Decisional Conflict in Peripheral Arterial Disease: Association with Treatment Choice and Health Status
Background: Symptom relief in peripheral arterial disease (PAD) can be obtained by invasive options such as endovascular stenting as well as exercise, and PAD medications. Each of these options have their own risks and benefits. A lack of knowledge about treatment options, risks and benefits, and how these matter to the patient, as well as a lack of support relating to treatment decisions can result in decisional conflict. We aimed to (1) document decisional conflict in patients facing PAD treatment decisions; (2) examine site variability in decisional conflict; and (3) examine whether decisional conflict is associated with PAD treatment strategy and 1-year health status outcomes. Methods: The PORTRAIT study is an observational prospective study that enrolled patients with new or an exacerbation of PAD symptoms from 16 PAD specialty clinics in the US, the Netherlands, and Australia. Patients were interviewed before they underwent PAD treatments to document their socio-economic background and their health status (Peripheral Artery Questionnaire – PAQ). Medical history was abstracted from the medical records. At 3 months, treatment information and decisional conflict (yes/no – 4-item SURE instrument) information was collected from the patient. One-year follow-up health status information was collected by phone interview. Median odds ratios were calculated to quantify the level of site variability. A multivariable logistic regression model was constructed to examine the association between decisional conflict and primary PAD treatment strategy (invasive vs. non-invasive). A multivariable linear regression model was built to examine the association between decisional conflict and 1-year PAQ summary scores, while adjusting for baseline PAQ summary scores. Results: The unadjusted median odds ratio (MOR) for site variability was 2.01 (95% CI 1.56-3.13; p<0.001), after adjusting for country, the MOR was 1.12 (95% CI 1.00-1.46; p=0.35). After adjustment for site and relevant patient covariates, decisional conflict was associated with lower odds of receiving invasive treatment (OR=0.58; 95% CI 0.34-1.00; p=0.050). Decisional conflict was also associated with lower 1-year health status gains for the PAQ summary score (adjusted B=-4.72; 95% CI -9.38;-0.06; p=0.047), even adjusting for primary PAD treatment strategy. Conclusion: One in five patients facing PAD treatment decisions experience decisional conflict. While there is considerable variation for the occurrence of decisional conflict, it is more common among non-US countries. As compared with patients who do not experience decisional conflict, those reporting conflict are more often managed non-invasively and experience lesser 1-year health status gains, not entirely explained by the primary PAD treatment modality. Increasing knowledge and support for non-invasive PAD treatment options may be ways to reduce decisional conflict in PAD.
Table of Contents
Introduction -- Methods -- Results -- Discussion