Why Shared Decision Making
FOR IMMEDIATE RELEASE
Medicare Patients Receiving Heart Stents Without Being Told Options
Medical Decision-Making Study Finds Patients Who Had Coronary Artery Stenting or Surgery for Prostate Cancer Not Always Fully Informed of Treatment Options, Pros and Cons
LEBANON, New Hampshire, March 2, 2012
—Nine out of 10 Medicare patients who received a stent procedure for coronary disease report that their physicians did not present them with the noninvasive alternative of managing their condition with medication, according to the results of a survey published online today by the Journal of General Internal Medicine. The study and its findings led the authors to conclude that physicians need to increase their efforts to inform and involve patients in decisions before performing elective procedures.
The authors surveyed Medicare patients who received stents or underwent prostate surgery for cancer to learn how decisions are made for two major “preference-sensitive” procedures where there are conservative, non-invasive alternatives and the options involve significant tradeoffs among possible outcomes. For example, stenting can provide relief from angina, or chest pain, but comparable benefits for most patients can be achieved with good medical management and lifestyle changes, as noted in a study published last week by the Archives of Internal Medicine.
Similarly, prostate surgery for cancer may offer a very slight survival advantage over alternatives like external beam radiation or doing nothing, but leaves most men impotent and many incontinent.
Consequently, when patients have options that deliver similar benefits and entail different risks, they should have a well-informed discussion of their options before treatment decisions are made.
“We wanted to see if patients knew about their options and, if not, find out where the process of becoming fully informed was breaking down from the patient perspective,” said Julie Bynum, MD, of The Dartmouth Institute for Health Policy and Clinical Practice, one of the co-authors of the study.
The mail survey was conducted of 1,600 Medicare beneficiaries, at least 66 years old, whose claims indicated they had either surgery for prostate cancer or elective coronary artery stenting in 2008. Patients were asked if the physicians presented options to them for serious consideration, the amount of time spent discussing the pros and cons of the procedures, and if they were asked about their preferences.
Of the respondents, the majority (64 percent) of prostate cancer surgery patients reported at least one alternative to surgery was presented to them as a serious option. A third said no immediate active treatment was presented as an option. Almost all (94 percent) said they discussed the pros of the surgery with their doctors, while 63 percent said they discussed the cons of surgery “a lot” or “some.” Most (76 percent) said they were asked about their treatment preferences.
Prostate cancer surgery patients report considerable interaction with physicians around the surgical decision. However, research indicates there is no survival value of surgery for men over 65, and, “given the limited survival benefit provided by surgery, we think that almost all surgical patients (not just 34 percent) should be offered conservative management as a serious option, particularly those over 70 and in poor health,” the authors said.
“The dynamics of the decision making reported by stent patients were quite different,” the authors noted. Of the patients receiving coronary artery stents, few (10 percent) said they were presented with options to seriously consider. Most (77 percent) said they talked with doctors “a lot” or “some” about the reasons for the stents, but few (19 percent) reported talking about the cons of the procedure. Only 16 percent were asked about their treatment preferences.
The authors said one possible reason for limited discussion is that many stent procedures are done in conjunction with a diagnostic angiogram, limiting the opportunities for discussion, since stents are often placed during the same time an angiogram procedure is performed. Given this frequency, the authors argued that a discussion of the potential decision to insert a stent should be a routine part of the decision to perform a diagnostic angiogram.
“Both groups document the need for increased efforts to inform and involve patients in treatment decisions. Providers have an ethical responsibility to do this, but we found that the majority of stent patients were not adequately informed or involved in the decision to have the procedure.” said principal investigator, Floyd Fowler, PhD, of the Informed Medical Decisions Foundation.
The U.S. government and medical societies have recognized for the past 30 years that patients should be encouraged to make informed decisions about their medical care. In 2010, an American Medical Association report stated that shared decision making, including the use of patient decision aids, has the potential to enhance the overall value of health care in the United States. The current thinking among medical associations is that the primary care physician and patient should discuss these decisions so that care is coordinated across the spectrum of the health care system.
Additional authors include Patricia M. Gallagher, PhD, Michael J. Barry, MD, F. Leslie Lucas, PhD, and Jonathan S. Skinner, PhD. The full study, “Decision-Making Process Reported by Medicare Patients Who Had Coronary Artery Stenting or Surgery for Prostate Cancer,” can be found at
For additional resources about making informed health care decisions, visit www.informedmedicaldecisions.org.
A mail survey was conducted of Medicare beneficiaries whose claims indicated they had surgery for prostate cancer or elective coronary artery stenting in 2008. Participants had to be enrolled in Medicare Parts A and B with no managed care participation for the previous 12 months and at least 66 years old at the time of the procedure. Nursing home residents were excluded. Claims-based algorithms were applied to identify potential subjects for the period August 1, 2008 through December 31, 2008. A random sample of 800 patients who had undergone each procedure was selected and sent to CMS, which removed deceased individuals and returned contact information for the rest.
The Dartmouth Institute for Health Policy and Clinical Practice
The Dartmouth Institute for Health Policy and Clinical Practice aims to drive real change in health care, based on 30 years of research. Our vision and our commitment: to achieve a patient-centered, high quality, cost-effective health care system with access and excellence for all.
Informed Medical Decisions Foundation
The Informed Medical Decisions Foundation has been working for over two decades to advance evidence-based shared decision making through research, policy, clinical models and patient decision aids. We believe that the only way to ensure high quality medical decisions are being made is for a fully informed patient to participate in a shared decision making process with their health care provider. We are a Boston-based organization, with a network of medical editors and clinical advisors from some of the most prestigious medical institutions in the world.
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