1. BHCAG Summit Minneapolis, MN February 23, 2012 Shannon Brownlee, MS Instructor, The Dartmouth Institute Acting Director, New America Foundation Health Policy

2. 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?

3. Jack Fowler Michael Barry Al Mulley Jack Wennberg

4. 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

7. PCI per 1,000 Enrollees (2003 – 2007)

9. “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

10. 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)

11. 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)

12. 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

13. What drives utilization? Well Bob, it looks like a paper cut, but just to be sure, I like to do lots of catheterizations.

14. 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

15. CABG in Minnesota

21. What do clinicians know about what their patients prefer? U. Mich Decision Survey

22. 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.

23. 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

24. 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

25. 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?

27. * P <.01 Source: N. Cochran, MD, WRJ V.A. Behavior Behavior Changes with Knowledge GREATER KNOWLEDGE LEADS TO DIFFERENT CHOICES