Cardiologists’ Discussions About PCI
Original Investigation Research
30. Légaré F, Turcotte S, Stacey D, Ratté S, Kryworuchko J, Graham ID. Patients’ perceptions of sharing in decisions: a systematic review of interventions to enhance shared decision making in routine clinical practice. Patient. 2012;5(1):1-19.
catheterization and revascularization be routinely undertaken? in mildly symptomatic patients, an invasive strategy with catheterization and revascularization should not be routinely undertaken. Circ Cardiovasc Interv. 2013;6(1):114-121.
31. Légaré F, Ratté S, Stacey D, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev. 2010;(5):CD006732.
36. Montori VM, Brito JP, Ting HH. Patient-centered and practical application of new high cholesterol guidelines to prevent cardiovascular disease. JAMA. 2014;311(5):465-466.
32. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011;(10): CD001431.
37. Ting HH, Brito JP, Montori VM. Shared decision making: science and action. Circ Cardiovasc Qual Outcomes. 2014;7(2):323-327.
33. Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med. 1995;40(7):903-918. 34. Coylewright M, Shepel K, Leblanc A, et al. Shared decision making in patients with stable coronary artery disease: PCI choice. PLoS One. 2012;7(11):e49827. 35. Maron DJ, Ting HH. In mildly symptomatic patients, should an invasive strategy with
41. Schmid Mast M, Hall JA, Roter DL. Caring and dominance affect participants’ perceptions and behaviors during a virtual medical visit. J Gen Intern Med. 2008;23(5):523-527. 42. Option Grids. Option Grid Web site. http://www.optiongrid.org/optiongrids.php. Accessed August 9. 43. Pope TM, Hexum M. Legal briefing: shared decision making and patient decision aids. J Clin Ethics. 2013;24(1):70-80. 44. Krumholz HM. Informed consent to promote patient-centered care. JAMA. 2010;303(12):1190-1191.
38. Choosing Wisely. American Board of Internal Medicine Foundation Web site. http://www .abimfoundation.org/Initiatives/Choosing-Wisely .aspx. Accessed August 19, 2013.
45. Braddock CH III, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282(24):2313-2320.
39. Braddock CH III. The emerging importance and relevance of shared decision making to clinical practice. Med Decis Making. 2010;30(5)(suppl):5S-7S.
46. Morgan MW, Deber RB, Llewellyn-Thomas HA, et al. Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease. J Gen Intern Med. 2000;15(10):685-693.
40. Coylewright M, Montori V, Ting HH. Patient-centered shared decision-making: a public imperative. Am J Med. 2012;125(6):545-547.
Invited Commentary
Fighting the “Oculostenotic Reflex” Grace A. Lin, MD, MAS; R. Adams Dudley, MD, MBA
In recent years, there has been intense focus in the scientific community and media on the potential overuse of percutaneous coronary interventions (PCI) in patients with stable angina. Although PCI has proven to be effective in Related articles pages 1614, decreasing mortality rates 1623 and 1630 among patients with acute myocardial infarction, it has not been shown to prevent cardiovascular events for patients with stable angina. It may, however, have a small effect on symptom relief in the short term when added to optimal medical therapy. Because of this small effect size and its short duration, researchers have concluded that PCI is not cost effective for treating patients with stable angina.1 About 30% of PCIs performed in the United States each year are to treat patients with stable angina. Analysis of the National Cardiovascular Data Registry has shown that almost half of PCIs done in patients with stable angina were either inappropriate or of uncertain appropriateness.2 In this issue, Bradley and colleagues3 extended that analysis to the health system level and found that National Cardiovascular Data Registry hospitals in which cardiac catheterizations are more likely to be given to asymptomatic patients are also more likely to have a higher rate of inappropriate PCIs. These results are consistent with the phenomenon of the diagnostic-therapeutic cascade, in which treatment is linked to the probability of having a diagnostic test, not the likelihood of benefit to the patient. With data demonstrating that the benefit of PCI is symptomatic, why are patients who would not benefit from the procedure receiving it? There are likely many factors involved, but in prior studies, physician decision making has emerged as a
major reason for current practice. Many physicians are influenced by the so-called oculostenotic reflex, in which any significant stenosis seen during the catheterization is subject to treatment, even if evidence suggests no benefit. In focus groups conducted in 2007,4(p1606) cardiologists described how patients “could not escape” a procedure once they were in the catheterization laboratory. One physician stated, “I think we all know that we’re not necessarily preventing heart attacks by treating asymptomatic stenosis…but nonetheless that patient leaves the lab with an open artery, the best that my interventional partners can offer.” The medical culture appears to reinforce this cognitive bias toward intervention, resulting in non–evidence-based treatment decisions. Unfortunately, such cognitive biases are also transmitted to patients in the decision-making process. Goff and colleagues5 analyzed audiotaped encounters and found that physician discussions about treatment options for stable angina are often incomplete and biased. For example, physicians did not often discuss the fact that PCI does not prevent future cardiovascular events and presented medical therapy as an inferior alternative. In addition, either explicitly or implicitly, physicians overstated the benefits of the procedure and downplayed the risks. Finally, many physicians used communication styles that discouraged patient participation in the decision-making process. Physicians also left little room for patient involvement in the decision-making process—for example, by using technical language and speaking during most of the encounter. The result of the current decision-making process is that patients who receive PCI have major misconceptions about treatment benefits, risks, and alternatives. Providing accurate and complete explanatory information about the pos-
