Study: Most doctors fail to involve patients in elective PCI decisions
Floyd J. Fowler, Jr., PhD, of the Center for Survey Research at the University of Massachusetts in Boston, and colleagues conducted a survey of Medicare beneficiaries who underwent surgery for prostate cancer or elective coronary stenting in the last half of 2008. They chose the two procedures to better understand the decision-making process in what they termed preference-sensitive interventions.
The authors noted that elective PCI can provide relief from angina but argued that similar benefit can be achieved through medical management. In prostate cancer, surgery may offer a small survival benefit but is associated with serious side effects. “Thus both interventions, while quite different clinically, are ideal for studying decision making because they have small, if any, mortality benefits over conservative management, potentially significant quality-of-life implications and no clinical urgency.”
For the survey, they obtained a random sample of 800 Medicare patients who underwent prostrate surgery and 800 Medicare patients who underwent PCI between Aug. 1, 2008, and Dec. 31, 2008, as indicated on Medicare claims. They eliminated patients in the PCI group who were admitted through the emergency department, who had a code for either an acute MI or unstable angina or had a claim for a PCI or CABG surgery within the past year.
The Centers for Medicare & Medicaid Services then mailed a letter informing the selected beneficiaries that they were selected for the study and could call to opt out. Those who did not opt out were sent a questionnaire with questions about their decision making, including whether their physician discussed alternative therapies; the duration of discussions; reasons for having the intervention; cons of the procedure; and what preferences the patient might have.
Of the 800 PCI patients, 778 initially were deemed eligible and 593 returned the questionnaire. Of the 593, a total of 472 met inclusion criteria for the analysis. Of that group, 38 percent were women; 54 percent reported no arm or chest pain a month prior to PCI; 28 percent had a CABG surgery in the past; and 21 percent had had a previous MI.
While 64 percent of patients who had prostate cancer surgery said their physician discussed alternatives as a serous option, only 10 percent of PCI patients reported such discussions. Seventy-six percent of prostate cancer patients said their physicians asked about preferences while only 16 percent of PCI patients said they were asked.
A majority in both groups reported that their physician discussed reasons for the intervention “some” or “a lot” (95 percent the prostate cancer surgery and 77 percent for PCI) but cardiologists were less likely to discuss reasons for electing not to have the procedure. Only 19 percent of PCI patients reported doctors discussing cons “a lot” or “some” vs. 63 percent of the prostate cancer patients. In both groups, primary care physicians rarely contributed to the discussion.
“[T]here is very little information sharing or discussion with patients when stent procedures are done,” Fowler and colleagues wrote. They observed that the PCI procedure may be performed in conjunction with a diagnostic test. “However, given the frequency with which stents are placed when angiograms are performed, we would argue that a discussion of the potential decision to insert a stent should be a routine part of the decision to perform a diagnostic angiogram.”
They recommended that in both interventions, physicians interact more with patients and involve them more in the decision-making process. They proposed bringing the patient’s primary care physician into the decision process. “Because primary care providers are likely to be less predisposed to a specific treatment than specialists, they may provide more balanced information and increase the likelihood that conservative options are considered,” the authors wrote.
They noted that the patient-centered medical home model also might help increase primary care physician’s involvement.
The data were limited by being self-reported and may not accurately reflect the patient-doctor interactions, the authors pointed out. “Meanwhile, these data provide a challenge and a baseline against which to measure the progress that is very much need,” they concluded.