August 26th, 2013

Practice Variations and Quality: Ask the “Uber” Expert


In response to recent reports of variation in practice and outcomes of elective PCI, CardioExchange’s Rick Lange asks Harlan Krumholz to elaborate on what constitutes high-quality decision making.

Three interesting studies recently released showed:

1. Physicians in New York State perform twice as many cardiac catheterizations per capita as those in Ontario, and the increased use of cardiac catheterization in New York relative to Ontario (regions with very different payment systems) is primarily the result of selecting more patients at low predicted probability of obstructive CAD.

2. Medicare Advantage (i.e., capitated payment) patients have lower rates of elective angiography and PCI than Medicare fee-for-service (FFS) patients. Furthermore, elective procedure rates vary widely (as much as 3–4-fold) by geographic region for both capitated and FFS payment patients.

3. New PCI programs from 2004 to 2008 did not improve timely access for patients with STEMI.  These new programs were more likely than not to be introduced in areas that already had a PCI program, near populations with higher rates of private insurance, in states that had weak or no regulation of new cardiac cath labs, and in wealthier and larger hospitals.

In a “take no prisoners” editorial, Harlan Krumholz (also editor-in-chief of CardioExchange) admonishes that variations in practice should “disturb physicians…. because of the possibility that such variations do not optimally serve the best interests of patients.”  He’s not bothered by variation in practice, “provided that variation is based on patient clinical differences and preferences rather than on other factors such as payment method, geography, or system proclivities.”   He urges “high-quality decision making.”

So, Harlan….

RL: What exactly is “high quality decision making?” Who decides? Can it be measured?

HK: In my JAMA editorial, I called for us to set standards for high-quality decisions, develop metrics for assessing the quality of decisions, and promote effort to ensure that we are promoting high-quality decisions by our patients. Since many decisions seem highly influenced by who provides the care, I wonder if we can say that the patients are guiding the decisions. By the way, I am talking about non-emergency decisions — when there is time for deliberation, and patient preferences ought to dominate – like the choice between PCI and optimal medical therapy for stable CAD.

So what does constitute a high quality decision? Good decisions are informed, value-concordant decisions. Patients can be overwhelmed by information, but do they know the key information? We conducted a study years ago that showed that most patients undergoing elective PCI incorrectly thought that the procedure would extend their life or help them to avoid a heart attack. More recently, a similar study essentially found similar results. If patients have misconceptions, they cannot make high-quality decisions. “Value-concordant” means that we do not force a decision on patients but ensure that their choice is consistent with their values, preferences, and goals. For many decisions, there is not a single right choice. The choice is among strategies that all have risks and benefits. Patients need to pick the one that fits them best.

There are best practices in decision-making — and I think we can start teaching them. And ultimately we may be able to measure whether a good decision is achieved — and to what extent.

What’s important here is that we would be assessing the process by which the decision was made — not the decision. We are not determining if patients made the “right” choice (especially if that is defined as what we would do) — but whether they were able to understand the key information and decide based on what is important to them.

Also, the decision should not be judged by the outcome. Good decisions can be followed by poor outcomes. And outcomes after decisions are probabilistic – that is the point. We can almost never guarantee an outcome in these types of decisions — so how people choose depends on their risk tolerance and how they feel about the possible interventions — what they may cost (yes, that is a real consideration for many people), and what may happen.

The tricky part is that sometimes patients are fearful and do need some coaching — but I believe that coaching ought to be an effort to give them the courage to determine what they want to do, not to coax them into doing something that they do not want to do.

The impression of patients after the decision may not be a good metric because most people, subject to cognitive dissonance, will express that they did the right thing — assuming that the result was not disastrous.

RL:  You advocate informing and guiding patients through decisions. On average, physicians spend 8 minutes with each patient. How does one create “well-informed” patients and understand patient preferences in that setting?

HK: We need to develop a different approach. Doctors are paid too much to spend the time that is necessary to educate patients. We need a team to participate — and we need to find ways to get people informed in a way that is affordable.

RL: What do you do when the patient’s — and sometimes referring physician’s — preference is at odds with evidence-based medicine? For example, the asymptomatic, low-risk patient who demands a coronary calcium score or myocardial perfusion scan. What is the “high-quality decision” in that setting?

HK: I do think that there are some decisions that are out of bounds. For example, if a patient asks me to give him cyanide — or to do a procedure that has no supporting evidence. We are talking about how choices are made among strategies that are all within bounds. The problem is that patients are often told there is only one good choice when, in fact, there are more — and reasonable people could choose among them. We need to be clear about what is within bounds and what is not.

7 Responses to “Practice Variations and Quality: Ask the “Uber” Expert”

  1. David Powell , MD, FACC says:

    “Doctors are paid too much to spend the time that is necessary to educate patients.”

