Michael B Rothberg1, Senthil K Sivalingam2, Reva Kleppel3, Marc Schweiger4, Bo Hu5, Karen R Sepucha6. 1. Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio. 2. Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester. 3. Division of General Medicine, Baystate Medical Center, Springfield, Massachusetts. 4. Division of Cardiology, Baystate Medical Center, Springfield, Massachusetts. 5. Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio. 6. Health Decision Sciences, Massachusetts General Hospital, Harvard Medical School, Boston.
Abstract
IMPORTANCE: Patients with stable coronary disease undergoing percutaneous coronary intervention (PCI) are frequently misinformed about the benefits of PCI. Little is known about the quality of decision making before angiography and possible PCI. OBJECTIVE: To assess the quality of informed decision making and its association with patient decisions. DESIGN, SETTING, AND PARTICIPANTS: We performed a cross-sectional analysis of recorded conversations between August 1, 2008, and August 31, 2012, among adults with known or suspected stable coronary disease at outpatient cardiology practices. MAIN OUTCOMES AND MEASURES: Presence of 7 elements of informed decision making and the decision to undergo angiography and possible PCI. RESULTS: Of 59 conversations conducted by 23 cardiologists, 2 (3%) included all 7 elements of informed decision making; 8 (14%) met a more limited definition of procedure, alternatives, and risks. Specific elements significantly associated with not choosing angiography and possible PCI included discussion of uncertainty (odds ratio [OR], 20.5; 95% CI, 2.3-204.9), patient's role (OR, 5.3; 95% CI, 1.3-21.3), exploration of alternatives (OR, 9.5; 95% CI, 2.5-36.5), and exploration of patient preference (OR, 4.8; 95% CI, 1.2-19.4). Neither the presence of angina nor severity of symptoms was associated with choosing angiography and possible PCI. In a multivariable analysis using the total number of elements as a predictor, better informed patients were less likely to choose angiography and possible PCI (OR per additional element, 3.2; 95% CI, 1.4-7.1; P = .005). CONCLUSIONS AND RELEVANCE: In conversations between cardiologists and patients with stable angina, informed decision making is often incomplete. More complete discussions are associated with patients choosing not to undergo angiography and possible PCI.
IMPORTANCE: Patients with stable coronary disease undergoing percutaneous coronary intervention (PCI) are frequently misinformed about the benefits of PCI. Little is known about the quality of decision making before angiography and possible PCI. OBJECTIVE: To assess the quality of informed decision making and its association with patient decisions. DESIGN, SETTING, AND PARTICIPANTS: We performed a cross-sectional analysis of recorded conversations between August 1, 2008, and August 31, 2012, among adults with known or suspected stable coronary disease at outpatient cardiology practices. MAIN OUTCOMES AND MEASURES: Presence of 7 elements of informed decision making and the decision to undergo angiography and possible PCI. RESULTS: Of 59 conversations conducted by 23 cardiologists, 2 (3%) included all 7 elements of informed decision making; 8 (14%) met a more limited definition of procedure, alternatives, and risks. Specific elements significantly associated with not choosing angiography and possible PCI included discussion of uncertainty (odds ratio [OR], 20.5; 95% CI, 2.3-204.9), patient's role (OR, 5.3; 95% CI, 1.3-21.3), exploration of alternatives (OR, 9.5; 95% CI, 2.5-36.5), and exploration of patient preference (OR, 4.8; 95% CI, 1.2-19.4). Neither the presence of angina nor severity of symptoms was associated with choosing angiography and possible PCI. In a multivariable analysis using the total number of elements as a predictor, better informed patients were less likely to choose angiography and possible PCI (OR per additional element, 3.2; 95% CI, 1.4-7.1; P = .005). CONCLUSIONS AND RELEVANCE: In conversations between cardiologists and patients with stable angina, informed decision making is often incomplete. More complete discussions are associated with patients choosing not to undergo angiography and possible PCI.
Authors: Gregg W Stone; Judith S Hochman; David O Williams; William E Boden; T Bruce Ferguson; Robert A Harrington; David J Maron Journal: J Am Coll Cardiol Date: 2015-11-23 Impact factor: 24.094
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