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International Society For Minimally Invasive Cardiothoracic Surgery

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To What Degree are Patients Willing to Choose Less Invasive Surgery even when faced with Inferior Outcomes?
Jason J. Han, Akhil Rao, Max Shin, Mark R. Helmers, Amit Iyengar, Benjamin Smood, William L. Patrick, John J. Kelly, Peter Altshuler, Alan Herbst, Pavan Atluri
Hospital of the University of Pennsylvania, Philadelphia, PA, USA

BACKGROUND: It has been empirically observed among patients undergoing cardiac surgery that given two operative options with equivalent outcomes, they will generally prefer the less invasive one. However, to what extent patients may prefer less invasive options even in the setting of facing inferior outcomes has not been explored. We undertook this study to outline the determinants of procedural choice by patients with regard to invasiveness of intervention.
METHODS: A 24-question survey was distributed to users older than 55 years of age from 10/1 to 10/20/2021 using Amazon Mechanical Turk (Seattle, WI), a virtual crowdsourcing platform. The survey provided hypothetical comparisons between open heart surgery and its endovascular counterpart (e.g. surgical vs. trans-catheter aortic valve replacement) regarding their peri- and post-operative requirements such as need for intubation, sternotomy, and overall expected intensive-care-unit (ICU) and hospital length of stay. Five-point Likert scale questions evaluated the salience and the degree of fear associated with a list of common operative complications and concerns. Negligible financial incentive was offered. Chi-squared/Fisherís exact test or Mann-Whitney U-tests were utilized.
RESULTS: Fifty-three individuals completed the survey with a median age of 62 [57-69] years. Of the group, 42% were male, 79% were Caucasian, 38% had bachelorís or more advanced degrees, 42% were retired and 34% had an annual income of less than ,000. Given a choice between open surgery and its endovascular counterpart, 67.9% replied they would consider open surgery only if it adds significant benefit while 32.1% replied they would unconditionally refuse it. Male (53% vs 36% p=0.25), non-Caucasian (35% vs 14% p=0.07) individuals were more likely to unconditionally refuse open heart surgery although analysis did not reach statistical significance. There were no differences based on age, and education, employment, or marital status (p>0.05). When asked to quantify the relative gain in years-of-life one would need to choose open surgery, 13.2% required at least 1 year, 18.9% required at least 3 years, and 35.3% required at least 5 years of life gained (Figure 1). Individuals rated avoiding a stroke (Likert average 4.2/5) and a re-operation (4.1) as their most important decision-making considerations. Their most feared complications were stroke (4.3), prolonged ventilator dependence requiring a tracheotomy (4.3) and kidney failure requiring dialysis (4.3) while their least feared complications were requiring a pacemaker (3.1) and developing a para-valvular leak (3.5).
CONCLUSIONS: When presented with a less invasive alternative, a significant minority of patients may consider open surgery a point of contraindication even when faced with a decrement of benefit. In a shared decision-making paradigm, these concerns can be addressed by providers more strategically. Greater conversation on the long-term risks and benefits may be warranted in optimal procedure selection.


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