jamainternalmedicine.com
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/29/2015
1621
Research Original Investigation
Cardiologists’ Discussions About PCI
sible treatment options could help combat these misconceptions and increase the probability that the patient is able to actively participate in a shared decision-making process. The potential of this approach is confirmed in the study by Rothberg and colleagues,6 in which patients were provided a hypothetical scenario with different levels of information before deciding on a treatment for angina. Patients who were given more explanatory information were 20% less likely to choose PCI as a treatment; on the other hand, the patients who believed that PCI could prevent myocardial infarction were almost 6 times more likely to favor PCI for treatment. Increased use of more balanced and accessible patient education methods such as decision aids, health coaches, and personalized consent forms—as well as concerted efforts to train and encourage physicians to use such tools to engage patients in a shared decision-making process—could help ensure that patients are being treated according to their informed preferences. However, it is not enough to encourage physicians to engage in shared decision making with patients through traditional mechanisms such as guidelines. Spreading best practices in this way can be a slow process, particularly if incentives are not aligned and there is little transparency in care. As the study by Goff and colleagues5 shows, physicians routinely dominate the conversation and give biased information. While there are many ways to encourage greater evidence-based decision making (eg, multidisciplinary tumor review boards, best practice alerts in the electronic medical record), in cases where care is sensitive to patient preferences, we need to ensure that patients are also educated and engaged in the decisionmaking process. We could do this by measuring the quality of the process (ie, decision quality) and then rewarding providers for high-quality decision making. In the case of treatments for stable angina, a measure of decision quality might involve asking a patient basic knowledge questions about the risks and benefits of PCI, preferences for treatment, and communication with physicians. Having a tool for measuring decision quality would also enable us, in conjunction with medical record data, to determine whether the treatment for stable ARTICLE INFORMATION Author Affiliations: Division of General Internal Medicine, University of California, San Francisco (Lin); Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (Lin, Dudley). Corresponding Author: Grace A. Lin, MD, MAS, Division of General Internal Medicine, University of California, San Francisco, PO Box 0320, San Francisco, CA 94143-0320 ([email protected]). Published Online: August 25, 2014. doi:10.1001/jamainternmed.2014.164. Conflict of Interest Disclosures: None reported. Funding/Support: This study was supported by grant 5K08HS017723-02 from the Agency for Healthcare Research and Quality (Dr Lin). Role of the Funder/Sponsor: The funding source had no role in the interpretation of the data;
1622
angina reflects the evidence base and the preferences of wellinformed patients. Aligning incentives to favor decision quality may also help interrupt the diagnostic-therapeutic cascade, because informed patients will be more likely to have an accurate sense of the relative risks and benefits of the procedure and, as a result, may decline procedures in situations where there are no clear benefits. One such example would be the asymptomatic patients in the study by Bradley et al.3 Finally, guidelines and appropriateness criteria need to be revised to include decision quality as a requirement. For example, the Appropriate Use Criteria from the American College of Cardiology focus on whether a procedure is indicated from the standpoint of a physician, with no mention of patient preferences. There is also no mention of how a decision is made or whether it is consistent with an individual patient’s values. Thus, a patient could have a procedure that meets the Appropriate Use Criteria, but have low decisional quality if the patient was not well informed or their preferences were not taken into account. This could result in a procedure the patient would not want or value if he or she had been fully informed. The decision to proceed with PCI should involve an assessment of clinical appropriateness and a high-quality, shared decision-making process. Interventions such as PCI have enhanced the lives of patients. However, use of treatments in inappropriately selected patients is wasteful and has the potential to do great harm, particularly if patients are undergoing procedures that, if informed, they would not have chosen for themselves. Physicians are integral to the decision-making process, and thus they hold the key to changing it. Providing patients with accurate and complete information appears to be an effective way to combat the reliance on the oculostenotic reflex. The standard of care should be a high-quality, shared decisionmaking process, and physicians should be held accountable for ensuring that treatment decisions are evidence-based and patient-centered. Achieving such a standard is critical to interrupting the diagnostic-therapeutic cascade and preventing patients from receiving unneeded and unwanted care.
preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
4. Lin GA, Dudley RA, Redberg RF. Cardiologists’ use of percutaneous coronary interventions for stable coronary artery disease. Arch Intern Med. 2007;167(15):1604-1609.
REFERENCES
5. Goff SL, Mazor KM, Ting HH, Kleppel R, Rothberg MB. How cardiologists present benefits of percutaneous coronary interventions to patients with stable angina: a qualitative analysis [published online August 25, 2014]. JAMA Intern Med. doi:10 .1001/jamainternmed.2014.3328.
1. Weintraub WS, Spertus JA, Kolm P, et al; COURAGE Trial Research Group. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med. 2008;359(7):677-687. 2. Chan PS, Patel MR, Klein LW, et al. Appropriateness of percutaneous coronary intervention. JAMA. 2011;306(1):53-61. 3. Bradley SM, Spertus JA, Kennedy KF, et al. Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry [published online August 25, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2014.3904.
6. Rothberg MB, Scherer L, Kashef MA, et al. The effect of information presentation on beliefs about the benefits of elective percutaneous coronary intervention [published online August 25, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2014 .3331.
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/29/2015
jamainternalmedicine.com
Original Investigation Research
30. Légaré F, Turcotte S, Stacey D, Ratté S, Kryworuchko J, Graham ID. Patients’ perceptions of sharing in decisions: a systematic review of interventions to enhance shared decision making in routine clinical practice. Patient. 2012;5(1):1-19.
catheterization and revascularization be routinely undertaken? in mildly symptomatic patients, an invasive strategy with catheterization and revascularization should not be routinely undertaken. Circ Cardiovasc Interv. 2013;6(1):114-121.
31. Légaré F, Ratté S, Stacey D, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev. 2010;(5):CD006732.
36. Montori VM, Brito JP, Ting HH. Patient-centered and practical application of new high cholesterol guidelines to prevent cardiovascular disease. JAMA. 2014;311(5):465-466.
32. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011;(10): CD001431.
37. Ting HH, Brito JP, Montori VM. Shared decision making: science and action. Circ Cardiovasc Qual Outcomes. 2014;7(2):323-327.
33. Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med. 1995;40(7):903-918. 34. Coylewright M, Shepel K, Leblanc A, et al. Shared decision making in patients with stable coronary artery disease: PCI choice. PLoS One. 2012;7(11):e49827. 35. Maron DJ, Ting HH. In mildly symptomatic patients, should an invasive strategy with
41. Schmid Mast M, Hall JA, Roter DL. Caring and dominance affect participants’ perceptions and behaviors during a virtual medical visit. J Gen Intern Med. 2008;23(5):523-527. 42. Option Grids. Option Grid Web site. http://www.optiongrid.org/optiongrids.php. Accessed August 9. 43. Pope TM, Hexum M. Legal briefing: shared decision making and patient decision aids. J Clin Ethics. 2013;24(1):70-80. 44. Krumholz HM. Informed consent to promote patient-centered care. JAMA. 2010;303(12):1190-1191.
38. Choosing Wisely. American Board of Internal Medicine Foundation Web site. http://www .abimfoundation.org/Initiatives/Choosing-Wisely .aspx. Accessed August 19, 2013.
