Your doctor believes he’s “patient-centered” because he wants to provide the the treatment he thinks you need as quickly as possible. Or as the fictional Dr. Heart tells his chest pain patient right after recommending a stent, “As it happens, I can do the procedure for you next week. Does that work for you?”
Before giving in to the gurney, what questions should patients ask? One data-driven script was presented in skit form at the recent Health Datapalooza 2015 meeting in Washington, D.C. The drama was light-hearted; the clinical and financial issues underlying it are not.
Dr. Heart was played by Glyn Elwyn, a theater student-turned-family practitioner recognized as one of the world’s leading researchers in patient preferences and values. Casey Quinlan, a writer and activist widely known for her unfiltered expression of those preferences and values, played the patient.
In the skit, a persistent Quinlan keeps pestering the doctor with questions about what a stent will accomplish that changing her medications won’t. At first glance, a stent sounds appealing because it props open the blood vessel. What could be better? However, when Quinlan asks directly about the effect of meds versus stenting on preventing a heart attack, the doctor admits that data show medication lowers the odds but stenting does not.
In addition, while medication gives Quinlan a 52 percent chance of conquering the stable angina (chest pain) that brought her to the doctor in the first place, stenting performs barely better at 59 percent. More worrisome is that medication has “some side effects,” but stenting brings with it a 1-in-100 risk of death, heart attack or stroke.
At this point I suspect the real-life Quinlan would “rip her doctor a new one” (a non-surgical procedure) for being so cavalier about her possibly becoming a corpse. In the skit, “The Mighty Mouth” (her self-selected nickname) politely settles for saying, “I think I need to think about this.”
The skit wasn’t meant to skewer cardiologists but to promote a new series of decision guides arranged as FAQs (frequently asked questions) from The Preference Lab at Dartmouth, where Elwyn is based. The guides are intended to provide a high-quality data synthesis an ordinary patient can use.
The procedure Elwyn picked is one in desperate need of pro-patient reinforcement. Researchers who analyzed conversations between cardiologists and patients with angina discovered that just two out of 59 covered everything a patient needed to know to make an informed decision. Doctors discussed alternative treatments to angioplasty and stenting just one quarter of the time, according to the research, published online in May in JAMA Internal Medicine. Not surprisingly, most patients believed stenting would prevent a heart attack or even death. (In Elwyn’s skit, Dr. Heart never plays his trump card by gazing directly at the patient and saying, “To be honest, if it were me, I’d get a stent.”)
The dramatic findings in a paper presented in March at the annual meeting of the American College of Cardiology demonstrate the extent of overuse. Implementing “appropriate use criteria” for coronary interventions at one community hospital caused volume to plummet 17 percent in the first year, researchers found, and another 17 percent the year after. Total reimbursement dropped by millions of dollars. Nationally, more than $10 billion is spent every year on what are called percutaneous coronary interventions.
Expenditures would decline by more than $2.3 billion if similar trends were extrapolated nationally, the authors estimated. “As physicians are more informed when making decisions, costs come down,” lead author Pranav Puri said in a statement.
Of course, a less optimistic way of framing that conclusion would be: “If physicians utilize these criteria, their income and the revenue of the hospital that supports them may drop sharply.”
The medical evidence, reimbursement policy and even factors such as local surgeons’ enthusiasm for surgery all influence the volume of procedures. Better informed patients may out-argue overeager proceduralists and help curb their enthusiasm. However, until financial incentives finally switch from volume to value, patient empowerment remains only one treatment option for the medical waste causing the health care system such acute financial pain.