之间的权衡。本文探讨了在确定多支冠状动脉疾病患者的治疗方法时发生的决策过程。研究1研究了在程序性注册表中接受临时PCI而非延迟PCI的多支冠状动脉疾病患者的临床结局。临时队列和延迟队列在整个队列中的死亡率或重复血运重建无显着差异。在三例血管疾病患者中，与延迟PCI相比，临时PCI导致更高的重复血运重建率。第二项研究通过对三个临床小插图的调查，评估了医疗服务提供者对多支血管治疗选择的态度。治疗选择与患者小插图和参与者类型显着相关，证明患者特征和提供者类型在治疗选择中起作用。心脏科医生最有可能选择多种治疗方法（CABG和PCI）作为适当的选择。外科医生最有可能只选择CABG作为适当的治疗选择。研究3使用定性的半结构化访谈来记录临床医生在决策和患者参与当前多支血管疾病实践模式方面的经验。直接内容分析产生了三个主题来描述临床医生对多支血管治疗决策的挫败感：1）由于涉及因素和临床医生的数量众多，多支冠状动脉疾病的治疗决策是多方面的； 2）由于临床医生缺乏正规的途径和作用，临床医生与临床医生之间的沟通不充分； 3）患者的交流时间不在临床工作流程中，并且患者对冠心病的了解很少。通过研究多支血管通路中的决策点，本论文阐明了治疗策略之间的权衡，确定了临床医生之间在适当治疗方案方面缺乏一致性，并记录了阻碍临床医生和患者最佳决策的工作流程和沟通障碍。

著录项

  • 作者

    Nichols, Elizabeth L.;

  • 作者单位

    Dartmouth College.;

  • 授予单位 Dartmouth College.;
  • 学科 Health sciences.;Epidemiology.;Public health.
  • 学位 Ph.D.
  • 年度 2018
  • 页码 134 p.
  • 总页数 134
  • 原文格式 PDF
  • 正文语种 eng
  • 中图分类
  • 关键词

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