45. Braddock CH III, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282(24):2313-2320.
39. Braddock CH III. The emerging importance and relevance of shared decision making to clinical practice. Med Decis Making. 2010;30(5)(suppl):5S-7S.
46. Morgan MW, Deber RB, Llewellyn-Thomas HA, et al. Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease. J Gen Intern Med. 2000;15(10):685-693.
40. Coylewright M, Montori V, Ting HH. Patient-centered shared decision-making: a public imperative. Am J Med. 2012;125(6):545-547.
Invited Commentary
Fighting the “Oculostenotic Reflex” Grace A. Lin, MD, MAS; R. Adams Dudley, MD, MBA
In recent years, there has been intense focus in the scientific community and media on the potential overuse of percutaneous coronary interventions (PCI) in patients with stable angina. Although PCI has proven to be effective in Related articles pages 1614, decreasing mortality rates 1623 and 1630 among patients with acute myocardial infarction, it has not been shown to prevent cardiovascular events for patients with stable angina. It may, however, have a small effect on symptom relief in the short term when added to optimal medical therapy. Because of this small effect size and its short duration, researchers have concluded that PCI is not cost effective for treating patients with stable angina.1 About 30% of PCIs performed in the United States each year are to treat patients with stable angina. Analysis of the National Cardiovascular Data Registry has shown that almost half of PCIs done in patients with stable angina were either inappropriate or of uncertain appropriateness.2 In this issue, Bradley and colleagues3 extended that analysis to the health system level and found that National Cardiovascular Data Registry hospitals in which cardiac catheterizations are more likely to be given to asymptomatic patients are also more likely to have a higher rate of inappropriate PCIs. These results are consistent with the phenomenon of the diagnostic-therapeutic cascade, in which treatment is linked to the probability of having a diagnostic test, not the likelihood of benefit to the patient. With data demonstrating that the benefit of PCI is symptomatic, why are patients who would not benefit from the procedure receiving it? There are likely many factors involved, but in prior studies, physician decision making has emerged as a
major reason for current practice. Many physicians are influenced by the so-called oculostenotic reflex, in which any significant stenosis seen during the catheterization is subject to treatment, even if evidence suggests no benefit. In focus groups conducted in 2007,4(p1606) cardiologists described how patients “could not escape” a procedure once they were in the catheterization laboratory. One physician stated, “I think we all know that we’re not necessarily preventing heart attacks by treating asymptomatic stenosis…but nonetheless that patient leaves the lab with an open artery, the best that my interventional partners can offer.” The medical culture appears to reinforce this cognitive bias toward intervention, resulting in non–evidence-based treatment decisions. Unfortunately, such cognitive biases are also transmitted to patients in the decision-making process. Goff and colleagues5 analyzed audiotaped encounters and found that physician discussions about treatment options for stable angina are often incomplete and biased. For example, physicians did not often discuss the fact that PCI does not prevent future cardiovascular events and presented medical therapy as an inferior alternative. In addition, either explicitly or implicitly, physicians overstated the benefits of the procedure and downplayed the risks. Finally, many physicians used communication styles that discouraged patient participation in the decision-making process. Physicians also left little room for patient involvement in the decision-making process—for example, by using technical language and speaking during most of the encounter. The result of the current decision-making process is that patients who receive PCI have major misconceptions about treatment benefits, risks, and alternatives. Providing accurate and complete explanatory information about the pos-
jamainternalmedicine.com
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/29/2015
1621
Research Original Investigation
Cardiologists’ Discussions About PCI
sible treatment options could help combat these misconceptions and increase the probability that the patient is able to actively participate in a shared decision-making process. The potential of this approach is confirmed in the study by Rothberg and colleagues,6 in which patients were provided a hypothetical scenario with different levels of information before deciding on a treatment for angina. Patients who were given more explanatory information were 20% less likely to choose PCI as a treatment; on the other hand, the patients who believed that PCI could prevent myocardial infarction were almost 6 times more likely to favor PCI for treatment. Increased use of more balanced and accessible patient education methods such as decision aids, health coaches, and personalized consent forms—as well as concerted efforts to train and encourage physicians to use such tools to engage patients in a shared decision-making process—could help ensure that patients are being treated according to their informed preferences. However, it is not enough to encourage physicians to engage in shared decision making