    Quite the sentence. Are not doctors best positioned to educate? Shouldn’t they be the most appropriate educators? Doctors are decision framers. For me, this is one of the most rewarding and important parts of my job.

    But, efficiency is bound to be a factor. For some patients, giving them brief written education before the discussion with the physician may improve the process at minimal cost.

    If the statement implies that some physicians consider such patient discussions as unfavorable due to financial considerations, it would be important to modify financial incentives to align with best care. Some firm of capitation seems likely. But the risks of unintended negative effects on patient care with capitation is worrisome.

  2. This is a comment worthy of attention – as is my sentence. I wonder what others think? If there is a need for 30-45 minutes of patient education, is it affordable to have doctors do it? Most of us enjoy spending a lot of time with patients – but can the health system afford us if we are billing at what we really make per hour (even in an 80 hour week).

  3. Edgar Abovich, MD says:

    To say: “doctors are paid too much…” is not going to go well with most physicians, no matter what context it is in. I think predominant feeling is that doctors are not paid enough to educate the patients and therefore end up outsourcing education to other health professionals. I disagree with that. I think doctors are the ones in the best position to explain things as they are and should spend more time with the patients and families. It is in the interest of the patients, but it is not a direction we age going unfortunately.

  4. To be clear… I did not say doctors are paid too much. I said they are paid too much to spend time as health educators (and by that I mean as real health educators with dedicated appointments for health education – obviously we fit in brief educational messages all the time in regular appointments). Figure out what you are making for each hour of work – and think about whether you should be scheduling 30-45 minutes for patient education – and I am not even bringing up the issue about whether we rec’d any formal training about how to be effective health educators. I am just saying that we are very expensive health educators – and if you think we are worth it – then I guess, in a health system that is too expensive, it would be up to us to prove it. Love this back and forth though.

  5. Enrique Guadiana, Cardiology says:

    One of the reason the health system is too expensive is because the society has many misconceptions regarding health issues and a very important contributor is the lack of adequate doctors – patient health education. I can’t imagine how I could start a treatment if I’m not sure that my patient understands the diagnosis, the severity and the different therapeutic options including risks, cost and prognosis.

    The expectations that the patient have are very important, if these are unrealistic you have a recipe for a quick patient – physician relation deterioration, many dragging to a lawsuit and this is a big contributor in the health system cost. Every time I explain a patient their diagnosis, severity, therapeutic options and prognosis I ask them to explain it back to me and it is very frequent that they didn’t understand, not because I forced a decision in the patient, but because they are under great deal of stress, they are afraid and, when you are afraid, Who would you like to speak with?, I would like to speak with the individual who is going to be responsible, my doctor, not a nurse or an educator, nobody else.

    Many doctors are not happy with the public misconception that we are paid to much. I believe that there is a campaign to blame the medical community for the increase cost of health care and this is not true, like any profession we have bad apples but nothing compared with the misconduct, problems and inappropriate charges from insurance companies, hospitals, laboratories, etc. This campaign is to justify the increase in cost and in consequence revenue for everybody, except the doctors of course. It’s very simple, follow the money and you will find that most of it is not in our backyard.

  6. John E Brush, MD says:

    This is a terrific discussion. I would like to get back to some of the points that Harlan made in his JAMA editorial – that decision-making should be better codified, that we should define a set of core competencies for decision making, that we should set standards and metrics for good decisions, and that we should develop visual aids to help patients make better therapeutic decisions. These are all great suggestions.

    We need better teaching – more explicit instruction focused on the mental habits that lead to good medical decisions. These habits have been defined and can be taught. We should encourage our trainees to deliberately practice these habits. And we need more research in this critically important area.

    Ask a random 4th year medical student about Bayes’ Rule and you will likely get a blank stare. Ask him or her about the Golgi apparatus, and you will get an answer. Which is more important in clinical medicine? Somehow we have decided to give medical decision-making short shrift in our curriculum design. That needs to change.

    Thank you, Richard and Harlan for raising this important issue for discussion.

  7. Siqin Ye, MD says:

    We are discussing the first two articles at our fellows’ weekly journal club today, and just this evening I was having a Facebook discussion with Tariq Ahmad on issues of equity and efficiency in the US healthcare system.

    I think another reading of these articles is that healthcare systems produce the results they are set up to produce. Differences in angiography rates and redundant PCI capacity are as much due to the characteristics of local markets and payment systems, as they are to quality of decision making in individual patient encounters. An analogy might be that, to induce physicians to wash hands before examining patients, it’s not sufficient to just teach them the rationale, but also to make structural changes such as placing a Purell dispenser at every bedside.

    So I suspect that in addition to better education and research about high quality decision making, we as a profession will also go through difficult but necessary structural changes on, yes, matters such as how doctors are paid. But on this eve of Dr. King’s speech, it is my hope that eventually we will have a more perfect (and higher quality, and more equitable) healthcare system.