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BHCAG Summit Minneapolis, MN February 23, 2012 Shannon Brownlee, MS Instructor, The Dartmouth Institute Acting Director, New America Foundation Health Policy
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Clinicians, patients and preference- sensitive (elective) care What do patients know about tradeoffs? What do they need to know? What do clinicians know about patient preferences? How does knowledge change behavior?
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Jack Fowler Michael Barry Al Mulley Jack Wennberg
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Involves tradeoffs -- more than one treatment exists; not getting treated is often an option; and the outcomes are different Decisions should be based on the patient’s preferences... But provider opinion/preference often determines which treatment is delivered
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PCI per 1,000 Enrollees (2003 – 2007)
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“Yes, medical therapy is as effective as PCI, but when I see a lesion, the bottom line is that the oculostenotic reflex always wins out.” “[The patient] is not going to get out of the cath lab without a stent.” Grace A. Lin, et al ARCH INTERN MED/VOL 167 (NO. 15), AUG 13/27, 2007
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WHAT DO PATIENTS KNOW (1990s)? 75% believed PCI would help prevent an MI 71% believed PCI would help them live longer Less than half could name even one possible complication of PCI 85% were “consented” just before the procedure (by a fellow or an NP) From a survey of consecutive patients scheduled for an elective coronary revascularization procedure at Yale New Haven Hospital in 1997-1998. (Holmboe ES. JGIM 2000; 15:632)
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What patients know (2010)... 88% believed PCI would help prevent an MI 76% believed PCI would help them live longer (Baystate Medical Center in 2007-2008 Rothberg MB. Annals Intern Med 2010; 153:307)
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Only 31% had activity limiting chest pain C ardiologists’ perception of the patient’s angina was often greater than the patient’s MB Rothberg Ann Intern Med. 2010 Sep 7;153(5):307-1
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What drives utilization? Well Bob, it looks like a paper cut, but just to be sure, I like to do lots of catheterizations.
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H. Vernon Anderson et al Circulation 2005;112;2786-2791 Relationship Between Procedure Indications and Outcomes of Percutaneous Coronary Interventions by American College of Cardiology/American Heart Association Task Force Guidelines
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CABG in Minnesota
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What do clinicians know about what their patients prefer? U. Mich Decision Survey
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What do Clinicians Know? Sepucha K, et al. Patient Education and Counseling 2008 and Lee et al. 30th Annual Society for Medical Decision Making Conference, Philadelphia, 2008.
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DECISION Survey: How can you know if you don’t ask? Surgery: About 1/2 the time for the orthopedic surgeries; 1/3 for cataracts Screening: Less than 1/5 of the time for decisions about cancer screening Medications: About 1/3 of the time SOURCE: U. of Mich. DECISION Survey
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What do patients know? Clinical experts identified 4-5 facts, e.g. common side effects Respondents were asked the knowledge questions related to their decision. For 8 out of the 10 decisions, less than half of respondents could get more than 1 of the knowledge questions right. U. Mich Decision Survey
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Clinicians, patients and preference- sensitive care What do patients know about tradeoffs? Not much What do they need to know? A lot more What do clinicians know about patient preferences? Not much How does knowledge change behavior?
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* P <.01 Source: N. Cochran, MD, WRJ V.A. Behavior Behavior Changes with Knowledge GREATER KNOWLEDGE LEADS TO DIFFERENT CHOICES
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