Among patients undergoing percutaneous left atrial appendage occlusion (LAAO), shared decision-making and decision aid reporting was high but varied by institution, and Medicare patients were not more likely to have reported shared decision-making with decision aids, despite the Centers for Medicare and Medicaid Services (CMS) requirement, according to a recent study published in JAMA Network Open.

Joshua Rager, MD, et al., included 147,296 patient encounters (59% male, mean age 77 years) from 830 institutions captured by ACC's LAAO Registry between Oct. 1, 2022 and June 30, 2024. They sought to identify patient, operator and institutional factors associated with the use of shared decision-making and decision aids in patients undergoing first-time percutaneous LAAO.

Overall, 99.9% of institutions reported on shared decision-making and 98.4% reported on decision aid use. The authors found the rate of patient encounters with reported shared decision-making and decision aid use grew steadily over the study period from 62.5% in October 2022 to 75% in June 2024, resulting in an overall rate of 64.7%.

An adjusted analysis found that variance in reporting was large and mainly attributable to the institution level (median odds ratio 115.64; 95% CI 79.71-151.56). Estimated probability of reported shared decision-making and decision aid use by institution ranged from 0.1% to 76.4% (mean [SD] 52% [28.6%]).

"Surprisingly, whether a patient is reported to have undergone [shared decision-making] and been presented with a [decision aid] is much better explained by knowing at which institution the patient is having the procedure than any patient or operator characteristic we identified," write the authors.

Additionally, despite the CMS requirement to report shared decision-making and decision aid use as a condition for reimbursement, the authors found no significant difference in the likelihood of Medicare patients having this reporting (odds ratio 1.03; 95% CI 0.98-1.09).

In an accompanying editorial comment, Haya Kaliounji, MD, and Benjamin Adam Steinberg, MD, FACC, note that when CMS first published its national coverage decision in 2016 requiring shared decision-making reporting, clinicians expressed concern over the burden of the requirement. "Despite clinician concerns, high [shared decision-making] rates are achievable, yet it seems use of [decision aids] is lagging," they write. "We can only speculate that this may relate to a lack of local, in-clinic availability, awareness, and/or time for a [decision aid]; lack of system-wide implementation; or insufficient documentation for abstraction."

They propose future work may focus on "moving from [shared decision-making] alone to broad and efficient implementation of evidence-based [decision aids] to support this therapeutic journey."