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Informed Decision Making for PCI | Journal Scan
Study Questions:
What is the quality of informed decision making in patients with stable coronary disease undergoing cardiac catheterization with possible percutaneous coronary intervention (PCI)?
Methods:
Using a market database of recorded physician–patient encounters, a cross-sectional analysis of conversations between August 1, 2008, and August 31, 2012, was performed among patients with known or suspected stable coronary disease at outpatient cardiology practices who were being referred for cardiac catheterization with possible PCI. At least two reviewers examined the presence of seven established elements of informed decision making (Braddock CH III, et al. JAMA 1999;282:2313-20) regarding the decision to undergo angiography and possible PCI.
Results:
A total of 59 conversations by 23 cardiologists were reviewed. The majority of cardiologists did not self-identify as interventional cardiologists. Of these, two (3%) included all seven elements of informed decision making; eight (14%) met a more limited definition of procedure and clinical issues, alternatives, and pros/cons. Some elements were significantly associated with not choosing cardiac catheterization and possible PCI, included discussion of uncertainty (odds ratio [OR], 20.5; 95% confidence interval [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). Clinical factors did not seem to matter as much. In a multivariable analysis, the total number of elements of informed decision making included in the discussion was a predictor of a lower likelihood to choose cardiac catheterization and possible PCI (OR per additional element, 3.2; 95% CI, 1.4-7.1; p = 0.005).
Conclusions:
The authors concluded that conversations between cardiologists and patients regarding cardiac catheterization and possible PCI were “often incomplete,” with more complete discussions “associated with patients choosing not to undergo [the procedure].”
Perspective:
This is a very cool study by Michael Rothberg and colleagues that builds on prior work by his group and others (e.g., Goff SL, et al. JAMA Intern Med 2014;174:1614-21). It leverages a unique data source, the Verilogue Point-of-Practice Database. In earlier studies, it is clear that patients are not well informed of their decision to undergo cardiac catheterization and possible PCI, rarely understanding the clinical issues, alternatives, and pros/cons. This study adds to that prior work by examining specific elements of the informed consent process as they are provided in ‘real-world’ practices through voice recordings. Although this was not a random sample of physicians or patients, the practices included appear to be very diverse and the interactions are not simulations, but real conversations. Interventional cardiologists will find the table with examples fascinating, as they mimic many of the ‘key’ boilerplate language and phrases we all use in describing these procedures to our patients in an efficient manner. In my opinion, this study will have a large impact on how we think about informed decision making. At the very least, it will encourage greater use of standardized consent processes with checklists that prevent physicians from missing key elements in this discussion. I personally believe this process could be further augmented through visual or video tools that allow for even more detailed understanding.
Keywords: Angiography, Cardiac Catheterization, Checklist, Coronary Disease, Cross-Sectional Studies, Decision Making, Informed Consent, Myocardial Ischemia, Outpatients, Patient Preference, Percutaneous Coronary Intervention, Physician-Patient Relations, Uncertainty
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