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'Informed Decision' May Irk Surgeons as It Cuts Costs, Improves Quality

 |  By cclark@healthleadersmedia.com  
   August 16, 2012

Get ready for the latest idea in healthcare, the informed shared medical decision.  It's a concept that will either make you angry enough to scream or restore your faith in the system.

I hope it does the latter.

Because if this idea takes off, as it probably will, it's certain to dramatically narrow the field of patients who unnecessarily go under the knife or scope, even if it upsets some surgeons and interventionalists in the process. 

Yes, it could hurt fee-for-service specialists' and hospitals' pocketbooks by reducing volume. But it could greatly improve quality of care and the health of the healthcare dollar.

The process might work like this: Instead of the primary care physician referring a patient to a specialist for a non-emergent procedure—say, an operation on a bum knee—as is done today, the PCP would order and review the imaging tests, and then refer the patient to a class, a DVD, or an interactive online tool.

The surgeon isn't part of the process.

Instead, patients would learn from experts—perhaps hired by the health system or the payers—whether they meet indications for the procedure or whether there are feasible alternatives.

They'd see data on complication and infection rates, track records and experience levels for the hospital and/or the surgeon, adverse events of required medications, post-procedure functional limitations, challenges to recovery, and rates of repeat surgery.

They would learn about the likelihood of the procedure actually accomplishing what is expected, even if all goes perfectly. And patients who have undergone the procedure would explain what happened to them.

Unnecessary surgeries

Some healthcare systems will bridle at this idea. Specialists insist they never operate on a patient who is unlikely to benefit.  And family doctors may not want to be bothered with more bureaucratic steps in a referral process they have to do more to vet.

But consider just a few recent headlines to see the paving of the large runway that may enable this plane to take off.

• A New York Times story last week revealed some 1,200 patients underwent unnecessary invasive cardiology procedures in one South Central Florida hospital, and many other facilities in the large HCA chain are under federal investigation.

• A Grand Rapids surgeon's study in September's Journal of Clinical Oncologysays far too many patients undergo unnecessary surgery to remove tumors in patients with advanced colon cancer when chemotherapy and a drug have a better success rate.

• A report in the New England Journal of Medicine found many women with breast cancer are unnecessarily undergoing a second surgery to remove more tissue for wider margins.

National blindspot

Some surgeons themselves think this is an idea whose time has come.

"We have a major national blindspot, and that blindspot is unnecessary medical care, and there's a ton of it that goes on," says Martin Makary, MD, a gastroenterology surgeon and researcher at Johns Hopkins School of Medicine.

Makary is the author of an upcoming and extremely controversial book, Unaccountable, about dangerous practices that persist in a culture that is allowed to hide its mistakes. He tells me that preliminary results of his research project reveal that when asked, surgeons think the amount of unnecessary surgery that hospital culture chooses to ignore is huge, "in the ballpark of 10% to 20%."

These are the big drivers of cost, Makary says. " [They are] big ticket items, like coronary artery bypass graft surgeries, colectomies, hysterectomies, and back surgeries. They not only have the biggest price tags, but they also have the highest complication profiles of anything we do in healthcare."

The Dartmouth Atlas of Health Care presents another exhibit for the case that the problem of unnecessary procedures is significant. The Atlas, with its dramatic charts showing wide regional variation in volume of surgical procedures around the country, demonstrates little evidence that more surgeries are producing better outcomes.

Informed medical decision-making sessions, if done appropriately, Makary says, "can begin to address this problem that surgeons themselves are recognizing."

"Eventually you could die"

Makary confesses that as a trainee, he engaged in a practice he called "patient manipulation" as a survival mechanism.

"I was under pressure to get [patients] to sign surgical consents. If a patient asked, 'What if I don't have this done?' I would cut right to the chase and say, 'Eventually you could die.' That was a phrase that circulated a lot among residents."

The idea to get patients to consider their own unique health status before making a decision is, in part, the brainchild of James Weinstein, DO, a spine surgeon and former head of the Dartmouth Institute. He is now President and CEO of Dartmouth-Hitchcock healthcare system. 

Just in his field of spine surgery, he says, "we know that in shared decision-making models, when patients are given good information, 30% choose not to have surgery."

Some versions of the concept have been rolled out at Dartmouth for a variety of orthopedic procedures, Weinstein says. All take the surgeon out of the decision-making equation because of obvious conflicts of interest they may have, conscious or unconscious.

Decisions about non-emergent surgeries "should be made at the primary care doctor level. That's what we at Dartmouth do," he says.

Naturally, the idea will get the best reception in healthcare systems with salaried surgeons, like Dartmouth-Hitchcock or Makary's Johns Hopkins.

Several systems, like Intermountain and the Mayo Clinic, are rolling out versions of this model soon. At Mayo Clinic, it's being adopted to help patients choose how to choose medications for their diabetes.

A $26 million incentive

The Center for Medicare & Medicaid Innovation in June gave Dartmouth $26 million to implement shared-decision models throughout 15 million healthcare systems covering 50 million patients in 17 states.

In Boston, the Informed Medical Decisions Foundation is developing tools for health plans and others to help patients learn more about the procedures they are about to undergo.  The foundation defines an informed decision even more broadly.

"We're now suggesting that medical necessity is not only an appropriate procedure, but one the fully informed patient wants," says Richard Wexler, MD, the foundation's director of patient support strategies. "Even though the operation may be clinically appropriate, some people may not want to take the risk once they know what that is. They may give up the tennis game rather than incur the pain and the risk of complications."

And even some professional societies are guardedly getting on board with the idea, even if in a preliminary way.

"Surgeons don't always present things in an unbiased fashion," acknowledges Lisa Cannada, MD, spokesperson for the American Academy of Orthopaedic Surgeons who works at Saint Louis University in Missouri.

"A surgeon with a specialty in a certain procedure believes a patient will benefit, and instead of trying physical therapy and injections, they'll just go right ahead and do the procedure," when conservative approaches might be better.

David Hoyt, MD, a former trauma surgeon who is executive director of the American College of Surgeons, says his organization is working on a "risk calculator" to help surgeons "have an informed-consent discussion" with their patients based on their co-morbid conditions.

"We support patient education that gets to their expectations about what an operation involves," he says.

And there is the Choosing Wisely campaign, a collaboration of nine specialty societies to help patients and their doctors ask the right questions about the type of care they really need.

Of course there are downsides.  New information may confuse or scare patients away from getting what they need. But smart thinkers can design these models to minimize that chance.

Bottom line: If patients have a better appreciation of what's about to happen to them, and really are a bigger part of this decision, how can that be a bad thing for healthcare?

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