This NHLBI K23 Mentored Patient-Oriented Research Career Development Award (PA-18-374) submission by Anuj B. Mehta, MD will enable him to achieve his overarching career goal of improving shared decision-making (SDM) in the intensive care unit (ICU) by combining qualitative research methodologies with ?big data?. Dr. Mehta is a Pulmonary and Critical Care Physician at National Jewish Health. This award will build on Dr. Mehta?s prior health services research in delivery science and provide him with protected research time and support to pursue advanced education and training in 1) qualitative research 2) advanced statistical methodologies in health services research, 3) SDM, and 4) decision aid development. With this proposal, we seek improve SDM for tracheostomy by developing and piloting a personalized decision aid (AIM 3) with a qualitative decisional needs assessment through semi-structured interviews of surrogate decision-makers (AIM 1) and development of tailored tracheostomy prediction models (AIM 2). The dramatic increases in tracheostomy utilization that we have previously reported has large personal and societal implications. Patients who receive a tracheostomy overwhelmingly require long-term hospitalization with significant morbidity, mortality, long-term care needs, and caregiver stress. Evidence suggests that there is large patient and surrogate frustration with the decision-making process with significant decision conflict, misalignment of care delivered with patient values, and discordance between surrogates? expectations and actual outcomes. These findings raise the possibility that patients may be receiving unwanted, invasive, and expensive care not consistent with their underlying values. SDM is the collaborative process of patients, surrogates, and healthcare providers reaching an informed, collective agreement on the treatments consistent with patient?s values. Decision aids are a key tool with which to facilitate SDM. SDM and decisions have been shown to improve the patient-centeredness of care, improve patient knowledge of treatment options and possible outcomes, better align chosen treatments with patient values, and reduce decisional regret and conflict. Multiple societies now recommend that SDM be a cornerstone of patient centered care in the ICU bit its penetration and uptake are limited. We hypothesize that a personalized web based decision aid for tracheostomy will improve the shared decision making process. Dr. Mehta has strong institutional support from National Jewish Health. Dr. Mehta has assembled a team of mentors well suited to ensuring his success during this Career Development Award led by Dr. Ivor Douglas and Dr. Daniel Matlock. Dr. Mehta?s work will serve as model for developing SDM tools in the ICU. Dr. Mehta?s proposed training and research will directly impact patient care related to tracheostomy by improving SDM, and better aligning the care received with patient and surrogate values.
Tracheostomy utilization is increasing in the United States but evidence suggests patients and their decision- makers experience substantial decisional conflict and regret exists as they feel uninformed about prognosis and feel that their values and preferences were not considered. In order to better improve the patient centeredness of care, align treatments with patient values, reduce unwanted procedures, and reduce healthcare costs, multiple societies strongly recommend the use of shared decision-making in the intensive care unit which can often be facilitated with decision aids. Our proposal seeks to combine qualitative value assessments with long-term outcome predictions for patients with tracheostomy in order to create a personalized web based tracheostomy decision aid that we hypothesize will reduce decisional conflict and regret as well as better align patient care with underlying values and expectations.