with patients through traditional mechanisms such as guidelines. Spreading best practices in this way can be a slow process, particularly if incentives are not aligned and there is little transparency in care. As the study by Goff and colleagues5 shows, physicians routinely dominate the conversation and give biased information. While there are many ways to encourage greater evidence-based decision making (eg, multidisciplinary tumor review boards, best practice alerts in the electronic medical record), in cases where care is sensitive to patient preferences, we need to ensure that patients are also educated and engaged in the decisionmaking process. We could do this by measuring the quality of the process (ie, decision quality) and then rewarding providers for high-quality decision making. In the case of treatments for stable angina, a measure of decision quality might involve asking a patient basic knowledge questions about the risks and benefits of PCI, preferences for treatment, and communication with physicians. Having a tool for measuring decision quality would also enable us, in conjunction with medical record data, to determine whether the treatment for stable ARTICLE INFORMATION Author Affiliations: Division of General Internal Medicine, University of California, San Francisco (Lin); Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (Lin, Dudley). Corresponding Author: Grace A. Lin, MD, MAS, Division of General Internal Medicine, University of California, San Francisco, PO Box 0320, San Francisco, CA 94143-0320 ([email protected]). Published Online: August 25, 2014. doi:10.1001/jamainternmed.2014.164. Conflict of Interest Disclosures: None reported. Funding/Support: This study was supported by grant 5K08HS017723-02 from the Agency for Healthcare Research and Quality (Dr Lin). Role of the Funder/Sponsor: The funding source had no role in the interpretation of the data;
1622
angina reflects the evidence base and the preferences of wellinformed patients. Aligning incentives to favor decision quality may also help interrupt the diagnostic-therapeutic cascade, because informed patients will be more likely to have an accurate sense of the relative risks and benefits of the procedure and, as a result, may decline procedures in situations where there are no clear benefits. One such example would be the asymptomatic patients in the study by Bradley et al.3 Finally, guidelines and appropriateness criteria need to be revised to include decision quality as a requirement. For example, the Appropriate Use Criteria from the American College of Cardiology focus on whether a procedure is indicated from the standpoint of a physician, with no mention of patient preferences. There is also no mention of how a decision is made or whether it is consistent with an individual patient’s values. Thus, a patient could have a procedure that meets the Appropriate Use Criteria, but have low decisional quality if the patient was not well informed or their preferences were not taken into account. This could result in a procedure the patient would not want or value if he or she had been fully informed. The decision to proceed with PCI should involve an assessment of clinical appropriateness and a high-quality, shared decision-making process. Interventions such as PCI have enhanced the lives of patients. However, use of treatments in inappropriately selected patients is wasteful and has the potential to do great harm, particularly if patients are undergoing procedures that, if informed, they would not have chosen for themselves. Physicians are integral to the decision-making process, and thus they hold the key to changing it. Providing patients with accurate and complete information appears to be an effective way to combat the reliance on the oculostenotic reflex. The standard of care should be a high-quality, shared decisionmaking process, and physicians should be held accountable for ensuring that treatment decisions are evidence-based and patient-centered. Achieving such a standard is critical to interrupting the diagnostic-therapeutic cascade and preventing patients from receiving unneeded and unwanted care.
preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
4. Lin GA, Dudley RA, Redberg RF. Cardiologists’ use of percutaneous coronary interventions for stable coronary artery disease. Arch Intern Med. 2007;167(15):1604-1609.
REFERENCES
5. Goff SL, Mazor KM, Ting HH, Kleppel R, Rothberg MB. How cardiologists present benefits of percutaneous coronary interventions to patients with stable angina: a qualitative analysis [published online August 25, 2014]. JAMA Intern Med. doi:10 .1001/jamainternmed.2014.3328.
1. Weintraub WS, Spertus JA, Kolm P, et al; COURAGE Trial Research Group. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med. 2008;359(7):677-687. 2. Chan PS, Patel MR, Klein LW, et al. Appropriateness of percutaneous coronary intervention. JAMA. 2011;306(1):53-61. 3. Bradley SM, Spertus JA, Kennedy KF, et al. Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry [published online August 25, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2014.3904.
6. Rothberg MB, Scherer L, Kashef MA, et al. The effect of information presentation on beliefs about the benefits of elective percutaneous coronary intervention [published online August 25, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2014 .3331.
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/29/2015
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