More than one-third of Medicare patients who underwent a prostatectomy, and 90% who had elective insertion of a coronary stent, said their physicians gave them no advance information about more conservative options that produce similar survival outcomes, says a survey conducted by the Dartmouth Institute and the Informed Medical Decisions Foundation.
The results indicate that rather than guide patients to thoughtfully consider alternatives, physicians are still paternalistically making those decisions for their patients—without discussion—on grounds that they think they know what's best for their patients, says principal investigator Floyd J. Fowler.
"There's a big tradition of physicians taking responsibility, and being paternalistic when these decisions are made," Fowler says. "I won't argue that they weren't trying to be beneficent when they made these decisions, but we think this is not the way decisions like this should be made," especially when the invasive procedures in question carry considerable risks and side-effects.
The paper by Fowler and colleagues is published in the March 2 issue of the Journal of General Internal Medicine.
The research group sent surveys to 800 patients for whom Medicare claims records indicated they'd had prostate cancer surgery and 800 who'd undergone a non-emergent stent during the last six months of 2008. Some 685 prostate cancer patients' and 472 stent patients' responses were included. The patients were given a $5 in cash as an incentive.
Fowler emphasized there is good evidence that other options in prostate cancer, such as brachytherapy, eternal beam radiation or conservative management, has equivalent survival benefit for people over age 65.
Likewise, medical management and changes in diet and exercise can relieve angina pain for patients with coronary artery disease, but 54% of the stent patients had no arm or chest pain in the month preceding the sampled stent procedure.
Several recent reports in medical journals increasingly call attention to the proliferation of unnecessary or inappropriate stenting procedures by interventional cardiologists, including one July 6 in the Journal of the American Medical Association, which found that of elective percutaneous coronary interventions, 50.4% were appropriate, 38% uncertain and 11.6% inappropriate.
But Fowler's new study was not about which procedure was best for each patient.
Rather, the project attempted to learn how much these patients were told by their physicians about these options in advance, and whether they were engaged in a discussion about the pros and cons.
One possible weakness in the study was in the length of time between the intervention and the time the patient returned the survey, which averaged 14 months with a range from 12 to 16 months. Memory problems in older patients, especially during a time of health status stress, could mean that more doctors had engaged their patients than the study says.
But Fowler says he doesn't think so, because the responses varied so much between prostate cancer patients and stent patients. That indicates that they largely remembered their experience.
"Clearly those two populations have really different reports" (about being given information on options), he says. "So that makes the argument, that people make this stuff up or they forget what really happened and it all gets homogenized or forgotten, harder to make."
There is some evidence that for those patients who didn't have information about more conservative approaches, about 20% to 25% would have foregone the more aggressive intervention, Fowler says.
That might indicate physicians are thinking more about their financial benefit from performing the surgery or stent procedure than involving the patient in that decision that might prompt them to delay or seek another type of treatment.
But Fowler says that even though the fee-for-service Medicare system, which reimburses specialists and surgeons on the basis of how many procedures they do, "I don't feel comfortable with a purely monetary explanation for the physician's motives."
Rather, he says, "I think physicians are genuinely trying to do good for their patients, but that they just don't come by shared-decision making naturally."
Doctors generally make decisions about whether to insert a stent during the course of an angiography, when the patient is least equipped to discuss alternatives, Fowler says. "We would argue that a discussion about the potential decision to insert a stent should be a routine part of the decision to perform a diagnostic angiogram," Fowler and colleagues wrote in the paper.
Additionally, they stress, these kinds of decisions should include input from the primary care provider. In this survey, fewer than 3% of the prostate cancer and stent patients who responded said their primary care provider played a major role in their decisions.
Fowler says he hopes this trend—to inform and include patients in the decision-making process—will change in coming months and years with the launch of accountable care models, patient-centered medical homes and bundled payments, in which payment to doctors is based on quality measures and wellness, not on the number of procedures.
"That there would be redistribution of medical care dollars, and maybe some reductions—that is a possibility when the world is working right," he says.