Majority of Informed Decision Making Discussions Involving Angioplasty and PCI Are Incomplete
More Informed Patients Less Likely to Choose Procedures
In conversations between cardiologists and patients with stable angina regarding angiography and possible percutaneous coronary intervention (PCI), informed decision making is often incomplete, according to results of study published May 17 in JAMA: Internal Medicine. Meanwhile, more informed patients were more likely not to choose the procedures.
Study authors performed a cross-sectional analysis of recorded conversations between Aug. 1, 2008, and Aug. 31, 2012, among adults with known or suspected stable coronary disease at outpatient cardiology practices. Transcripts were reviewed for the presence of seven elements of informed decision making, including discussions of the patient's role in the decision-making process; the clinical issue or nature of the decision; alternatives; pros and cons of alternatives; uncertainties associated with the decision; and patient preference.
Overall results found that of 59 conversations conducted by 23 cardiologists, the majority failed to meet the seven elements of informed decision making. Only two conversations (3 percent) included all seven elements, while eight (14 percent) met a more limited definition of procedure, alternatives, and risks.
The study authors noted the specific elements significantly associated with a decision not to choose angiography and possible PCI were those involving discussions around uncertainty, the patient's role, exploration of alternatives and exploration of patient preference. Discussions relating to the presence of angina and/or the severity of symptoms were not associated with a decision to have or not have angiography or possible PCI. A multivariable analysis using the total number of elements as a predictor, found that "better informed patients were less likely to choose angiography and possible PCI."
According to the study authors, "as long as the reimbursement system continues to encourage PCI in all cases, it seems unlikely that the process will improve." However, based on the study results, they suggest "one potential remedy" might be to create new quality measures around informed consent and shared decision making. "More important, 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," they said.
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