부산대학교 도서관

Megan E Branda,1,2 Marleen Kunneman,1,3 Alejandra I Meza-Contreras,1,4 Nilay D Shah,5 Erik P Hess,6 Annie LeBlanc,7 Jane A Linderbaum,4 Danika M Nelson,4 Margaret R Mc Donah,8 Carrie Sanvick,9 Holly K Van Houten,10 Megan Coylewright,11 Sara R Dick,12 Henry H Ting,5 Victor M Montori1 1Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA; 2Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA; 3Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands; 4Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; 5Delta Air Lines, Atlanta, GA, USA; 6Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; 7Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; 8Mayo Clinic Health System, Mayo Clinic, Rochester, MN, USA; 9Department of Nursing, Mayo Clinic, Rochester, MN, USA; 10Robert D and Patricia E Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA; 11Section of Cardiovascular Medicine, Erlanger Heart and Lung Institute, Chattanooga, TN, USA; 12Education Project Management Office, Mayo Clinic, Rochester, MN, USACorrespondence: Victor M Montori, 200 First Street SW, Rochester, MN, 55905, USA, Tel +1 507-284-2511, Email Montori.victor@mayo.eduObjective: Adherence to guideline-recommended medications after acute myocardial infarction (AMI) is suboptimal. Patient fidelity to treatment regimens may be related to their knowledge of the risk of death following AMI, the pros and cons of medications, and to their involvement in treatment decisions. Shared decision-making may improve both patients’ knowledge and involvement in treatment decisions.Methods: In a pilot trial, patients hospitalized with AMI were randomized to the use of the AMI Choice conversation tool or to usual care. AMI Choice includes a pictogram of the patient’s estimated risk of mortality at 6 months with and without guideline-recommended medications, ie, aspirin, statins, beta-blockers, and angiotensin-converting enzyme inhibitors. Primary outcomes were patient knowledge and conflict with the decision made assessed via post-encounter surveys. Secondary outcomes were patient involvement in the decision-making process (observer-based OPTION12 scale) and 6-month medication adherence.Results: Patient knowledge of the expected survival benefit from taking medications was significantly higher (62% vs 16%, p< 0.0001) in the AMI Choice group (n = 53) compared to the usual care group (n = 53). Both groups reported similarly low levels of conflict with the decision to start the medications (13 (SD 24.2) vs 16 (SD 22) out of 100; p=0.16). The extent to which clinicians in the AMI Choice group involved their patients in the decision-making process was high (OPTION12 score 53 out of 100, SD 12). Medication adherence at 6-months was relatively high in both groups and not different between groups.Conclusion: The AMI Choice conversation tool improved patients’ knowledge of their estimated risk of short-term mortality after an AMI and the pros and cons of treatments to reduce this risk. The effect on patient fidelity to recommended medications of using this SDM tool and of SDM in general should be tested in larger trials enrolling patients at high risk for nonadherence.Trial Registration Number: NCT00888537.Keywords: shared decision making, acute myocardial infarction, adherence, randomized trial