A team from Dartmouth and the Informed Medical Decisions Foundation* published a paper in the Journal of General Internal Medicine, “Decision-Making Process Reported by Medicare Patients Who Had Coronary Artery Stenting or Surgery for Prostate Cancer.”
It describes a survey of Medicare patients who had surgery for prostate cancer or stents put in place for coronary artery disease.
The majority (64%) of prostate cancer surgery patients reported that at least one alternative to surgery was presented as a serious option. Almost all (94%) said they and their doctors discussed the pros, and 63% said they discussed the cons of surgery a lot or some. Most (76%) said they were asked about their treatment preferences. Few who received stents said they were presented with options to seriously consider (10%). While most (77%) reported talking with doctors about the reasons for stents a lot or some, few (19%) reported talking about the cons. Only 16% said they were asked about their treatment preferences.
While prostate cancer surgery patients reported more involvement in decision making than elective stent patients, the reports of both groups document the need for increased efforts to inform and involve patients facing preference-sensitive intervention decisions.
One possible reason for limited discussion is that many stent procedures are done in conjunction with a diagnostic angiogram, limiting the opportunities for discussion. A possible reason those with angina symptoms report a better decision process is that they may have been interacting with physicians about possible options over a longer period of time. 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. Another explanation comes from recent focus groups with cardiologists. While the cardiologists knew that existing clinical studies had found no survival benefit for those with stable angina, many were still convinced of the benefits of PCI (ed. note: percutaneous coronary intervention – an umbrella term that includes stents), even for asymptomatic patients.
Efforts to improve decision making should continue to focus on increasing patient involvement, but we also think increasing the involvement of primary care providers when decisions are being made would be beneficial. Fewer than three percent of respondents said their primary care provider played a major role in their decisions. Because primary care providers are likely to be less predisposed to a specific treatment than specialists, they may provide more balanced information and may increase the likelihood that conservative options are considered. In addition, there is evidence that patients believe that important decisions are best carried out with their primary care providers. As patient-centered medical homes become robust centers for care coordination it should become more common for patients to rely on that setting for information and guidance when facing decisions. The results also point to the potential value of decision aids: routinely providing patients with unbiased, balanced material in print, DVD or web-based form would be a major step to ensure that patients know all the reasonable options and the pros and cons of each.The implementation of the primary care medical home should bring more involvement of primary care physicians in decisions about interventions and increase the likelihood that patients facing major decisions will understand all their options and have their voices heard. The routine use of decision aids would also increase patients information about options, though not necessarily their involvement in decisions. … Meanwhile, these data provide a challenge and a baseline against which to measure the progress that is very much needed.
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