According to current estimates, about 10 million Americans have chronic stable angina, and many of these patients undergo elective PCI to improve symptoms of their disease in the near term. “While PCI can help manage many symptoms of chronic stable angina, the procedure has no effect on the risk of subsequent heart attacks or death,” explains Michael B. Rothberg, MD, MPH. “Despite this fact, studies show that many patients still believe that PCI will reduce these risks, and many cardiologists will perform PCI for patients with minimal or no symptoms.”
Published research has shown that few cardiologists believe PCI offers benefits beyond reducing angina symptoms. However, many admit to performing PCI based on their own beliefs in its value. Sometimes, they will provide PCI to alleviate patient anxiety or to avoid medicolegal fallout from not performing it. Further complicating matters is that patients may have biases or misconceptions on the true benefits of PCI, even if they are given accurate information from cardiologists that contradicts these beliefs.
“Little is known about why patients believe that PCI reduces mortality or how some beliefs impact decision making,” says Dr. Rothberg. “It’s possible that cardiologists are not explicitly discussing the benefits of PCI, meaning that patients are left to their own assumptions about its benefits. A full discussion of the risks and benefits associated with PCI is necessary to achieve true informed consent.”
A Closer Look
Previous research has identified seven elements of informed decision making that are required for complex decisions surround procedures like PCI. These elements include discussing the patient’s role in decision making, the clinical issue or nature of the decision, alternatives, pros and cons of alternatives, and uncertainties. They also include assessing patient understanding and exploring patient preferences.
For a study published in JAMA Internal Medicine, Dr. Rothberg and colleagues examined the content of 59 recorded discussions between 23 cardiologists and patients regarding decisions to proceed to angiography and possible PCI for stable coronary disease. The purpose was to quantify the extent to which the seven aforementioned elements of informed decision making were present in these conversations. The authors assessed the relationship between completeness of informed decision making and patients’ decisions to pursue angiography and possible PCI.
Inadequately Informed Decisions
According to the study results, only two of the 59 recorded conversations—or 3%— included all seven elements of informed decision making about PCI. Even when the researchers used a more limited definition that included only discussions about the clinical issue, alternatives, and pros and cons, informed decision making occurred in just eight cases (14%).
Patients who discussed more elements of informed decision making with their cardiologists were less likely to undergo angiography and possible PCI (Figure). Specific elements that were significantly associated with not choosing angiography and possible PCI included discussions of uncertainty and the patient’s role as well as exploration of alternatives to PCI and patient preferences.
Angiography and possible PCI was recommended in about 75% of cases, and these patients usually followed that recommendation. In the few cases in which no recommendation was made, none of the patients chose to have angiography and possible PCI. The presence of angina and severity of symptoms were not associated with choosing angiography and possible PCI.
“Many of the elements of informed decision making about PCI were not prevalent or incomplete,” Dr. Rothberg says. “For example, patients were told that they had a role in decision making in only about half of the conversations analyzed. This rate is better than what was seen about 20 years ago, but still warrants improvement.”
Open the Dialogue
Dr. Rothberg says that medical therapy has proven benefits for coronary heart disease, but few patients in the study were offered it as an alternative to PCI. “Patients tend to go along with whatever their physicians recommend,” he says. “The problem is that they may be unaware that medical therapy can be used as an alternative. Some patients might have elected to use medical therapy instead of PCI if they knew that it was an option that they should seriously consider. Physicians need to initiate conversations like this with patients to ensure that they’re making informed decisions.”
The study authors note that one possible way to fix the problem is to create new quality measures around informed consent and shared decision making. “Ultimately, we need pragmatic strategies to ensure that patients understand the evidence on a proposed intervention and indicate a clear preference for the procedure,” says Dr. Rothberg. “Providing more information will take time, but this is a worthwhile effort considering the potential downstream implications.” The time and resources spent with discussions to better inform decision making might be offset by the savings generated from performing fewer PCIs. In addition, measuring and rewarding informed decision making is likely to enhance medical care.
Readings & Resources (click to view)
Rothberg MB, Sivalingam SK, Kleppel R, Schweiger M, Sepucha KR. Informed decision making for percutaneous coronary intervention for stable coronary disease. JAMA Intern Med. 2015;175:1199-1206. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=2294234.
Rothberg MB, Sivalingam SK, Ashraf J, et al. Patients’ and cardiologists’ perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med. 2010;153:307-313.
Goff SL, Mazor KM, Ting HH, Kleppel R, Rothberg MB. How cardiologists present the benefits of percutaneous coronary interventions to patients with stable angina: a qualitative analysis. JAMA Intern Med. 2014;174:1614-1621.
Larobina ME, Merry CJ, Negri JC, Pick AW. Is informed consent in cardiac surgery and percutaneous coronary intervention achievable? ANZ J Surg. 2007;77:530-534.