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.”
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.