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Informed decision making for PCI often incomplete
In a cross-sectional analysis of conversations between cardiologists and patients with or suspected of having stable angina, few discussions contained all elements of informed decision making, and better-informed patients were less likely to choose angiography and possible PCI, researchers found.
Michael B. Rothberg, MD, MPH, and colleagues assessed the quality of informed decision making and its association with patient decisions by analyzing 59 recorded conversations conducted by 23 cardiologists with patients with stable or suspected coronary disease (mean age, 65 years; 69% men).
Seven elements
The researchers assessed conversations for the presence of the following seven elements of informed decision making:
- discussion of the patient’s role in the decision making;
- discussion of the clinical issue or nature of the decision;
- discussion of the alternatives;
- discussion of the pros and cons of the alternatives;
- discussion of the uncertainties associated with the decision;
- assessment of the patient’s understanding; and
- exploration of patient preference.
They also assessed the association of each element with patients’ decision.
Only two of the 59 conversations (3%) included all seven elements of informed decision making, and eight (14%) met a more limited definition of procedure, alternatives and risks, according to the results.
Forty-four patients chose to undergo angiography and possible PCI and 15 did not. Physicians made recommendations in 55 cases, all but six recommendations for angiography and possible PCI. Of the patients who received a recommendation for angiography and possible PCI, 90% followed it and 10% did not. Of the four patients who did not receive a recommendation for a physician, all decided not to undergo angiography and possible PCI.
Factors involved in choice
The following elements were independently associated with not choosing angiography and possible PCI:
- discussion of the uncertainties associated with the decision (OR = 20.5; 95% CI, 2.3-204.9);
- discussion of the patient’s role in the decision making. (OR = 5.3; 95% CI, 1.3-21.3);
- discussion of the pros and cons of the alternatives. (OR = 9.5; 95% CI, 2.5-36.5); and
- exploration of patient preference (OR = 4.8; 95% CI, 1.2-19.4).
Rothberg and colleagues found that the presence of angina was not associated with the decision to choose angiography and possible PCI, nor was the severity of symptoms.
When the cardiologist stated that the patient had a blockage that could be “fixed,” the patient was more likely to choose angiography and possible PCI (82% vs. 58%; P = .04), according to the researchers.
When the researchers conducted a multivariable analysis using total number of elements as a predictor, the better-informed patients were less likely to choose angiography and possible PCI (OR per additional element = 3.2; 95% CI, 1.4-7.1).
“As long as the reimbursement system continues to encourage PCI in all cases, it seems unlikely the process will improve,” Rothberg, from the Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, and colleagues wrote. “One potential remedy would be to create new quality measures around informed consent and shared decision making. … 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.” – by Erik Swain
Disclosure: One researcher reports receiving salary support as a medical editor from the Informed Medical Decisions Foundation, a part of Healthwise.