Qualitative Analysis of Patient-Physician Discussions About the Benefits and Tradeoffs of Heart Failure Medications.

Background: How physicians frame medication benefits and tradeoffs while engaging in shared decision making with patients is not well described in the management of heart failure with reduced ejection fraction (HFrEF).

Methods: This qualitative, secondary analysis of recorded encounters between clinicians and patients with HFrEF sought to identify major themes regarding communication of medication benefits and tradeoffs. Encounters occurred in six clinics within two academic health systems. English-speaking adult patients with a diagnosis of HFrEF (ejection fraction ≤40%) were enrolled.

Results: A total of 247 patient encounters were analyzed. Patients' mean (SD) age was 62.9 (13.9); 70.5% were male; 64.0% were White, 26.3% Black, and 3.2% Hispanic/Latinx. Overall, 70% of encounters contained a discussion involving medication benefits. Substantial variability was observed, and four main themes emerged. 1) Primary benefits (increased survival, reduced hospitalizations, better quality of life) were commonly discussed, but clinicians described the magnitude in only two cases; 2) Adjunctive drug benefits (improved physiology, tolerability, affordability) were described nonspecifically; 3) Persuasive forms of communication were common, including direct appeals to authority/guidelines, references to pharmaceutical advertisements, and emotive language; 4) Significant heterogeneity was present in the content and character of benefit tradeoff discussions.

Conclusions: Rare inclusion of medication benefit magnitude, variability in the presentation of benefits, and use of persuasive and emotive communication all challenge traditional notions of shared decision-making but are commonly encountered in clinical interactions for heart failure. Recognizing these contextual factors and evaluating which are consistent with effective decision-making in HFrEF and other chronic conditions is important and needed.