BHCAG SummitMinneapolis, MN

February 23, 2012

Shannon Brownlee, MSInstructor, The Dartmouth Institute

Acting Director, New America Foundation Health Policy

Clinicians, patients and preference-sensitive (elective)

care•What do patients know about tradeoffs?

•What do they need to know?

•What do clinicians know about patient preferences? •How does knowledge change behavior?

Jack Fowler

Michael Barry

Al Mulley

Jack Wennberg

• Involves tradeoffs -- more than one treatment exists; not getting treated is often an option; and the outcomes are different

• Decisions should be based on the patient’s preferences . . .

• But provider opinion/preference often determines which treatment is delivered

PCI per 1,000 Enrollees (2003 – 2007)

“Yes, medical therapy is as effective as PCI, but when I see a lesion, the bottom line is that the oculostenotic reflex always wins out.”

“[The patient] is not going to get out of the cath lab without a stent.”

Grace A. Lin, et al ARCH INTERN MED/VOL 167 (NO. 15), AUG 13/27, 2007

WHAT DO PATIENTS KNOW (1990s)?

75% believed PCI would help prevent an MI

71% believed PCI would help them live longerLess than half could name even one possible

complication of PCI85% were “consented” just before the

procedure (by a fellow or an NP)

From a survey of consecutive patients scheduled for an elective coronary revascularization procedure at Yale New Haven Hospital in 1997-1998. (Holmboe ES. JGIM 2000; 15:632)

What patients know (2010) . . .

88% believed PCI would help prevent an MI

76% believed PCI would help them live longer

(Baystate Medical Center in 2007-2008 Rothberg MB. Annals Intern Med 2010; 153:307)

• Only 31% had activity limiting chest pain

• Cardiologists’ perception of the patient’s angina was often greater than the patient’s

MB Rothberg Ann Intern Med. 2010 Sep 7;153(5):307-1

Well Bob, it looks like a paper cut, but just to be sure, I like to do lots of catheterizations.

H. Vernon Anderson et al Circulation 2005;112;2786-2791

Relationship Between Procedure Indications and Outcomes of Percutaneous Coronary Interventions by American College of Cardiology/American Heart Association Task Force Guidelines

CABG in Minnesota

What do clinicians know about what their patients

prefer?

U. Mich Decision Survey

What do Clinicians Know?

Sepucha K, et al. Patient Education and Counseling 2008 and Lee et al. 30th Annual Society for Medical Decision Making Conference, Philadelphia, 2008.

DECISION Survey: How can you know if you don’t ask?

Surgery: About 1/2 the time for the orthopedic

surgeries; 1/3 for cataracts Screening:

Less than 1/5 of the time for decisions about cancer screening

Medications: About 1/3 of the time

SOURCE: U. of Mich. DECISION Survey

What do patients know?Clinical experts identified 4-5

facts, e.g. common side effectsRespondents were asked the

knowledge questions related to their decision.

For 8 out of the 10 decisions, less than half of respondents could get more than 1 of the knowledge questions right.

U. Mich Decision Survey

Clinicians, patients and preference-sensitive care

•What do patients know about tradeoffs? Not much•What do they need to know? A lot more

•What do clinicians know about patient preferences? Not much •How does knowledge change behavior?

* P < .01 Source: N. Cochran, MD, WRJ V.A.

Behavior Behavior Changes with Knowledge GREATER KNOWLEDGE LEADS TO DIFFERENT

CHOICES