Informed patients more likely to opt against angiography, PCIs

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Patients who were more fully informed about angiography and the possibility of PCI were more likely to decide against it, a study published online May 18 in JAMA Internal Medicine found. Overall, the cardiologist-patient discussions were short and incomplete.

Michael B. Rothberg, MD, MPH, of the Center for Value-Based Care Research at the Cleveland Clinic, and colleagues applied seven elements that are considered needed in a doctor-patient discussion for patients to make complex decisions: their role in the decision making; the clinical issue or nature of the discussion; alternatives; pros and cons; uncertainties; an assessment of the patient’s understanding; and the patient’s preference.

They used the Verilogue Point-of-Practice database to identify outpatient encounters between a cardiologist and a patient with stable coronary disease that included a discussion about angiography and possible PCI. All encounters took place between 2008 and 2012, with the discussions recorded and transcribed. The final count was six interventional cardiologists and 17 clinical cardiologists who counseled 59 patients.

Of those patients, 50 percent reported exertional angina; 56 percent dyspnea; 29 percent activity-limiting angina; and of those with no angina, 73 percent had a positive stress test.

Only 3 percent of the cardiologist-patient discussions included all seven elements. Using another definition that listed only procedure, alternatives and risks, 14 percent were considered complete.

The median length of conversation was 11.8 minutes. Each element added 1.8 minutes to a conversation.

Almost all conversations touched on the clinical issue and 63 percent included an assessment of the patient’s understanding. But only 53 percent went over the patient’s role in decision making; 54 percent hit on patient preference; 42 percent reviewed pros and cons; and 10 percent addressed uncertainties.

Interventional cardiologists were more likely to talk about pros and cons, the patient’s role in decision making and meet the limited list of complete elements; but the findings were not statistically significant.

The better informed a patient was, the more likely he or she was to decline to choose angiography and possible PCI.

The cardiologists recommended angiography and possible PCI in 75 percent of the cases; among those, 90 percent of the patients agreed. When they recommended against PCI, all patients followed the advice. The four patients whose physicians made no recommendation chose to not proceed with angiography and PCI.

Rothberg et al proposed creating quality measures for informed decision making, but cautioned the measures needed to avoid burdensome documentation. They acknowledged that providing all the elements for decision making took more time.

“[R]esources spent at this stage might be offset by savings generated from performing fewer PCIs,” they wrote. “More important, measuring and rewarding informed decision making might transform physicians’ perception of informed consent from a poorly understood legal obligation to a cornerstone of good medical care.”