The National Coverage Determination on carotid stenting by Medicare in October 2023 stipulates that patients participate in a shared decision-making (SDM) conversation with their proceduralist before an intervention. However, to date, there is no validated SDM tool that incorporates transcarotid artery revascularization (TCAR) into its decision platform. Our objective was to elicit patient and surgeon experiences and preferences through a qualitative approach to better inform the SDM process surrounding carotid revascularization. We performed longitudinal perioperative semistructured interviews of 20 participants using purposive maximum variation sampling, a qualitative technique designed for identification and selection of information-rich cases, to define domains important to participants undergoing carotid endarterectomy or TCAR and impressions of SDM. We also performed interviews with nine vascular surgeons to elicit their input on the SDM process surrounding carotid revascularization. Interview data were coded and analyzed using inductive content analysis coding. We identified three important domains that contribute to the participants' ultimate decision on which procedure to choose: their individual values, their understanding of the disease and each procedure, and how they prefer to make medical decisions. Participant values included themes such as success rates, “wanting to feel better,” and the proceduralist's experience. Participants varied in their desired degree of understanding of carotid disease, but all individuals wished to discuss each option with their proceduralist. Participants' desired medical decision-making style varied on a spectrum from complete autonomy to wanting the proceduralist to make the decision for them. Participants who preferred carotid endarterectomy felt outcomes were superior to TCAR and often expressed a desire to eliminate the carotid plaque. Those selecting TCAR felt it was a newer, less invasive option with the shortest procedural and recovery times. Surgeons frequently noted patient factors such as age and anatomy, as well as the availability of long-term data, as reasons to preferentially select one procedure. For most participants, their surgeon was viewed as the most important source of information surrounding their disease and procedure. SDM surrounding carotid revascularization is nuanced and marked by variation in patient preferences surrounding autonomy when choosing treatment. Given the mandate by Medicare to participate in a SDM interaction before carotid stenting, this analysis offers critical insights that can help to guide an efficient and effective dialog between patients and providers to arrive at a shared decision surrounding therapeutic intervention for patients with carotid disease.

中文翻译：

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经颈动脉血运重建时代的患者决策

Medicare 于 2023 年 10 月发布的颈动脉支架置入术全国覆盖决定规定，患者在干预前与程序专家进行共同决策 (SDM) 对话。然而，迄今为止，还没有经过验证的 SDM 工具将经颈动脉血运重建 (TCAR) 纳入其决策平台。我们的目标是通过定性方法了解患者和外科医生的经验和偏好，以便更好地为颈动脉血运重建的 SDM 流程提供信息。我们使用有目的最大变异抽样（一种旨在识别和选择信息丰富的病例的定性技术）对 20 名参与者进行纵向围手术期半结构化访谈，以确定对接受颈动脉内膜切除术或 TCAR 的参与者重要的领域以及 SDM 的印象。我们还采访了 9 名血管外科医生，以征求他们对颈动脉血运重建 SDM 流程的意见。使用归纳内容分析编码对访谈数据进行编码和分析。我们确定了有助于参与者最终决定选择哪种手术的三个重要领域：他们的个人价值观、他们对疾病和每种手术的理解，以及他们更愿意如何做出医疗决策。参与者的价值观包括成功率、“想要感觉更好”以及程序主义者的经验等主题。参与者对颈动脉疾病的期望理解程度各不相同，但所有人都希望与他们的程序专家讨论每个选项。参与者期望的医疗决策风格多种多样，从完全自主到希望程序主义者为他们做出决定。倾向于颈动脉内膜切除术的参与者认为结果优于 TCAR，并且经常表示希望消除颈动脉斑块。选择 TCAR 的人认为这是一种更新的、侵入性较小的选择，且手术时间和恢复时间最短。外科医生经常将年龄和解剖结构等患者因素以及长期数据的可用性作为优先选择一种手术的理由。对于大多数参与者来说，他们的外科医生被视为有关他们的疾病和手术的最重要的信息来源。围绕颈动脉血运重建的 SDM 是微妙的，其特点是患者在选择治疗时对自主性的偏好存在差异。鉴于 Medicare 要求在颈动脉支架置入术之前参与 SDM 互动，该分析提供了重要的见解，有助于指导患者和提供者之间进行高效且有效的对话，以就颈动脉疾病患者的治疗干预达成共同决策。